RCN Development Programme:
Transforming Dementia Care in Hospitals
Evaluation Report
Supported by
Contents
Key findings of the External Evaluation .......................................................................................... 5
1. Introduction ................................................................................................................................ 9
1.1 Context .................................................................................................................................. 9
1.2 The RCN development programme .................................................................................... 10
1.2.1
Overview of programme ......................................................................................... 10
1.2.2
Key programme aims and objectives:..................................................................... 11
1.2.3
Intended learning outcomes:.................................................................................. 11
1.3
2.
Participating NHS Trusts ................................................................................................. 12
The Evaluation ...................................................................................................................... 13
2.1 The Evaluation Team........................................................................................................... 13
2.2 The Evaluation Design ......................................................................................................... 13
2.3 Online questionnaire .......................................................................................................... 15
3.
2.3.1
Collation of outcomes for staff, patients and carers .............................................. 15
2.3.2
SPACE principles...................................................................................................... 15
2.4
Site visits ......................................................................................................................... 17
2.5
Programme participants ................................................................................................ 18
2.6
Motivations for applying for the programme ................................................................ 20
How course participants rated the programme ................................................................... 21
3.1
Development Days ......................................................................................................... 21
3.1.1 Networking................................................................................................................... 21
3.1.2 Sit and See Tool ............................................................................................................ 22
3.1.3 World Café Event ......................................................................................................... 22
4.
3.2
Site visits ......................................................................................................................... 22
3.3
Programme facilitation .................................................................................................. 23
Direct Benefits identified from Programme participation ................................................... 24
4.1
General Impact of participation in the programme ....................................................... 24
4.2
Tools for Change............................................................................................................. 24
4.2.1 Observational tools ...................................................................................................... 24
4.2.2 Triangle of Care ............................................................................................................ 25
Page 1
4.2.3 SPACE principles........................................................................................................... 25
4.3
5.
6.
7.
8.
Direct Benefits of Participating ...................................................................................... 25
4.3.1
Provided focus and structure for effective change ................................................ 25
4.3.2
Networking.............................................................................................................. 26
4.3.3
Facilitated partnership working within Trusts ........................................................ 27
4.3.4
Helped to validate changes ..................................................................................... 28
4.3.5
Boosted confidence and morale ............................................................................. 28
4.3.6
Raised the profile of dementia care ....................................................................... 29
4.3.7
Gave a sense of achievement ................................................................................. 29
4.3.8
Helped to develop carer engagement .................................................................... 30
4.3.9
Recommendations to others .................................................................................. 30
Lessons for future Development Programmes ..................................................................... 31
5.1
Networking with other Trusts ........................................................................................ 31
5.2
Wiki site .......................................................................................................................... 32
5.3
Tailoring the content of development days ................................................................... 32
5.4
Location of development days ....................................................................................... 32
5.5
Other suggestions .......................................................................................................... 32
Achievement of programme objectives and learning outcomes ......................................... 34
6.1
Programme Objectives ................................................................................................... 34
6.2
Learning Outcomes ........................................................................................................ 35
Progress on SPACE Principles ................................................................................................ 37
7.1
SPACE principle scores ................................................................................................... 37
7.2
Improvement in SPACE scores ....................................................................................... 40
7.3
Perceptions of SPACE scores .......................................................................................... 44
Progress on Trust Dementia Action Plans............................................................................. 46
8.1
Overview of achievements ............................................................................................. 46
8.2
Case Studies of Innovation ............................................................................................. 46
8.3
Factors affecting the achievement of objectives ........................................................... 51
8.3.1
Staff engagement .................................................................................................... 52
Page 2
9.
8.3.2
Funding ................................................................................................................... 54
8.3.3
Availability of space and staff time ......................................................................... 54
8.3.4
Difficulties with carer engagement......................................................................... 54
Considerations for Future programmes ............................................................................... 55
9.1 Programme facilitation ....................................................................................................... 55
9.2 Programme content ............................................................................................................ 56
10.
Maintaining Change ........................................................................................................... 58
11.
Summary and Conclusion .................................................................................................. 60
Appendix 1: Objectives fully achieved by participating Trusts ..................................................... 63
Appendix 2: List of supporting documents submitted by participating Trusts ............................ 67
Page 3
Lead authors
Dawn Brooker; Sarah Milosevic; Simon Evans; Christine Carter; Mary Bruce & Rachel Thompson
Acknowledgements
The evaluation team would like to thank all the Trusts and staff who participated in the
evaluation for making us feel so welcome on our visits to each Trust and for showcasing
excellent examples of the work they have achieved.
We would also like to thank the Carer Representatives: Frank Arrojo, Louise Langham, Helen
Taylor and Jean Tottie, for their valuable input and insight on all visit days. Thanks to Ruth
Burey, Val Hills and Christine McKenzie from the RCN learning development team for their
support in facilitating the programme. Also many thanks to Rachel Thompson and Nikki Mills at
the RCN for being so open in their approach to this evaluation.
The on-going support from Michael Watts and Jennifer Bray from the Association for Dementia
Studies was very much appreciated
Finally thanks to the RCN Foundation and the RCN for their support in funding the delivery and
evaluation of this programme.
Association for Dementia Studies
University of Worcester
Henwick Grove
Worcester
WR2 6AJ
Tel: +44 (0) 1905 542296
Email: dementia@worc.ac.uk
Page 4
Key findings of the External Evaluation
Between March 2013 and March 2014, the RCN worked with senior clinical nurse leads
responsible for dementia care within nine NHS Trusts providing acute hospital care. The
project aimed to improve the experience of care for people with dementia and their
carers in hospital by enhancing clinical practice. The following Trusts were successful in
gaining a place on the programme:

Basildon & Thurrock University Hospitals NHS Trust (Basildon Hospital)

Cambridge University Hospital NHS Foundation Trust (Addenbrookes Hospital)

Nottingham University Hospital Trust (City Campus)

Royal Devon & Exeter Foundation Trust (Wonford Hospital)

Kings Lynn NHS Foundation Trust (The Queen Elizabeth Hospital)

The Shrewsbury & Telford Hospitals NHS Trust (Princess Royal Hospital and
Shrewsbury & Telford Hospital)

Salford Royal NHS Foundation Trust

Walsall Healthcare NHS Trust (Manor Hospital)

Betsi Cadwaladr University Health Board (Ysbyty Glan Clwyd)
The Association for Dementia Studies (ADS) at the University of Worcester was
commissioned to undertake an external evaluation of the effectiveness of the
programme in developing practice and supporting improved outcomes for people with
dementia, family carers and staff.
How the programme was received within Trusts
1. Providing support to clinical nurse leads in acute hospitals through a structured
development programme was a catalyst to achieving positive outcomes for
patients and family carers of people with dementia.
2. Involvement of senior nursing staff, including dedicated dementia posts, was
essential in ensuring that changes were relevant, credible and visible.
Page 5
3. The inclusion of senior management from outside the nursing directorate
enabled changes to have broader influence and raised the profile of dementia
care.
4. Achievements appeared most successful where project teams had support from
the Trust/senior management, which was filtered through to dementia
champions working directly within clinical settings.
5. All nine Trusts reported that the objectives of the development programme were
either fully or partially achieved.
6. The majority of Trusts felt learning outcomes were ‘greatly’ or ‘partially
improved’. Most improved areas were: developing effective networks, skills for
leading and managing change, and supporting partnership working.
7. 85% of actions identified by Trusts were fully or partially achieved through the
course of the development programme. Each Trust made significant progress in
improving care for patients with dementia in hospital.
8. Over the course of the programme, all Trusts showed a statistically significant
increase in scores for each of the 5 overarching RCN SPACE principles [1] (as
rated on a 5 point scale). The average increase was 45%.
9. Most improved overarching areas were: ‘Partnership working with carers’ (53%),
‘Care plans which are person centred and individualised’ (51%) and
‘Environments that are dementia friendly’ (50%).
10. The Triangle of Care for dementia [2] and observational tools, including Sit and
See [3] and Dementia Care Mapping [4], were useful in assessing quality of care
and progressing carer engagement.
Outcomes for participants and NHS staff
Involvement in the development programme offered a number of benefits for staff
including:
1. Providing a focus and structure for making changes.
2. Acting as a ‘catalyst’ in moving developments forward at a faster rate.
3. Equipping participants with strategies and confidence to change practice
4. Encouraging partnership working and raising the profile of dementia care within
organisations.
Page 6
5. Enabling useful networking opportunities and sharing of ideas to support
practice.
6. Helping to validate changes in practice.
7. Boosting morale and confidence of staff as well as offering a sense of
achievement.
8. Helping to support staff to develop engagement with family carers.
Many participants in the programme trained staff within their Trusts in various aspects
of dementia care and were encouraged to evaluate this in practice. Examples of
improvement included:





One Trust surveyed training participants and questionnaires from 12 respondents
showed 83% found the training helpful and 83% thought their practice had changed
as a result of attending training.
In another evaluation of training for 78 non-clinical staff, participants reporting they
knew ‘enough’ or ‘a lot’ about dementia rose from 8% pre-training to 99% posttraining.
In one Trust, following training of 190 staff in mental health and dementia
awareness, a number of actions were identified such as involving relatives in
patients’ care and using the Abbey Pain assessment tool
63% of staff who had received dementia training across two wards said they were
‘very confident’ or ‘confident’ in their skills for caring for patients with dementia
In one Trust, among 607 staff trained in dementia, measures of confidence in
dementia showed statistically significant improvements from 11% pre training to
57% post training and knowledge in dementia scores indicated a significant increase
from a median score of 12 – 14.
Outcomes for patients and carers
It is difficult to measure outcomes for patients and family carers as part of routine
practice. However, the majority of participating Trusts managed to do this using a range
of measures. Examples of improvements included:


One Trust surveyed patients and reported that 100% of respondents felt involved in
their care.
In one Trust the use of personal profiles for relevant patients increased from 26% to
66% over a 12 month period.
Page 7




In another hospital, dementia care mapping was used and showed significantly
higher ‘well-being’ scores for those supported in a dementia activity room,
compared with usual care.
In one hospital area there was a reduction in complaints relating to dementia care
from 10 to 1.
One Trust surveyed families and 100% of carers felt their relatives were being
treated with dignity and respect.
In one Trust 63% of carers were offered a carers information pack as a result of the
programme.
Conclusions and next steps
All nine Trusts felt that organisations should invest in development programmes such as
this to support improvements in the experience of care for people with dementia and
their families. Four key areas were recommended for future consideration:
1. Improving opportunities for networking between Trusts to spread good practice
2. Improving access to on-line resources to support learning
3. Ensuring content of development programmes is tailored to support individual
learning needs
4. Developing regional development programmes
Page 8
1. Introduction
1.1 Context
Within acute hospitals, older people occupy some 60% of beds and of these, 40% may
have dementia [1]. Patients with dementia in acute hospitals experience poorer
outcomes for all types of admission, stay longer in hospital and are more likely to be
discharged to a care homes rather than returning home [2, 3, 4]. In 2011, the first
National Audit of Dementia [5] identified a mismatch between hospital policy and frontline practice and that the hospital workforce receives little dementia specific training.
Whilst old age liaison psychiatry services can greatly assist in improving quality
outcomes for people with dementia [6] there is also a need for a consistent response
from acute hospital staff to develop a culture of care where these patients needs are
met as part of routine practice. In 2013, the second report of the National Audit of
Dementia [7] found that, while some improvements have been made in hospital care for
patients with dementia, there was still a lack of training in two out of five hospitals, and
called for further education programmes and for specialist dementia nurses to be
employed in all hospitals.
Since 2011 the RCN has been active in facilitating a national project supported by the
Department of Health, to influence and guide the provision of dementia care in acute
care settings. A survey of health care professionals [8] sought to identify examples of
best practice that help to promote dignity, improve understanding and enhance the
delivery of care. Findings from over 700 staff respondents indicated that a number of
approaches are required to support improvements in care. However, most important
was felt to be the involvement of family carers, and the training and development of
staff.
Staff respondents emphasised the importance of having support from the Trust board,
backing from senior nurses, mental health liaison and dedicated dementia care posts to
provide leadership. Barriers to delivering good quality care included pressure of existing
workload and insufficient staffing, movement of patients between wards, inappropriate
environment in terms of lighting and space, and a lack of funds to support and drive
improvements.
A subsequent survey of people with dementia and carers [9] was also carried out to
identify the most important factors from a patient perspective of improving hospital
care. A total of 1,484 responses were received with more than 90 per cent of
respondents considered the following as very important:
Page 9

education and training of staff

involvement of family carers

clear care plan, identifying needs

availability of a specialist skilled assessment.
1.2 The RCN development programme
It was within this context that the RCN Development Programme was conceived, funded
and supported by the RCN Foundation. It builds on the work carried out during 2011/12
by the RCN on improving dementia care in general hospital settings [10], funded by the
DH. http://www.rcn.org.uk/development/practice/dementia/rcn_dementia_project
Under the leadership of Rachel Thompson the project aimed to improve the experience
of care for people with dementia and their carers in hospital by developing nursing
leadership in dementia care within NHS Trusts providing Acute Hospital Care. During
December 2012 hospital sites from across the England and Wales were invited to apply
for a place on the development programme. Applicants were asked to submit an initial
action plan based on areas for improvement and were required to demonstrate:

Support from their Trust Board including the Director of Nursing

Willingness to commit to a series of development days

Evidence of commitment to the principles of engagement/collaboration with
patients and carers.
Following a selection process in February 2013, places were offered to nine NHS Trusts
who nominated three key clinical leads with responsibility for dementia care in their
organisation.
1.2.1 Overview of programme
The programme was made up of the following components:

An opening event for candidates on 25th March 2013 to which each organisation
was invited to bring 2-3 additional clinicians/leaders/stakeholders

2 development days (11 June and 3 December 2013) at RCN HQ to be attended
by the 3 clinical leads from each organisation
Page 10

A site visit in September/October 2013 whereby Trust Board members,
patient/carer groups, local participants and staff teams were invited to meet the
RCN facilitation team and carer representative

A final conference event (20 May 2014) to showcase the outcomes of the service
improvements
1.2.2 Key programme aims and objectives:
To improve the experience of care for people with dementia and their families within
hospital settings by:

supporting participants to develop effective partnerships with patients and
carers and other key professions and organisations involved in the delivery of
care

facilitating the learning and development of staff in delivering positive
approaches to dementia care in the hospital setting

supporting participants to develop practice and lead on quality improvements in
the care delivered for people with dementia and their families

facilitating the evaluation of outcomes of quality improvement initiatives which
focus on patient/ carer experience
1.2.3 Intended learning outcomes:
1. Identify, critically assess and develop a range of best practice and interventions,
that support good dementia care in hospital settings
2. Develop a strategic approach to partnership working that demonstrates the
understanding of the role of carers, families and friends and principles of
engagement
3. Identify and utilise knowledge and skills for effective influencing to lead and
manage change to support and develop practice
4. Work in partnership with key stakeholders to develop, implement and evaluate
local action plans to support quality improvement initiatives in dementia care
5. Implement and embed the principles of the new ‘Triangle of Care for dementia’
into practice to support partnership working
Page 11
6. Evaluate and consider appropriate patient outcome measures to evaluate the
quality of care experienced by people with dementia and their carers/families
with particular regard to equality of access to general care services
7. Collate and analyse patient outcome measures to evaluate quality of care as
experienced by people with dementia and their carers/families
8. Work to develop effective networks both internally and externally for the
dissemination and sharing of good practice
1.3 Participating NHS Trusts
The nine NHS Trusts and their hospital sites selected to take part in the programme
were:

Basildon & Thurrock University Hospitals NHS Trust (Basildon Hospital)

Cambridge University Hospital NHS Foundation Trust (Addenbrookes Hospital)

Nottingham University Hospital Trust (City Campus)

Royal Devon & Exeter Foundation Trust (Wonford Hospital)

Kings Lynn NHS Foundation Trust (The Queen Elizabeth Hospital)

The Shrewsbury & Telford Hospitals NHS Trust (Princess Royal Hospital and
Shrewsbury & Telford Hospital)

Salford Royal NHS Foundation Trust

Walsall Healthcare NHS Trust (Manor Hospital)

Betsi Cadwaladr University Health Board (Ysbyty Glan Clwyd)
Page 12
2. The Evaluation
2.1 The Evaluation Team
This external evaluation of the of the RCN Foundation programme ‘Transforming
dementia care in hospital’ was undertaken by the Association for Dementia Studies
(ADS) at the University of Worcester. ADS is a specialist team that brings a broad range
of relevant experience and knowledge to this evaluation including expertise in dementia
care, clinical practice, academic leadership, patient and user engagement, qualitative
and quantitative research methods, and dissemination to diverse audiences. The team
presented a detailed breakdown of their proposed evaluation methods and were
engaged by the RCN in October 2013 and completed in April 2014.
Overall project management at ADS was provided by Professor Dawn Brooker, Director
of the Association for Dementia Studies. An ADS/RCN Evaluation project team was
established in October 2013 consisting of

Dawn Brooker, Professor of Dementia Studies, Overall project management

Mike Watts, Senior Administrator, Project administration

Simon Evans, Principal Research Fellow, Evaluation Lead

Christine Carter, Senior Lecturer, Site evaluator

Mary Bruce, Senior Lecturer, Site evaluator

Sarah Milosevic, Research Assistant, on-line survey, site evaluation and data
analysis and management
The evaluation also benefited from the Steering Group that was established by the RCN
and chaired by Rachel Thompson. This group met using telephone conferencing, on a
regular basis (usually monthly) throughout the project. ADS provided progress reports
against key milestones to the steering group throughout the life of the project. The
project was given approval by an ethics committee at the University of Worcester.
2.2 The Evaluation Design
The final design was made in negotiation with the RCN Steering group. The initial
general approach was to build an electronic survey around the key indicators. This was
completed as an on-line survey by course participants. In addition, independent site
visits were undertaken by senior lecturers with many years’ experience of working in
dementia care in hospitals. This had the benefit of triangulating the self-assessment
data with other data forms to provide a richer data set. Evaluation was based on
Page 13
collation of staff, patient and carer outcomes from participating hospitals and changes
in practice. This included analysis of evidence submitted by each participating hospital,
perceived changes, and delivery of action plans.
The following timeline details key events in the development programme and
programme evaluation:
25th Mar – development programme
opening event for candidates
Mar 2013
11th Jun – programme development
day
Jun 2013
Site visits to Trusts by RCN
facilitation team and Carer
Representative
Sep 2013
3rd Dec – programme development
day
Oct 2013
Dec 2013
18th Dec – launch of online survey
15th Jan – deadline for online survey
Jan 2014
20th May – final conference event to
showcase outcomes of service
improvements
31st Jan – first evaluation site visit
Feb 2014
7th, 13th and 28th Feb - evaluation
site visits
Mar 2014
7th, 14th, 27th and 28th Mar evaluation site visits
Apr 2014
17th Apr – final evaluation site visit
Publication of evaluation report
May 2014
20th May – presentation of
evaluation findings at conference
Page 14
2.3 Online questionnaire
An online questionnaire was administered to course participants, with one
questionnaire completed per Trust. The questionnaire was designed to assess the
impact of the development programme and gain feedback regarding the programme
from participants. The following areas were explored in the questionnaire:

The Trust’s motivation for applying for the development programme

The extent to which participants felt the objectives and learning outcomes of the
programme had been achieved

The project team’s experiences of different elements of the programme,
including the development days, site visits by the RCN and overall programme
facilitation

The extent to which participants felt the objectives set out in their own action
plan had been achieved in their Trust, including factors which helped or hindered
the achievement of these objectives

The use of tools such as the Sit and See and the Triangle of Care assessment tool

Additional outcomes or benefits of the development programme

Suggestions as to how the development programme could be improved
2.3.1 Collation of outcomes for staff, patients and carers
Course participants were asked to provide evidence of measured outcomes for staff,
patients and carers. For example, if delivering training was in the action plan,
participants could aim to demonstrate changes in knowledge and attitudes amongst
staff.
2.3.2 SPACE principles
The SPACE principles are a set of five principles for the care of people with dementia in
hospital settings, developed by the RCN and a range of stakeholders in collaboration
with people with dementia and carers [10]. A checklist for each principle provides a set
of sub-statements which can be used to assess progress and identify areas for further
development:
1. Skilled staff who are informed and have enough time to care
Page 15
-
2.
3.
4.
5.
Good quality training and education in dementia that is easy to access,
practical and focuses on attitudes/approach and communication
- Training is available to all staff based on an analysis of training needs
- Training includes the perspectives of people with dementia and carers
- Identified clinical leads for dementia are available e.g. dementia
specialists/nurses, mental health liaison, dementia champions
- Careful consideration of staffing levels to ensure appropriate skill mix, ratio
and numbers
Partnership working with carers
- Process in place for the recognition and assessment of carers needs
- Involvement of families/friends in assessment, care planning and decision
making, including discharge planning
- Flexible visiting for carers
- Flexible approaches to care which include and involve carers i.e. direct
involvement where requested
- Support is available for carers e.g. support groups, carer leads etc.
Assessment and early identification of dementia
- Assessment and early identification of dementia
- Skilled knowledgeable practitioners available to support assessment e.g.
dementia specialist, mental health liaison
- Clear delirium protocols are in place
- Clear dementia pathway is in place across services
- Clinical reviews of antipsychotic medication
Care plans which are person-centred and individualised
- Routine gathering of personal life story information using an agreed template
- Person with dementia and/or carers involved in care planning
- Use of mental capacity assessments and advance care planning to inform
care
- Use of dementia appropriate tools e.g. assessment of nutrition, pain,
function, risk etc.
- Support and activity is available for rehabilitation and maintenance of
function e.g. physiotherapy, occupational therapy
Environments that are dementia friendly
- Policies are in place to ensure minimal moves between wards
- Appropriate lighting and floor covering is in place
- Aids are available for orientation and visual stimulation e.g. clocks, signage,
pictures etc.
Page 16
-
Adequate space and resources are available to support activity and
stimulation
Availability of activity coordinators and/or trained volunteers to support
activity and pastoral care
The programme facilitation team asked course participants to complete a scale based
on the SPACE principles at the beginning and middle of the programme, in June and
November 2013. This scale was also included in the online questionnaire (January 2014)
in order to obtain a third measure for comparison. For each principle, participants rated
the extent to which the five sub-statements were achieved in their Trust, using the
following five-point scale:





Level 1: I do not see these things happening
Level 2: There is an awareness of this but little action
Level 3: This happens some of the time but not always
Level 4: This happens most of the time but not always
Level 5: I see these things happening all the time
2.4 Site visits
Site visits were carried out by a Senior Lecturer and Research Assistant from the
University of Worcester, and an independent Carer Representative. The Carer
Representative visiting each Trust had previously taken part in the site visit by the RCN
to the same Trust as part of the programme.
Site visits comprised an initial discussion with programme participants around a clinical
based scenario of a patient with dementia and their carer, which enabled participants to
share examples of work they had achieved from their action plan. Further bespoke
questions were developed by the evaluation team based on the results of the
questionnaire each Trust had completed. Following the discussion the evaluation team
visited the ward or unit where changes had been implemented. The team were also able
to meet and have discussions with carer representatives, volunteers and key staff
members in some of the Trusts visited. The site visit concluded with a discussion
focusing on the impact of the development programme on the Trust.
A typical timetable for site visits was as follows:
Page 17
11 – 12
Discussion with programme team based around clinical scenario, focusing
on changes made as part of the Trust action plan
12 – 12.30
Lunch
12.30 – 1.30 Discussion with Carer Representatives
1.30 – 2.30
Visit to clinical area
2.30 – 3.30
Discussion with programme team focusing on the impact of the
development programme
2.5 Programme participants
There were 31 programme participants overall across the nine Trusts (see Table 1).
Table 1: Role details of programme participants
Project
team
Team 1
Role title
Area of specialism
Area of responsibility
AD Quality & Nursing
Matron
Senior Sister
Dementia Intensive
Support Team
Consultant Nurse
Matron
Quality Governance
Older People
Older People
Dementia
Whole hospital
Older People’s wards
Ward
Whole hospital
Dementia Care
Care of the Elderly
Ward Sister
Ward Sister
Senior Clinical Nurse
Senior Sister
Senior Sister
Senior Sister
Mental Health Liaison
Practice Development
Nurse
Lead for Dementia
Practice Development
Matron
Pain Nurse Specialist
Care of the Elderly
Stroke
Medicine for the Elderly
Medicine for the Elderly
Medicine for the Elderly
Medicine for the Elderly
Mental Health
Development
Whole health board
Care of the Elderly Wards
in one DGH
One ward
One ward
Department
Ward
Ward
Ward
Whole hospital
Stroke Unit and Care of the
Elderly
Whole hospital
Whole hospital
Team 2
Team 3
Team 4
Team 5
CQUIN
Older People and
Dementia
Pain
Whole hospital
Page 18
Ward Manager
Senior Nurse
Ward Matron
Team 6
Team 7
Team 8
Team 9
Consultant Nurse for
Older People
Lead Nurse for
Dementia/Delirium
Dementia Specialist
Nurse
Matron
Professor in Dignity in
Care for Older People
Associate Director for
Patient Quality and
Experience
Dementia Project Lead
Nurse
Associate Director of
Nursing
Lead Nurse Older People
and Vulnerable Adults
Practice Development /
Dementia Lead
Interim Associate Director
of Facilities
Health Care of Older
People
Trauma & Orthopaedics
Healthcare for Older
People
Healthcare for Older
People
Dementia Care / Older
People
Mental Health
Ward
Trauma & Orthopaedic
wards
Two wards
Whole hospital
Whole hospital
Whole hospital
Older People
Dignity / Dementia
Complex Ageing
Whole hospital
Quality and Patient
Experience
Corporate
Dementia
Corporate
Nursing
Whole hospital
Nursing
Whole hospital
Practice Development
Whole hospital
Facilities
Whole hospital
The majority of programme participants were Senior Nurses, including Consultant
Nurses, Matrons and Practice Development Nurses; project teams at five Trusts
consisted solely of Senior Nurses. The involvement of senior nursing staff in the project
team appeared to be essential in ensuring that changes were relevant, credible and
visible. However the wider inclusion of senior management from outside the nursing
directorate enabled changes to have broader influence and was helpful in terms of
raising the profile of dementia care at a higher level. The achievement of the project
appeared to be most successful where project teams had effective support from the
Trust/senior management which was then filtered right through to dementia champions
working directly within clinical settings.
Page 19
The most common areas of specialism for course participants were ‘Older People’ (12
participants) and ‘Dementia’ (6 participants). On average participants reported that 10.6
hours per week were set aside for the development of dementia care in their role (range
0 – 37.5). However, 16 hours per week were on average spent (range 1.5 - 50) on the
development of dementia care. On average, whole project teams had 38.8 hours per
week set aside for the development of dementia care (range 0 – 112.5) and actually
spent an average of 48.2 hours per week altogether on this area (range 4 – 120).
2.6 Motivations for applying for the programme
All Trusts said that the following motivated them to apply for the dementia
development programme:

To increase knowledge and understanding in how to support quality
improvements in dementia care

To raise awareness and understanding of developments in dementia care within
the organisation

To develop confidence and competence of staff in leading and driving forward
improvements in dementia care

To develop practice in evaluating outcomes for people with dementia and their
carers
Seven Trusts (78%) said that they were motivated to apply for the programme to
network/share ideas with others, and six (67%) to have the opportunity to work with
the RCN. One Trust explained that they were motivated by the prospect of working
with the RCN so that they could gain endorsement for the work they were already
doing and support to further enhance this.
Page 20
3. How course participants rated the
programme
3.1 Development Days
Overall participants rated the development days as being ‘very good’, with all
development days rated as at least ‘fairly good’ by all participants (see Figure 1). The
majority (56%) of programme participants reported that the development days fully
contributed to the progression of their project, with only one Trust (11%) reporting that
the development days did not contribute at all to project progression. In this case it was
because it was felt that all project work was already being carried out prior to the
programme.
Figure 1: Overall ratings of the programme development days
90%
80%
70%
60%
50%
Excellent
Very good
40%
Fairly good
30%
20%
10%
0%
Day 1 (10 respondents)
Day 2 (14 respondents)
Day 3 (15 respondents)
3.1.1 Networking
Networking and/or sharing ideas with other Trusts was consistently rated as being a key
learning outcome on each development day, cited by 70% of participants on Day 1, 46%
on Day 2 and 40% on Day 3.
Page 21
3.1.2 Sit and See Tool
Almost half (47%) of Day 3 participants rated the session on the Sit and See tool [11] as
being a key learning outcome of the day, with 80% rating this session as ‘very’ or ‘fairly’
useful. However, during discussions it was raised that the Sit and See session was not
helpful for some Trusts who were already aware of the tool. In addition, one Trust
reported that the Sit and See session felt like a marketing opportunity for just one
particular approach.
3.1.3 World Café Event
The world café event on the third development day was particularly popular with
programme participants, who commented that it was an excellent opportunity for them
to network and share the work they had been doing with other Trusts.
3.2 Site visits
The majority (56%) of participants reported that the site visits from the RCN fully
contributed to the progression of their project, with only one Trust reporting that they
did not contribute at all to project progression. Participants reported that the visits
enabled them to evaluate and validate what they had achieved so far, and that they
gained valuable feedback and advice which helped them to structure and focus future
development. The site visits were generally thought to be a positive experience:
‘… the opportunity to sit back and reflect on all the work that has been done
and get that feedback was really very good and boosted the morale’
One Trust described how involving the Trust board in the visit enabled them to gain
valuable support for their work:
‘… it was a big statement to our board… the chief of staff, deputy director
of nursing, etc. were there, hearing very good things, and that has
cemented their support of what we’re doing’
However one Trust said that they would have found it more useful if they themselves
had been able to visit another hospital site, and reported that the visit felt like the RCN
was ‘checking up’ on their work.
It was noted that few of the suggestions made by the RCN on the site visits had been
taken up or planned for implementation by the Trusts by the time of the evaluation
visits. Some of these suggestions may be acted upon over the longer term; however it
may be useful to consider how these recommendations can be highlighted to Trusts
more effectively.
Page 22
3.3 Programme facilitation
All Trusts reported that the facilitation of the development programme was ‘fairly’ or
‘fully’ flexible, supportive and enabling (see Figure 2).
Figure 2: To what extent do you feel that the facilitation of the RCN development programme,
including the site visit, was:
Flexible
Fully
Supportive
Fairly
Not at all
Enabling
0
1
2
3
4
5
6
7
8
9
Number of Trusts
The support that programme participants received appears to have been a particular
strength of the programme, with eight out of nine Trusts identifying that programme
facilitation was fully supportive. This was backed up by the qualitative responses on the
questionnaire, which particularly mentioned this aspect; for example:
‘Rachel has been a great support and inspiration’.
It was identified that at times facilitation was perceived as too rigid in relation to
networking opportunities although it was acknowledged that time constraints were an
issue. Some participants felt that more participant autonomy in some sessions would
have allowed them to network more effectively with other Trusts.
Page 23
4. Direct Benefits identified from
Programme participation
4.1 General Impact of participation in the programme
It was generally reported that Trusts would have made the changes set out in their
action plan if they had not been on the programme, but that they would have happened
at a slower rate and may have been more problematic to implement. It was felt that the
programme provided the focus and structure for Trusts to make changes, and supported
actions through equipping participants with the strategies and confidence to change
practice. In addition, it encouraged partnership working within organisations, provided
networking opportunities, and helped to raise the profile of dementia care in Trusts.
However, participants recognised other factors which had facilitated change aside from
the programme, including support from senior staff within the Trust, and the
implementation of dementia-related CQUIN targets. Externally, links with local groups
and other hospitals, and the high national profile of dementia care (including the
Dementia Action Alliance and National Dementia Strategy) were identified as helpful.
In addition to the facilitation of change in Trusts, programme participants reported a
number of ways in which the programme had a beneficial impact on themselves as
individuals. For example, it boosted morale and confidence, gave participants a sense of
achievement, and equipped them with the skills and strategies to implement further
change in the future.
4.2 Tools for Change
4.2.1 Observational tools
Five out of nine Trusts reported that they had used an observation tool to assess quality
of care. In discussions on evaluation site visits, three Trusts mentioned using the Sit and
See tool in particular, with one Trust using an in-house tool and another utilising
Dementia Care Mapping. A further Trust reported that they planned to use the Sit and
See tool to more formally evaluate the impact of the dementia training they had
delivered. The Sit and See was viewed as being a useful tool which was ‘very powerful’ in
enabling staff to question their practice, and in picking up very small details that often
go unnoticed but can make a big difference to patient wellbeing. Trusts reported that
they found the tool to be a way of highlighting positive work rather than just focusing on
areas of bad practice. One Trust explained that using the Sit and See tool had enabled
Page 24
the project team to give praise to staff who were delivering excellent care, which they
felt was valuable as often nurses do not receive positive feedback.
4.2.2 Triangle of Care
Four out of nine Trusts said that they had used the Triangle of Care assessment tool
[12], and all who used it rated it as fairly (3 Trusts) or very (1 Trust) useful. One Trust
explained that since the introduction of the Triangle of Care there had been more of a
focus on ensuring staff identify and pay attention to the needs of carers. Another
particularly valued being able to access the Triangle of Care document prior to its official
launch, as this allowed the project team to quickly start addressing issues around carer
engagement.
4.2.3 SPACE principles
One Trust mentioned that the SPACE spider diagrams were very useful in assessing
progress and identifying areas to focus on. The project team planned to continue to
complete the spider diagrams every six months to keep focused on the changes they are
aiming to implement.
4.3 Direct Benefits of Participating
4.3.1 Provided focus and structure for effective change
The main benefit of the development programme reported by Trusts was that it
provided them with a structure for change, and gave them focus and determination to
achieve their objectives. Although work was being carried out around dementia care
prior to the programme, it was reported that the programme was a ‘catalyst’, giving
changes a new impetus and helping actions to be achieved more easily and quickly.
Participants identified that the programme had an ‘invigorating effect’, inspiring them
to consider new changes and helping them to keep motivated throughout the
achievement of their project:
‘It’s kept up that enthusiasm for the year and a bit as well, which might
have dwindled without a programme behind it’
Part of the success of the programme can be attributed to the fact that it encouraged
Trusts to focus on one key project, which was effective as some participants reported
that they had previously been carrying out small pieces of work in lots of different areas
with no coherent structure:
Page 25
‘You could bet that if we were doing this as… individual projects on their
own, they would have folded I think by now, because so much other, other
work would have come in to take over that. And it’s because we’ve been
part of this that it’s continued’
It may therefore be important to consider how to ensure the focus, commitment and
enthusiasm for change is maintained following the end of the programme and the
discrete project identified by each Trust.
The process of setting out clear actions and milestones, and the knowledge that they
would have to report back as part of the programme, gave participants the ‘energy’ and
‘momentum’ to push forward with changes. In particular, participants wanted to make
sure that they had progress to share with other Trusts. The programme gave Trusts ‘a
real sense of focus’, allowing them to think about dementia care in their organisation,
and identify and focus on the areas in most need of improvement.
‘… it’s a framework that [has helped] me define what we needed to do, and
given me direction as to where we needed to take the project…’
‘It has been fantastic, because it made us sit down and think about what we
wanted to do’
The structure provided by the programme was viewed as particularly valuable as this
gave participants the confidence to implement new work through equipping them with
strategies for change:
‘And the beauty of the course is… we’ve got ideas, but whereas before we’d
be sitting thinking, “Oh that ain’t gonna work”… But now we’re thinking, “It
is gonna work, these are the barriers, these are the people we need to get
involved in it, this is when we’re gonna get it implemented by”, and I think…
that structure has come… from this programme’
4.3.2 Networking
Programme participants felt that the opportunity to network with staff from other
hospitals and find out about the work they were doing was very helpful. In some cases
this motivated and reassured Trusts who had experienced a lot of challenges, as they
found that other Trusts had experienced the same problems. Participants were able to
share how they had overcome issues, which was beneficial to others on the programme.
Networking also enabled participants to pick up new ideas which they felt they could
implement in their own Trust:
Page 26
‘You hear things from other groups and you think well we could implement
that, or that if we tweaked this with ours we could achieve that’
This helped participants to validate changes in their own Trust, as they were able to
show senior managers that new initiatives had already been successfully implemented
in other areas. Participants felt that sharing the changes they had implemented at the
development days was highly motivating, as it enabled them to see that their work was
innovative in some areas and also encouraged them to make further changes.
Project teams reported that following the programme they feel able to contact other
Trusts or staff at the RCN if they need help with a particular issue. The new relationship
Trusts built with the RCN was valued, and some programme participants recognised that
they are now more likely to access the expertise and resources around dementia care
provided by the RCN, some of which they were not aware of prior to the programme. It
was identified that obtaining information from other Trusts had previously been
difficult, but that following the programme participants feel more able to contact one
another and share ideas.
4.3.3 Facilitated partnership working within Trusts
It was reported that participation in the programme brought Trust staff closer together
as a team by allowing them time to work together and discuss plans for improvement.
Having this mutual support and common goal was effective in facilitating change.
‘I think personally for me it’s that collaboration, working together as a close
knit team. It’s been far easier to… get a sense of togetherness and
cohesiveness… Before people had their own workstreams… I think
everyone’s pulled together in the same way now’
As other staff within the Trust became interested in the work being carried out as part
of the programme, programme participants were enabled to build networks within the
Trust and engage more people in the changes.
‘I think what the programme’s given is you get a buy-in from other groups
don’t you… the programme gives you a platform to buy into it. So porters
and security and catering staff are interested in what’s going on’
Project teams explained that as colleagues started to see the benefits of the changes
being rolled out for patients with dementia, they were keen to become involved. For
example, programme teams reported developing links with specialist pain nurses, the
nutrition team, the audiology department, porters, housekeepers, health care support
workers, security staff and mental health teams. These additional staff members also
Page 27
benefitted from the project team’s involvement in the programme: for example,
programme participants reported that they were able to identify staff with an interest in
dementia care and to cascade their learning throughout the Trust to colleagues.
‘[One of the support workers is] so enthusiastic about dementia care…
which I wouldn’t have picked up if I wasn’t in this programme building up a
network of champions. She would have been lost’
‘It’s not necessarily [just] us who have learnt loads, but all the people
around us’
One Trust identified that the programme motivated them to make greater contact with
carers groups in the local area, which has made a big difference to the way the hospital
is perceived by carers. Carers now know that the Trust are prepared to listen to and
work together with them.
4.3.4 Helped to validate changes
Programme participants reported that the programme gave status and ‘kudos’ to the
changes they were implementing, as the fact that they were working with the RCN was
seen as prestigious by colleagues and senior staff. The programme enabled project
teams to gain support for changes, which helped them to overcome any barriers
encountered and empowered them to challenge practice. Some participants reported
that senior staff accepted changes more readily because the project teams had
committed to achieving their action plan with the RCN, which gave the work credibility.
In addition, one Trust reported that the programme had taught them to develop an
evidence base for the changes they wanted to implement and had provided them with
the tools to prove that changes they made had an impact on patients, carers and staff.
This enabled them to validate their work and to use their knowledge to achieve further
changes.
4.3.5 Boosted confidence and morale
Successfully gaining a place on the programme boosted morale for some Trusts, who
felt fortunate to be chosen to take part. Some participants explained that it was good to
be involved in something positive at a time when there was a lot of negative publicity
about the health service as a whole:
‘Just being picked by the RCN to be part of it was actually a very positive
message for us’
Page 28
The realisation that other Trusts were experiencing the same problems gave programme
participants confidence to tackle these issues and to implement changes. Project teams
reported that they felt empowered to present their case for change to senior staff, and
to challenge existing practice:
‘Our confidence has increased, nothing fazes us anymore!’
‘The programme has supported us in having the strength… and the
commitment to know that what you’re doing is for the greater good, and
you just keep, keep going’
4.3.6 Raised the profile of dementia care
The programme gave participants the opportunity to raise the profile of dementia care
within their Trusts. For example one project team explained that they were asked to
provide updates on the programme to the Trust board, which allowed them to keep
dementia care in the spotlight. Participants reported that as changes were implemented
and senior Trust staff started to see the benefits, they began to publicise areas of good
practice as good news stories. As previously mentioned, engaging staff throughout the
Trust in the changes being made helped to raise dementia awareness across
organisations. One project team described how this had resulted in a culture change in
their Trust:
‘It’s when you get the daft phone calls… I had a phone call… “I’ve got to
order some new drip stands. Can you tell me what’s dementia friendly?”
And I thought, dementia friendly drip stands? (laughs)… So you know,
rather than laughing and thinking what on earth are you on about, I
actually phoned Stirling University… and they said, “Get something bright
footed… that cannot be mistaken for anything else… So I went back to
them… And now everybody says, “We’ve got the dementia friendly drip
stands!”’
4.3.7 Gave a sense of achievement
Taking part in the programme appeared to be a very positive process for Trusts. It
motivated programme participants through enabling them to look at what they had
already achieved, and facilitated the implementation of further changes that made a
clear difference to patients and staff. Some programme participants identified that they
felt greater job satisfaction and pride following the changes that had been made as part
of the programme.
Page 29
4.3.8 Helped to develop carer engagement
Trusts valued learning about carer engagement on the programme, as they recognised
that this was an area where a big culture change was needed. One project team
reported that they would not have engaged with carers to the extent they had if they
had not been on the programme. They explained that local carers are now assured that
the Trust are actively trying to engage with carers and have a positive plan to achieve
this. It was recognised that increased partnership working with carers resulted in better
care for patients with dementia, and fewer complaints from patients and relatives.
4.3.9 Recommendations to others
The programme appears to have been beneficial to Trusts who started at a range of
levels, as it allowed participants to look at what they had already achieved and identify
how they could move forward with further changes.
Programme participants valued the time the programme gave them to come together
with colleagues to reflect on the work they had already achieved and discuss future
plans, allowing them to ‘take stock and re focus’.
All but one Trust said that they would recommend the development programme to
colleagues, mainly as it provided focus for programme participants, and a structure for
organisational improvement:
‘It makes you focus on your own organisation and where improvements can
be made and makes you aware of good practice’
‘Provides a framework for quality improvement in relation to dementia
care’
‘It has been a valuable exercise for the team members who have had the
opportunity to think through a specific project and bring it to reality’
One Trust said they would not recommend the programme, as it did not provide enough
time for networking. All Trusts agreed that organisations should invest in development
programmes like this to support improvements in the experience of care for people with
dementia and their families.
Page 30
5. Lessons for future Development
Programmes
Four key areas for improvement were consistently identified through discussions with
programme participants; these will be discussed in turn in this section.
5.1 Networking with other Trusts
Networking was identified as a key benefit of the programme by participants; however
there were a number of suggestions as to how this aspect of the programme could be
improved. For example, few Trusts reported making lasting contacts with others as a
result of attending the programme, and identified that this was mainly due to a lack of
time available to network during the programme days. It was felt that the structure of
the programme limited networking opportunities at times, particularly on the second
development day when Trusts were asked to present their action plans. Some
participants did not feel sufficient time was allocated for each presentation, which
meant they had little idea of what other Trusts were doing and did not have the
opportunity to present their own ideas. It was suggested that dedicating a whole day to
the presentation of action plans and related discussions would have been helpful,
particularly given that all Trusts planned to make changes in similar areas. It was also
felt that holding a question and answer session following each presentation would be
less confusing than participants writing down questions for each Trust. The ‘world café’
on the third development day was identified by Trusts as an excellent opportunity to
network and share ideas, and it was suggested that more opportunities like this towards
the beginning of the programme would have been beneficial.
Some participants felt that the facilitation of the programme at times put limits on
networking. For example, at the world café event participants were instructed to visit
each stand for a set amount of time. It was suggested that it may have been useful for
Trusts to have the autonomy to visit a limited number of stands they were interested in.
At times some participants also felt that the strict timing of the presentation of action
plans where some presenters were stopped mid-sentence was unhelpful. Having more
freedom in the timetable of the development days for more natural networking could
have been more effective than being directed to network.
A number of programme participants said that it would have been very useful if they
had been able to visit other Trusts as part of the programme to see examples of their
work. This could also take the form of visiting centres of excellence in dementia care to
Page 31
look at best practice. It was identified that this would need to be on an official
programme day so that programme participants could justify time away from work. It
was also suggested that linking up Trusts in pairs through a buddy system may have
been beneficial.
5.2 Wiki site
Accessing the Wiki site was identified as being problematic for a number of Trusts,
which meant that they were unable to easily share their work with other programme
participants or gain access to the resources on the site. As this would have been a
valuable resource it would be useful to consider an alternative, more easily accessible
platform for future programmes.
5.3 Tailoring the content of development days
Some of the sessions on the development days were not useful to all Trusts. For
example, the Sit and See session was particularly identified as not being beneficial for
some Trusts who were already familiar with the tool. Programme participants suggested
that it may have been helpful for the RCN to consult Trusts prior to the beginning of the
programme to find out what they would most like to learn on the programme and
whether there were any speakers they would particularly like to hear. It was also
identified that the programme content could have been more responsive to the
challenges participants reported on the first development day, as the issues raised were
similar across all Trusts but were not specifically addressed later in the programme.
5.4 Location of development days
Some participants reported that having to travel so far to attend the development days
was tiring; however it was acknowledged that it would be difficult to identify a
convenient location for everyone to attend. One suggestion was that the programme
could be run regionally in the future: this would also facilitate the building of links
between Trusts, as the fact that the Trusts in the initial programme were relatively far
apart geographically made networking difficult.
5.5 Other suggestions
It was identified that a mentor for each Trust to provide a regular point of contact and
give bespoke support would have been beneficial for project teams. Having a mentor to
visit at regular intervals would be helpful as this would provide independent input, and
would mean any issues could be picked up and addressed early on. It was suggested
that the mentor could be a member of RCN staff, or a previous participant of the
programme.
Page 32
A small number of Trusts felt that it would have been helpful to have clearer
information from the RCN about the format of the programme and expectations for
programme participants.
Page 33
6. Achievement of programme objectives
and learning outcomes
6.1 Programme Objectives
All nine Trusts said that the objectives of the development programme were fully or
partially achieved (see Figure 3):
Figure 3: To what extent do you think each of the following objectives has been achieved as a result of
the RCN development programme?
Supporting you to develop effective partnerships with
patients and carers and other key professions and
organisations involved in the delivery of care
Facilitating the learning and development of staff in
delivering positive approaches to dementia care in
the hospital setting
Supporting you to develop practice and lead on
quality improvements in the care delivered for people
with dementia and their families
Facilitating the evaluation of outcomes of quality
improvement initiatives which focus on patient/carer
experience
0
1
2
3
4
5
6
7
8
Number of Trusts
Fully achieved
Partially achieved
Not at all achieved
Participants commented that although in most cases the work they were doing around
dementia care was already in progress prior to the RCN programme, the programme
was a ‘catalyst’ or a ‘driving force’ in moving developments forward more quickly. It was
also beneficial in equipping Trusts with a research based foundation to build upon, and
with the tools to evaluate the work they were doing more effectively.
Page 34
6.2 Learning Outcomes
The majority of Trusts felt that they had greatly or partially improved in respect of all
the learning outcomes of the programme (see Table 2). Most improved was Trust’s
ability to develop effective networks internally and externally for the dissemination and
sharing of good practice, with five Trusts reporting that they had greatly improved in
this aspect.
Least improved were Trusts’ abilities to evaluate, consider, collate and analyse
appropriate patient outcome measures to evaluate the quality of care experienced by
people with dementia and their carers/ families, with only one Trust reporting that they
had fully achieved these objectives. Therefore, it may be useful for any future
programme to include more content in this area.
Table 2: As a team, to what extent do you feel you have improved in your ability to do the following as a
result of the RCN development programme?
Learning Outcome
Identify, critically assess and develop a range of best
practice and interventions which support good dementia
care in hospital settings
Develop a strategic approach to partnership working that
demonstrates the understanding of the role of carers,
families and friends and principles of engagement
Identify and utilise knowledge and skills for effective
influencing to lead and manage change to support and
develop practice
Work in partnership with key stakeholders to develop,
implement and evaluate local action plans to support quality
improvement initiatives in dementia care
Implement and embed the principles of the new ‘Triangle of
Care for dementia’ into practice to support partnership
working
Evaluate and consider appropriate patient outcome
measures to evaluate the quality of care experienced by
people with dementia and their carers/families with
particular regard to equality of access to general care
services
Collate and analyse patient outcome measures to evaluate
Trust response (no. of Trusts)
Greatly
Partially
Not at all
improved
improved
improved
3
6
0
3
6
0
4
4
1
3
6
0
4
4
1
1
8
0
1
7
1
Page 35
quality of care as experienced by people with dementia and
their carers/families
Work to develop effective networks both internally and
externally for the dissemination and sharing of good
practice
5
3
0
Page 36
7. Progress on SPACE Principles
7.1 SPACE principle scores
Project teams from each Trust completed a scale based on the SPACE principles in June
2013, November 2013 and January 2014. This enabled the measurement of progress
relating to each SPACE principle over this seven-month period. As can be seen from
Figures 3-8, the average score for each overarching and individual SPACE principle was
higher in November 2013 and January 2014 than the initial score in June 2013.
Figure 4 shows the change in average score for each overarching SPACE principle, from
June 2013 to January 2014.
Figure 4: Average scores across each overarching SPACE principle
Skilled staff who are informed and have enough
time to care
Partnership working with carers
Jun-13
Assessment and early identification of dementia
Nov-13
Care plans which are person centred and
individualized
Jan-14
Environments that are dementia friendly
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Average score out of 5
Figures 4-8 show the change in average score for each individual SPACE principle, from
June 2013 to January 2014.
Page 37
Figure 5: Skilled staff who are informed and have enough time to care
Good quality training and education in dementia
that is easy to access, practical and focuses on
attitudes/approach and communication
Training is available to all staff based on an
analysis of training needs
Training includes the perspectives of people with
dementia and carers
Jun-13
Nov-13
Identified clinical leads for dementia are available
e.g. dementia specialists/nurses, mental health
liaison, dementia champions
Jan-14
Careful consideration of staffing levels to ensure
appropriate skill mix, ratio and numbers
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Average score out of 5
Figure 6: Partnership working with carers
Process in place for the recognition and
assessment of carers needs
Involvement of families/friends in assessment,
care planning and decision making, including
discharge planning
Jun-13
Flexible visiting for carers
Nov-13
Flexible approaches to care which include and
involve carers i.e. direct involvement where
requested
Jan-14
Support is available for carers e.g. support
groups, carer leads etc.
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Average score out of 5
Page 38
Figure 7: Assessment and early identification of dementia
Assessment and early identification of dementia
Skilled knowledgeable practitioners available to
support assessment e.g. dementia specialist,
mental health liaison
Jun-13
Clear delirium protocols are in place
Nov-13
Jan-14
Clear dementia pathway is in place across services
Clinical reviews of antipsychotic medication
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Average score out of 5
Figure 8: Care plans which are person centred and individualised
Routine gathering of personal life story
information using an agreed template
Person with dementia and/or carers involved in
care planning
Use of mental capacity assessments and advance
care planning to inform care
Jun-13
Nov-13
Use of dementia appropriate tools e.g.
assessment of nutrition, pain, function, risk etc.
Jan-14
Support and activity is available for rehabilitation
and maintenance of function e.g. physiotherapy,
occupational therapy
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Average score out of 5
Page 39
Figure 9: Environments that are dementia friendly
Policies are in place to ensure minimal moves
between wards
Appropriate lighting and floor covering is in place
Aids are available for orientation and visual
stimulation e.g. clocks, signage, pictures etc.
Jun-13
Nov-13
Adequate space and resources are available to
support activity and stimulation
Jan-14
Availability of activity coordinators and/or trained
volunteers to support activity and pastoral care
0
0.5
1
1.5
2
2.5
3
3.5
4
Average score out of 5
7.2 Improvement in SPACE scores
All Trusts participating in the programme showed an increase in their overall SPACE
scores (as rated on a 5-point scale - see Section 2.3.2) between June 2013 and January
2014, with an average increase of 45%.
Table 3 shows that the increase in scores for each of the five overarching SPACE
principles during this period was statistically significant.
Table 3: Percentage increase in score across all participating Trusts for each SPACE principle from
June 2013 to January 2014, with statistical significance stated
% increase
in score
Statistically
significant?1
Skilled staff who are informed and have enough time to care
40%
Yes
Good quality training and education in dementia that is easy to access,
practical and focuses on attitudes/approach and communication
52%
No
Training is available to all staff based on an analysis of training needs
54%
Yes
SPACE principle
1
A Wilcoxon Signed-Ranks test was carried out to determine whether the changes in score for each SPACE
principle were statistically significant at p > 0.05
Page 40
Training includes the perspectives of people with dementia and carers
16%
No
Identified clinical leads for dementia are available e.g. dementia
specialists/nurses, mental health liaison, dementia champions
28%
No
Careful consideration of staffing levels to ensure appropriate skills mix,
ratio and numbers
59%
Yes
Partnership working with carers
53%
Yes
Process in place for the recognition and assessment of carers needs
69%
No
Involvement of families/friends in assessment, care planning and
decision making, including discharge planning
48%
Yes
Flexible visiting for carers
46%
Yes
Flexible approaches to care which include and involve carers i.e. direct
involvement where requested
28%
Yes
Support is available for carers e.g. support groups, carer leads, etc.
84%
Yes
Assessment and early identification of dementia
32%
Yes
Assessment and early identification of dementia
24%
Yes
Skilled knowledgeable practitioners available to support assessment e.g.
dementia specialist, mental health liaison
28%
No
Clear delirium protocols are in place
46%
Yes
Clear dementia pathway is in place across services
65%
Yes
Clinical reviews of antipsychotic medication
13%
No
Care plans which are person centred and individualised
51%
Yes
Routine gathering of personal life story information using an agreed
template
50%
Yes
Person with dementia and/or carers involved in care planning
78%
Yes
Use of mental capacity assessments and advance care planning to inform
care
70%
Yes
Use of dementia appropriate tools e.g. assessment of nutrition, pain,
function, risk etc.
36%
Yes
Page 41
Support and activity is available for rehabilitation and maintenance of
function e.g. physiotherapy, occupational therapy
32%
Yes
Environments that are dementia friendly
50%
Yes
Policies are in place to ensure minimal moves between wards
70%
Yes
Appropriate lighting and floor covering is in place
42%
Yes
Aids are available for orientation and visual stimulation e.g. clocks,
signage, pictures etc.
33%
Yes
Adequate space and resources are available to support activity and
stimulation
47%
Yes
Availability of activity coordinators and/or trained volunteers to support
activity and pastoral care
65%
Yes
Although all scores increased over the seven-month period, percentage increase in
score was variable, ranging from 13 - 84%. The most improved overarching areas were
respectively ‘Partnership working with carers’ (53%), ‘Care plans which are person
centred and individualised’ (51%) and ‘Environments that are dementia friendly’ (50%).
The most improved individual areas are listed in Table 4, with examples of relevant work
achieved by Trusts:
Page 42
Table 4: Most improved individual areas from the SPACE principles
SPACE principle
(% increase in score)
‘Support is available for carers e.g.
support groups, carer leads, etc.’
(84%)
‘Person with dementia and/or
carers involved in care planning’
(78%)
‘Policies are in place to ensure
minimal moves between wards’
(70%)
Examples of work achieved in each area

Identification of key staff as a point of contact for carers,
who provide support, advice and signposting

Leaflets, posters and information boards for carers
publicising where they can get support

Implementation of flexible visiting for carers

Emphasis on carer engagement in care pathways and staff
training

Promotion of the use of the ‘This is Me’ document or similar
to help plan patients’ care

Increased involvement of carers in care planning, and
acknowledgment that carers are the experts in their
relative’s care

Formal consideration of whether and how carers want to be
involved in the care of their relative while they are in hospital

Minimisation of patient moves: new policies of not moving
patients with dementia unless there is a clinical need

Raised awareness amongst staff of the impact of ward moves
on patients with dementia, achieved through dementia
training

Implementation of identifiers of patients with dementia or a
cognitive impairment, enabling staff to quickly identify which
patients it would be inappropriate to move

Empowerment of staff, including porters, to challenge
inappropriate patient moves

Collection of data relating to ward moves
The overarching area showing least improvement was ‘Assessment and early
identification of dementia’ (32%). However this may have been because this area was
Page 43
given the highest score in self-assessments at the beginning of the programme so there
was less potential for improvement. Furthermore it should be noted that improvement
in this area as a whole was statistically significant, and that this area was also given the
highest score at the latest measure in January 2014.
Only six individual SPACE principles did not show a statistically significant improvement
in score over the seven-month period, namely

‘Clinical reviews of antipsychotic medication’ (13%),

‘Training includes the perspectives of people with dementia and carers’ (16%),

‘Identified clinical leads for dementia are available e.g. dementia
specialists/nurses, mental health liaison, dementia champions’ (28%)

‘Skilled knowledgeable practitioners available to support assessment e.g.
dementia specialist, mental health liaison’ (28%)

‘Good quality training and education in dementia that is easy to access, practical
and focuses on attitudes/approach and communication’ (52%)

‘Process in place for the recognition and assessment of carers needs’ (69%)
The lower rate of improvement in relation to some of these principles may reflect
that programme participants had little control over these areas. For example, it is
likely that clinical reviews of antipsychotic medication would be carried out by
medical rather than nursing staff. Ensuring that knowledgeable practitioners and
clinical leads are in post is also likely to be outside the remit of many programme
participants. Therefore it may be useful to review the inclusion of principles such as
these as part of the programme. In relation to including the perspectives of people
with dementia and carers in training, discussions held with programme teams
indicated little work had been done in this area. Difficulties were identified in
relation to identifying suitable people to help deliver training, and in making time to
include patient or carer stories in relatively brief training sessions. In any future
programme it may be useful to specifically include a session focusing on this
objective and how to overcome common barriers to its achievement.
7.3 Perceptions of SPACE scores
One Trust reported that they felt they initially overestimated their actions in relation to
all of the overarching SPACE principles. A further Trust reported that they did so in
Page 44
relation to the principles ‘Skilled staff who are informed and have enough time to care’
and ‘Partnership working with carers’.
The majority of Trusts (6) felt that the SPACE principle they had most improved on was
‘Skilled staff who are informed and have enough time to care’. This was not reflective of
the self-assessed SPACE scores, which indicated that this principle was fourth most
improved. However it may have been perceived by programme participants as the most
improved area as training was identified as a key focus for improvement in the majority
of Trusts and a lot of work had been carried out in this area, with new training
programmes being implemented and hundreds of staff being trained from all areas of
the hospital.
Page 45
8. Progress on Trust Dementia Action
Plans
8.1 Overview of achievements
Overall, participating Trusts identified 211 objectives as part of their action plans. It was
reported that 49% of objectives had been fully achieved on completion of the
questionnaire, 36% had been partially achieved, and only 15% had not been achieved
(see Figure 10). See Appendix 1 for a full list of all objectives rated as fully achieved and
Appendix 2 for a list of supporting documents provided by Trusts which demonstrate
outcomes for carers, patients and staff.
Figure 10: Percentage of objectives set out Trust action plans that have been fully, partially or
not at all achieved2
Fully achieved
Partially achieved
Not at all achieved
0%
10%
20%
30%
40%
50%
60%
8.2 Case Studies of Innovation
The evaluation found that much positive and innovative work had been achieved in
relation to the action plans set by each Trust, examples of which are presented in the
following case studies:
2
12 objectives were not rated in the survey, so findings relate to 199 objectives.
Page 46
Case study 1: Dementia friendly bays in A&E
Four bays in A&E were designed specifically with patients with dementia in mind. The
bays are spacious and relatively clutter-free, with appealing pictures of local scenes on
the walls and big clocks with time and date information. A secure area had been created
so that patients could walk around the area without being sent back into their own bay.
It was observed that A&E did not have the ‘clinical’ feel expected, but was light, airy and
calm. Anecdotal evidence suggests a reduction in incidents involving behaviour that
challenges. A&E staff (including security staff) attended dementia training, and now
increasingly see things from the patient’s perspective. Further improvements are
planned in the department, including the installation of new signage, and making books
and activities available.
Case study 2: Carers’ feedback workshop
A carers’ workshop was held so that Trust staff could get feedback on the needs of
carers while their relative was in hospital, which was very enlightening. Carers who
attended were given ‘five pounds’ to spend in Monopoly money and asked where they
would put their money to change things. Some carers wanted to be more involved in
their relative’s care while they are in hospital, and reported that they sometimes found
it difficult to get information about their relative over the telephone. Other issues raised
included the cost of parking and restricted visiting times.
In response to this feedback staff now use a simple checklist to check which aspects of
the patient’s care carers want to be involved in. Cards have been created for carers to
carry which give them permission to visit their relative as required, and also give a 10%
discount on food and drink at the hospital canteen. If carers give staff the registration
details of their car, parking staff are informed that they are entitled to park for free. A
password system has also been implemented, which enables staff to share more
information with carers over the telephone. It is planned that the carers’ workshop will
be repeated when the changes that have been made are embedded, to look at how
further improvements can be made.
Case study 3: Patient passport
An existing patient passport has been adapted to make it more person-centred, and it is
now used for patients with dementia. Carers can complete the passport on behalf of
their relative, so that staff have relevant information to enable them to provide
personalised care. As the passport has become embedded in practice some patients
who are re-admitted to A&E may already have a passport, which is very useful.
Page 47
Completed passports are scanned into the system in case patients do not bring their
paper copy with them on admission. There has been a culture change around the use of
patient passports, and staff now realise that making sure the passport is completed is
not just extra work, but can actually help them do their job. Carers are also becoming
more aware of the passport, and now remind staff to look at it. Funding has been
obtained so that blank copies of the patient passport can be provided to local care
homes, and passports have now started moving back and forth between the hospital
and the care homes, which has been very helpful and reduced the number of phone
calls needed.
Case study 4: Dementia awareness training
Dementia awareness training has been implemented at staff induction with the aim that
at every point through the hospital staff will be aware of the needs of patients with
dementia (including receptionists, porters, etc.). This training is extended to agency
staff as part of their mandatory induction. 219 staff across four elderly care wards have
attended more in-depth dementia training, which has covered communication with
patients with dementia and carers, psychosocial interventions, person-centred care and
behaviour that challenges. The project team have considered getting carers involved in
the delivery of training in the future so that they can tell their story. In addition to
formal training, mental health liaison workers pass on a lot of useful information to
other staff.
The training has contributed to a shift from the medical model to a more psychosocial
model of care. It has made a big difference to how staff respond to the behaviour of
patients with dementia, as it has increased understanding and awareness. For example,
there is now a greater focus on occupying patients with activities to reduce behaviour
that challenges, and staff are now seen to be walking around with patients with
dementia who are wandering when previously they would have told them to sit back
down.
Case study 5: Activity Room
An activity room has been created between two elderly care wards where activities are
provided every day (morning and afternoon sessions) for patients with dementia. The
room is run by an activity worker who previously worked as a health care support
worker and has had dementia training. There was no funding for this role, so the ward
released funding for one of its staff: this has proved to be a win-win situation as the
activity room frees up the time of staff on the ward. Activities include painting, wordsearches, dominoes, watching films, hand massage and manicure. Patients can choose
to eat their lunch in the activity room or go back to their bed if they prefer. Dementia
Page 48
care mapping has been carried out in the activity room, and a considerable difference in
wellbeing scores was observed between patients in this room and those on general
wards. Incidence of falls on the two wards has reduced from 19 in the six month period
before the activity room opened, to 9 in the six month period after.
Case study 6: Reduction of ward moves
There is an aim to minimise ward moves for patients with dementia and to ensure that if
a patient needs to be transferred to another ward that this is done during the day. A
formal list of patients recommended for no ward moves is generated on a Friday
afternoon in preparation for the weekend, as it was recognised that out of hours was a
key time when a patients were moved between wards. This list is sent to all the
executive teams and heads of nursing, and if staff want to move a patient on the list this
needs to be approved by the mental health liaison team. Ward moves are built into the
Trust Key Performance Indicators, and if a patient on the list is moved it is raised as a
clinical incident. This list is also given to the security manager so that security staff and
porters are aware of it. Porters and security staff have attended dementia awareness
sessions, and feedback from this has been very positive. The training has brought them
closer together with medical staff, and they are pleased to be engaged and to
understand more about dementia. They are now much more empowered to question
staff about whether a patient should be moved, and it has been observed that they now
engage with patients much more whereas previously they may have seen their role as
just moving a patient from A to B. Implementation of the new list has reduced patient
moves considerably.
Case study 7: Piloting of a pain assessment tool for patients with
dementia
The team carried out a survey of adult nursing staff to explore what would help improve
their assessment of pain in patients with dementia who have difficulty communicating.
They conducted a literature review to identify potential pain assessment tools, and
formed a multidisciplinary working group to decide which tool would be most suitable
for use within the acute hospital environment. A number of pain assessment tools were
evaluated, and the PAINAD (Pain Assessment in Advanced Dementia) tool is currently
being piloted, with staff feedback obtained via evaluation surveys. New questions have
been added to the ‘About Me’ document, which is for carers to complete on behalf of
patients with dementia, asking carers to outline signs that their relative may be in pain
and what may help to ease pain.
Page 49
Case study 8: Carers’ passport
A carers’ passport has been implemented which aims to value the contribution carers
make in caring for a person with dementia and ensure that staff recognise that the carer
can make a difference to the experience of the person while they are in hospital. The
passport allows carers to visit their relative at any time, and is pre-signed by the Director
of Nursing so that there is no longer any inconsistency whereby different nursing staff
allow different visiting practices. This scheme is publicised by posters outside the ward
area, and carers are encouraged to approach staff and ask for a passport. This facilitates
a discussion between the carer and ward manager about how best to plan the care of
the patient, which helps nursing staff to recognise that the carer is an expert in the care
of their relative and prompts them to engage more with carers. This conversation also
enables nurses to ask carers whether and how they want to be involved in supporting
their relative’s care whilst they are in hospital, and this can then be planned to suit the
carer. Carer feedback on the passport has been very positive, and they particularly value
being able to stay with their relative in hospital whenever needed, and the opportunity
to engage with nursing staff.
Page 50
Case study 9: Bay nursing for patients with dementia with
activities and dining table
Bay nursing for patients with dementia has been implemented on two wards, with plans
for wider roll-out. One nurse is responsible for each bay, which has enabled staff to get
to know a smaller number of patients and their families well. There is a table in each bay
which enables patients to eat together and to take part in activities such as bingo,
scrabble or puzzles. It has been recognised that bay nursing has made a huge difference
to patients and staff. For example, there has been a reduction in falls and in the number
of patients needing 1:1 nursing, as there is a nurse present in the bay at all times. Staff
satisfaction, morale and sickness levels have all improved, and there is a plan to
measure improvements in length of patient stay. Although additional nurses needed to
be recruited to implement bay nursing, this has been partially offset by a reduction in
1:1 nursing costs.
8.3 Factors affecting the achievement of objectives
Figure 11 shows the factors rated as most important by programme participants to
support, deliver and manage improvements in practice. Interestingly, ‘funds to support
improvements’ was only rated as important by two Trusts: this may be because the
majority of Trusts managed to make changes without securing additional funding, or
because other factors were viewed as having a greater influence over changes.
Page 51
Figure 11: What are the most important factors in your view to support, deliver and manage
improvements in practice?
Support from executive team
Dedicated dementia specialist post/s
Funds to support improvements
Collaborative working with other specialities
Dedicated wards for people with dementia
Organisational stability
Voice of patients/carers
0
1
2
3
4
5
6
7
8
9
Number of Trusts
Other important factors identified by programme participants were ‘skills and
competency of staff’, ‘dedicated time to achieve’ and ‘awareness and understanding at
all level[s]’.
Trusts were also asked to identify any factors which helped or hindered the
achievement of the objectives set out in their action plans; common themes are
summarised below.
8.3.1 Staff engagement
By far the biggest influencing factor identified was staff engagement in the project. It
was reported that where there was a high level of engagement, enthusiasm and
commitment to the project from frontline staff at all levels, this facilitated the
achievement of improvements in culture and practice:
‘The persistent hard work of the two support workers and the matron have
made this happen’
‘What has helped is a very proactive housekeeper in A&E who has
championed the dedicated bays’
Trusts reported that turnover of staff and recruitment issues made it difficult to achieve
some objectives due to time constraints, and could make changes less sustainable.
Page 52
Changing the culture and ways of working was also a challenge: for example, in some
Trusts protected mealtimes had previously been implemented, but staff were
subsequently asked to be flexible around this to allow carers to support their relative to
eat and drink. Educating the workforce was identified as being integral to the success of
new initiatives, in order that staff understood the reasons behind changes. It was
recognised across the majority of Trusts that project teams still had work to do to raise
awareness of changes and ensure new ways of working were embedded into everyday
practice, which may take a long time.
Engagement of medical staff was cited as a particular challenge; notably the inclusion of
this group in training. One project team explained that some doctors felt insulted by
being asked to complete dementia e-learning and were reluctant to do so. Where the
involvement of medics in training was reported, this tended to be in cases where
separate, specialist training was provided. This training focused more on the treatment
and management of the symptoms of dementia rather than communication with or
support of patients. One Trust identified that in other areas medics had been engaged
successfully after listening to patient and carer feedback, so planned to take this
approach to engaging this group in dementia-related changes.
Commitment to the programme from senior management was also identified as an
important factor in enabling changes to be made; for example the commitment to
release frontline staff for training, and support for changes to dementia care pathways.
It was generally reported that having contact with a member of staff at board level was
vital in supporting the programme in terms of increasing the influence and recognition
of the work of the project team throughout the hospital. It also enabled project teams
to gain the support of senior staff if they encountered any problems implementing
changes as part of the programme. Some Trusts reported that through their project
work senior managers involved in environmental or maintenance work had become
interested in dementia care. In these cases this has resulted in patients with dementia
being considered in the design of new areas, for example in terms of colours, signage
and flooring. In some cases it was identified that being on the programme had itself
helped raise the profile of dementia in the Trust: for example one Trust explained that
they were asked to give regular programme updates to the board, which gave them the
opportunity to keep raising the profile of dementia care and publicise examples of good
practice. The programme was generally seen as worthwhile and prestigious by senior
staff, which gave the project work credibility and support:
‘When we applied for [the programme], at a very senior level in this
organisation they were delighted that we got a place... And they saw it as a
Page 53
very important, high-level respectable endeavour that we were setting out
on’
Presenting patient stories appeared to be a successful strategy for engaging senior
management and board members in changes to practice around dementia care. Project
teams reported that this raised the profile of dementia, and made staff think about
what actually happens when a patient with dementia is admitted to the hospital.
Although Trusts generally felt supported by senior management to undertake the
programme some mentioned that they were given little protected time and no
resources to work on the project work they had identified.
8.3.2 Funding
Funding for the project was also identified as a key factor in supporting the achievement
of objectives. In most cases where funding was mentioned, a lack of funding for training,
resources or environmental improvements was reported. However in a minority of
cases funding was cited as a facilitating factor and some Trusts mentioned that they had
been successful in obtaining funding for discrete projects. Examples were funding for
professional artists to provide activities, the provision of new day rooms and gardens,
environmental improvements such as new clocks and signage, the purchase of activity
packs and RemPods, and specialist dementia training. This funding was from a variety of
sources, including government funding, the local Arts Council, and the League of
Friends.
8.3.3 Availability of space and staff time
A lack of space, for example for the creation of day rooms or activity rooms, was a
hindering factor for some Trusts. ‘Competing demands on staff time’, both those
participating in the programme and other staff, was another issue identified. In some
cases it was mentioned that prioritising certain objectives in the action plan led to
insufficient time being available to focus on others.
8.3.4 Difficulties with carer engagement
Trusts commonly reported difficulties in finding carers to engage with, as many carers
do not identify themselves as such. This resulted in low uptake of carer support in some
areas. Some project teams had implemented initiatives to try and overcome this
challenge, such as increasing publicity of the support available for carers through the
use of posters, leaflets and information boards, and implementing formal mechanisms
such as carers’ passports to assist in the identification of carers. However, it may be
useful to discuss strategies to tackle this issue in any future programme.
Page 54
9. Considerations for Future programmes
The development programme was undoubtedly beneficial for the majority of Trusts who
participated. In view of the feedback on the programme itself and the subsequent
impact the following recommendations are made for the future development of the
programme:
9.1 Programme facilitation
1. It may be useful to consider how suggestions made to Trusts following the RCN site
visits could be embedded more into the programme, as few of these
recommendations were acted upon by project teams at the time of the site
evaluation visit.
2. Informal networking opportunities were identified as particularly powerful and
thought needs to be given for how this could be facilitated.
3. Trusts valued hearing what colleagues were doing so time should be allocated for
participants to present their action plans, with a question and answer session
following each presentation, so that all programme participants have a good
understanding of the work being carried out by other Trusts.
4. The ‘world café’ session should be included in a similar format in future
programmes, as this was identified as an excellent opportunity for Trusts to network
and share ideas. However it may be beneficial for programme participants to be able
to move freely between stands, so that they can gain the information most relevant
to their own project.
5. It would be useful to consider an alternative IT platform for the sharing of progress
and resources, as accessing the Wiki site was problematic for many participants.
6. Holding the programme regionally in the future could be a possibility to consider:
this would make travelling to the development days easier for programme
participants and facilitate networking between Trusts.
7. It may be beneficial to implement a buddy system linking up Trusts in pairs, to
facilitate greater networking during and after the programme.
8. Appointing a mentor for each Trust on the programme is a possibility to consider for
the future. This would provide Trusts with bespoke support and a regular point of
Page 55
contact. The mentor could be a member of RCN staff or possibly a previous
programme participant.
9. Providing Trusts with clear, detailed information about the format of the
development programme prior to the start of the programme would help ensure
that participants’ expectations are met.
10. It would be useful to consider how the focus, commitment and enthusiasm for
change demonstrated by Trusts while on the programme can be maintained
following the end of the programme.
9.2 Programme content
11. More content could be included in the development days regarding the evaluation
and analysis of patient outcome measures, as this was the least improved area in
relation to the programme objectives.
12. Strategies to engage and identify with carers could be discussed explicitly on the
programme, as many participants found this challenging. In particular, a session
could be included focusing on the inclusion of the perspectives of people with
dementia and carers in training and how to overcome barriers to this, as this was an
area where Trusts found it difficult to progress.
13. It may be useful to review the inclusion of particular SPACE principles which
programme participants are unlikely to have a significant influence over, including
‘Clinical reviews of antipsychotic medication’, ‘Identified clinical leads for dementia
are available…’ and ‘Skilled knowledgeable practitioners available to support
assessment…’
14. The engagement of medical staff in changes could be discussed on the programme,
as Trusts experienced particular difficulties in this area.
15. Visits between Trusts could be considered as a formal part of the programme, as it
was suggested by a number of Trusts that it would have been very useful to see
examples of their counterparts’ work in practice. Alternatively this could take the
form of participants being able to visit areas of good practice in dementia care
identified by the RCN.
16. It would be beneficial to consult programme participants prior to the beginning of
the programme to find out what they would most like to learn on the programme
and whether there are any speakers they would particularly like to hear. If possible,
Page 56
content of subsequent development days could be responsive to the challenges
participants report on the first day if any common themes emerge.
Page 57
10. Maintaining Change
In all cases, Trusts reported they felt that objectives they had achieved would continue
to be achieved over the next 12 months. Many Trusts had made specific plans for future
additional changes, which often included the roll out of changes made as part of the
programme to a wider area within the hospital or Trust. It was identified by programme
participants that changes would continue because they felt passionate about improving
care for patients with dementia and were strongly committed to carry on this work.
However, as project teams explained that participation in the programme gave them
enthusiasm and drive which they might not otherwise have maintained over the period,
it is important to consider how this will continue following the end of the programme.
The programme itself appeared to be helpful in sustaining future change in two main
ways: firstly by raising the importance and profile of dementia care within Trusts, and
secondly in equipping participants with strategies for the future. Participants reported
that the programme provided a starting point for change. They predicted that changes
would continue as staff became aware of and enthused by work already carried out,
which had raised expectations for the future.
‘I think what this has done has raised expectation amongst the whole of the
health economy. So I don’t think it’s going to go away… the pressure to
continue to improve patient experience of someone with dementia, I think
the pressure’s always going to be there, and I think what we’ll have done is
laid the foundation for that to go forward.’
The programme enabled participants to develop an evidence base for new initiatives,
and provided a focused framework for change. Participants reported feeling
empowered to challenge existing practice and implement change, and identified that
they had gained a lasting confidence to move forward with developments. Aside from
the programme the high profile of dementia nationally, and the inclusion of dementiarelated CQUIN targets by individual Trusts, were seen as key factors in driving change
forward.
Changes in staffing were seen as a potential barrier to the sustainability of the work
achieved: for example, it was viewed as vital that key roles were given continued
funding, and that staff leaving should be replaced with someone with equal enthusiasm
and passion for dementia care. It was also acknowledged that the delivery of changes
should not be solely dependent on the project team, but needed to be more widely
adopted in the Trust to ensure sustainability. One programme participant explained that
Page 58
as her role was not solely focused on dementia, she felt she may not be given time to
work on changes following the end of the programme as it was seen as a standalone
project by her managers.
One Trust identified that it would be helpful if the programme could continue in some
way after the official end in May 2014; for example if there was an IT facility which
would enable Trusts on the programme to network with each other:
‘We kind of hope in some way, I know that the programme’s going to end,
but in some way it carries on… All good things come to an end, and you kind
of wish… it was carrying on a bit longer.’
Page 59
11. Summary and Conclusion
The development programme was successful in the achievement of its specified
objectives and learning outcomes, with all participating Trusts reporting that objectives
were fully or partially achieved, and that they had improved in respect of all learning
outcomes of the programme. Project teams showed an average increase of 45% in their
overall SPACE scores between June 2013 and January 2014. The increase in scores on
each of the five SPACE principles was statistically significant.
Of the 211 action plan objectives identified by participating Trusts, 85% had been fully
or partially achieved by January 2014. It was identified that much positive and
innovative work had been achieved by Trusts during the programme. Project teams
reported that although much of the work they were doing in relation to dementia care
had started prior to the programme, the programme acted as a ‘catalyst’ in moving
developments forward at a faster rate.
The majority of programme participants reported that the development days and site
visits from the RCN contributed to the progression of their project. It was felt that the
programme provided the focus and structure for Trusts to make changes, and supported
actions through equipping participants with the strategies and confidence to change
practice. In addition, it encouraged partnership working within organisations, provided
networking opportunities, and helped to raise the profile of dementia care in Trusts.
In all cases project teams reported they felt that objectives achieved on the programme
would continue to be achieved over the next 12 months, and many had made specific
plans for the roll out of changes made as part of the programme to a wider area within
the hospital or Trust.
Recommendations for the future development of the programme include the preconsultation of participants to establish what they would most like to learn on the
programme, an increase in opportunities for informal networking on development days,
and the establishment of an alternative IT platform easily accessible to programme
participants. The formal introduction of visits between Trusts and the implementation
of a mentor or buddy system for participating Trusts are further suggestions for
consideration.
Page 60
12. References
[1] National Audit Office (2007). Improving services and support for people with
dementia. London: The Stationary Office.
[2] Suarez, P. and Farrington-Douglas, J. (2010). Acute awareness: improving hospital
care for people with dementia. London: The NHS Confederation.
[3] Alzheimer’s Society (2009). Counting the cost: Caring for people with dementia on
hospital wards. London: Alzheimer’s Society.
[4] Banerjee, S. (2009). Report on the prescribing of anti-psychotic drugs to people with
dementia: time for action. London: Department of Health.
[5] Royal College of Psychiatrists’ Centre for Quality Improvement (2011). Report of the
National Audit of Dementia Care in General Hospitals. London: Royal College of
Psychiatrists.
[6] Parsonage, M. and Fossey, M. (2011). Economic evaluation of a liaison psychiatry
service. London: Centre for Mental Health.
[7] Royal College of Psychiatrists (2013). National Audit of Dementia care in general
hospitals 2012-13: Second round audit report and update. Editors: Young J, Hood C,
Gandesha A and Souza R. London: HQIP.
[8] Thompson, R. (2011) Dignity in Dementia; Transforming General Hospital Care.
Outcomes from Survey of Practitioners & Report of the Findings and Analysis from
Employment Research Ltd: London: Royal College of Nursing.
[9] Thompson, R. (2011) Dignity in Dementia; Transforming General Hospital Care.
Summary of Findings from Carer and Patient Survey & Report of the Findings and
Analysis from Employment Research Ltd. London: Royal College of Nursing.
[10] Thompson, R. and Heath, H. (2013). Dementia; Commitment to the Care of People
with Dementia in Hospital Settings. London: Royal College of Nursing.
[11] Phair (2014). Sit & See [online]. Available at: http://sitandsee.co.uk [Accessed 12
May 2014]
[12] Carers Trust/ RCN (2013). The Triangle of Care – Carers included: A guide to best
practice for dementia care. London: Carers Trust. Available at
Page 61
http://www.rcn.org.uk/development/practice/dementia/triangle_of_care [Accessed 12
May 2014]
Page 62
Appendix 1: Objectives fully achieved by
participating Trusts
Skilled staff who are informed and have enough time to care































Promote RCN programme to Trust staff, create discrete section on Hub
Develop e-learning package for basic and enhanced awareness
Agree a training matrix for all Trust staff
Make contact with Dementia Champions in other Health Boards or Trusts
Question 50+ staff on what a Dementia Champion means to them
Ask the Dementia Champions how they see the role and what they want from it
Meet current champions to assess their own knowledge and skills to fulfil the role
Identify areas where there are unmet training or education needs
Work with Consultant Nurse and others to introduce training opportunities for champions
Evaluate the Dementia Champion role on Care of the Elderly wards
Recruit two Dementia Support Workers, provide training and induction and introduce to
Care of the Elderly wards
Engage in supervision and reflection on interventions to identify skills and knowledge
required to provide the intervention in an effective manner
Develop a network of Dementia Champions on two wards
Ensure Dementia Champions have attended Dementia Champion training sessions
Produce a Top Tips for Specialing guide
Produce a How to Special guide
Produce specialing kits with resources to help provide meaningful activities
Dementia Champions to receive additional dementia training
Staff to contribute to the 5 Ds dementia training module
Benchmark staffing numbers against the RCN framework
Review roster templates to ensure effective rostering
Review training currently being delivered
Develop and deliver a training plan that links to national and Trust dementia strategy
Deliver further training sessions on the CQUIN process including any changes made after
review
Deliver Dementia Champion training
Identify key groups of staff requiring training, i.e. porters and ward receptionists
Identify gaps in knowledge and skills through Dementia Champions network
Engage support of Dementia Champions and researchers from local University to inform
training programme
Outline training programme for delivery
Identify resources for training delivery (rooms/trainers)
Include training programme as part of Trust dementia education strategy
Page 63













Identify booking system for training
Circulate training dates to relevant staff groups
Maintain record of staff trained using OLM (Oracle Learning Management)
Plan and devise a programme that provides a range of training and education to MDT
(multidisciplinary team)
Liaise with colleagues in Higher Education
Use ‘Away Day’ concept to enable all staff to attend dementia training
Produce VERA posters
Produce VERA lanyard cards
Provide VERA framework training to all team members on two wards
VERA to be taught at corporate induction
Involve dementia steering group (regarding staff training)
Develop a dementia network, through association with the RCN development programme
Promote aims of the dementia collaborative, to ensure participants have identified tests of
change prior to learning event
Partnership working with carers









Implement the carers satisfaction survey
Develop a carers information pack
Alzheimer’s Society to be invited to Dementia Strategy Group
Encourage flexible visiting on the Older People’s wards that meets the needs of the patient
and their carers
Develop a communication pack for carers to be given on admission
Develop a menu-style card allowing carers to select from a range of options those things
that they feel will improve communication in their case and allow them to feel supported
Work in partnership with the local carers group to develop a plan for the commencement of
a carers café within the organisation
Ensure there is access to information for contacting the HELP phone where necessary
Provide a presence at local dementia events
Assessment and early identification of dementia





Maintain performance with assessment, investigation and onward referral initiative
Ensure dementia screening question is asked on admission
Review the current assessment process for people aged 75 years+ admitted as an
emergency
Promote use of 6-CIT cognitive screen for all eligible patients
Carry out an audit of internal measures to identify people with cognitive impairment at
ward level
Page 64

Ensure that where a patient is considered to have a dementia, this concern is shared with
the GP to ensure a referral to the memory assessment team is made
Care plans which are person centred and individualised

























Ensure that patients requiring support with meals and fluid intake are assessed and have a
personalised care plan developed in their electronic patient record
Ensure that support with nutrition and hydration is reported at handover and safety
huddles
Record level of support on the nutrition board in the ward kitchen
Accurately record food and fluid intake in the patient evaluation
Have clear medical and nursing management plans in place
Ask patients about their management plans on senior nurse clinical walk rounds that occur
twice a month
Identify patients’ preferred form of address at admission
Agree the dementia care pathway with wide range of stakeholders
Obtain information demonstrating good practice developed in other areas
Liaise with services previously involved in supporting the patient at home
Scope current pain tools in use
Engage key stakeholders in identifying chosen pain tool to pilot
Pilot chosen pain tool
Audit current level of completion of ‘About Me’ booklet
Cascade audit findings (of completion of ‘About Me’ booklet) to clinical leads, Matrons,
Ward Sisters/Charge Nurses, Practice Development matrons and Dementia Champions
Re-audit completion of ‘About Me’ booklet
Address deficits in completion (of ‘About Me’ booklet) through training, communication
strategy and support of Dementia Champions network
Raise profile of the Dementia Strategy requirement for improved dementia care in General
Hospitals throughout the organisation
Review the current CQUIN process and pathway
Involve the dementia steering group (regarding the care of people with dementia in A+E)
Share good practice across the community
Establish regular contact with Trust Executives/Board Members to raise the profile of
dementia and secure support to develop dementia care
Ensure that the Concern Log is updated by Matrons/Lead nurses who feed back to
individual areas if a concern has been raised
Make Dementia Support Workers responsible for ensuring the ‘This is me’ document is
made available to people with dementia who are admitted, and handed over to nursing
staff once completed
For Dementia Support Workers to lead on the implementation of documentation and use its
completion as a method of building a relationship with those admitted and their families
Page 65
Environments that are dementia friendly














Order and supply phase one equipment and signage, to include clocks, signage and toilet
seats
Identify an area for the activities room
Incorporate appropriate intervention including memory work and music therapy in order to
provide dignified and mentally stimulating care provision
Create a relatives / quiet room
Undertake research into garden design / projects already undertaken
Develop dedicated bays within A+E for patients with dementia, e.g. using pictures/photos,
orientation equipment, hospital passports and possibly distraction toolkits
Develop understanding and share knowledge of national policy and initiatives that will
support a dementia friendly approach to care delivery, including changes to the
environment and staff awareness of the needs of people living with dementia
Provide single sex accommodation
Liaise with outside agencies to develop a robust system for the management and delivery of
therapies in the activities room
Meet with the Trust’s art therapy service leader to discuss best practice for the
implementation of this service
Progress the application to the DOH (Department of Health) for funding to change the
environment on one ward
Use TOPAS service to control moves into DME
SCNs to gate keep moves out of DME
Involve dementia steering group (regarding environmental changes)
Page 66
Appendix 2: List of supporting documents
submitted by participating Trusts
The following documents were submitted as supporting evidence of outcomes for
patients, carers and staff:
Outcomes for patients
Document name
Outline of outcomes
Patient experience
questionnaire results
(Quarter 3, 2013)

More patients than previously believed that they had been involved with
decisions about their care and treatment: 100% of respondents said that
they were always involved as much as they wanted to be in these decisions
Audit of ‘About Me’
completion in May
2012 and May 2013

In May 2012 91% of inpatient areas included in the audit had a stock of the
‘About Me’ document and could locate where it was stored. This improved
to 100% for the May 2013 audit.
In May 2012 21% of staff questioned were unaware of the ‘About Me’
document; 6% were unaware in May 2013.
Of the patients on each ward identified as requiring an ‘About Me’
document, 26% had an ‘About Me’ completed in May 2012 and 66% in May
2013.
Dementia care mapping showed a considerable difference in terms of wellbeing scores in comparison to general wards and a specialist mental health
dementia unit.
On a wellbeing scale from -5 (significant ill-being) to +5 (significant wellbeing) the following average scores were found:
- Specialist mental health dementia ward = 2.09
- Ward 1 = 0.76
- Ward 2 = 0.45
- Dementia activity room = 3.36
In terms of time spent in state of ill or well-being, 100% of the time in the
dementia activity room was spent in a state of wellbeing; 94% with scores
of 3 or higher. 88% of the time spent on ward 1 and 73% of time spent on
ward 2 was scored at +1, with 12% and 27% of time respectively spent in a
state of ill-being (-1).
In the six months before the role of dementia support worker was
introduced, 10 complaints were received relating to dementia care. In the
six months after the role was introduced 1 complaint was received.


Dementia Care
Mapping results for
dementia activity
room




Page 67

The average fall rate fell from 19 per month in the six months before the
role of dementia support worker was introduced to 9 per month in the six
months after.
Outcomes for carers
Document name
Outline of outcomes
Carer experience
questionnaire results
(Quarter 3, 2013)

Responses suggested improvement in carers’ feelings about whether their
relative was treated with respect and dignity, with 100% reported that this
always happened. An increased proportion of carers (62.5%) reported
being offered an information pack.
Outcomes for staff
Document name
Outline of outcomes
Dementia training
satisfaction
questionnaire results

Non-clinical
dementia training
evaluation






Of 12 respondents, 83% found the training helpful, and 83% said that they
thought their practice had changed as a result of attending the training
Comments included:
- ‘[I have a] better understanding of dementia as a whole’
- ‘With a better understanding of dementia, I feel more confident to
communicate with patients’
- ‘I will look for reasons to explain a particular behaviour’
- ‘I will look to approach a patient in a manner that won’t frighten them’
- ‘I have an increased awareness of patients’ perceptions’
78 evaluations were completed across 5 separate training sessions for nonclinical staff
Prior to the session, 8% of staff reported that they knew ‘enough’ or ‘a lot’
about dementia. Following the session this had increased to 99%.
Prior to the session, 12% of staff reported that they knew ‘enough’ or ‘a lot’
about the difficulties someone with dementia may have in communicating.
Following the session this had increased to 99%.
Prior to the session, 12% of staff reported that they knew ‘enough’ or ‘a lot’
about what a patient may be trying to communicate through their
behaviour. Following the session this had increased to 96%.
Prior to the session, 22% of staff reported that they knew ‘enough’ or ‘a lot’
Page 68



Mental health and
dementia awareness
training evaluation




Assessing dementia
skills and time to
care on two
inpatient wards

Evaluation of a
training programme
for supporting
people with
dementia in general
hospitals




about person-centred care. Following the session this had increased to
97%.
Prior to the session, 14% of staff reported that they knew ‘enough’ or ‘a lot’
about what can affect eating and drinking in a person with dementia and
what they could do to help. Following the session this had increased to
97%.
Prior to the session, 13% of staff reported that they knew ‘enough’ or ‘a lot’
about how the hospital environment impacts on a person with dementia.
Following the session this had increased to 99%.
Respondents identified a number of things they would do differently in
their role as a results of the training, including:
- Spend more time communicating with patients with dementia
- Make sure the ‘About Me’ document is used
- Make sure other staff understand about patients’ nutritional needs
Comments about the delivery of the training were very positive
190 staff trained.
The vast majority of staff trained reported that they were ‘extremely’ or
‘very’ likely to use the training in their job
Staff identified a number of specific actions that they planned to take into
their work setting as a result of the training:
- ‘Take more time to listen to patients who are having difficulty
expressing themselves’
- ‘I plan to encourage the patients’ relatives to become more involved in
the patient’s care’
- ‘I will use the Abbey pain assessment tool to know when patient is in
pain’
- ‘Use Abbey pain scale, ABC chart and 6-CIT’
- ‘Educate ward doctors about specific areas of dementia’
39% of staff on the two wards had received face-to-face training in
dementia care; 31% had completed e-learning
63% of staff said that they were ‘very confident’ or ‘confident’ in their skills
for caring for patients with dementia
607 staff completed the training programme
Respondents completed the CODE (confidence in dementia) scale pre- and
post-training. Prior to the training, 11% were rated as ‘very confident’,
which rose to 57% post-training. The change in score was statistically
significant (p < .001).
Scores on the KIDE (knowledge in dementia) scale indicated a significant
increase in knowledge following the training, from a median score of 12 to
a median score of 14.
Page 69

Respondents completed a controllability beliefs scale to measure their
beliefs about the controllability of behaviour that challenges. There was a
significant decrease in scores following the training, indicating that staff
held a more person-centred perspective on challenging behaviour after the
session.
Page 70