Clonakilty Community Hospital A New Model of Care

1. 1 Clonakilty Community HospitalA New Model of Care John Linehan Doreen Lynch October 2009 � NHI Conference

2. 2 Outline of presentation Background The New Model of Care Process of change Education Research Challenges!

3. 3 Profile of residential care for older people 28,000 residential care places 4.6% people over 65 65% in private or non for profit care 35% in public care (Coyle 2008)

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5. 5 Need for change��. There is a growing acknowledgement that the current model of residential care does not always support older people to continue to exercise self determination and lead a full life no matter what their level of dependency. New buildings or upgrades give an opportunity to develop to develop a new vision

6. 6 New Standards of Care Rights Based Person centred Self Determination Choice Privacy and Dignity Maintain contact with families and friends

7. 7 A new vision�� Create a new model of residential care which supports older peoples ongoing right to home and continued meaningful connectedness to their family and friends

8. 8 Objective To drive a change in culture from a task orientated institutional model to one which supports older people to continue to direct their own lives supported by consistent and valued teams

9. 9 Teaghlach Based on similar work in the USA Eden Model Household model UK � �My Home Life� Model for newly developed community nursing units (CNU�s)

10. 10 Teaghlach The word Teaghlach � in Irish � has many connotations. It means a family group, living comfortably together, cosily warm around a glowing fire, each person protective of the others. It suggests a respect and familiarity and a happy and helpful ambience of share experiences Small scale living

11. 11 Teaghlach Model An environment in which both residents and the staff are valued and thrive. Staff enter care giving relationship with the resident based on individual needs/desires. Residents continue to live their life to the fullest Residents and staff design schedules that reflect needs/desires.

12. 12 Teaghlach Model Decision-making closer to resident. Environment reflects comforts of home. Spontaneous activities available around the clock. Residents and staff share a feeling of community & belonging Direct their own lives through a responsive highly valued and decentralised self led team that is supported by values driven leadership philosophies, practices, policies and systems

13. 13  CLONAKILTY HOSPITAL Clonakilty hospital is a 194 bed hospital. The hospital serves the West Cork Local Health Office area. Provided continuing care, respite care, palliative care and community support Dementia specific unit �Saoirse�

14. 14 What it was: Block 2b was a 96 bed unit Long corridor Noisy Busy Not homely Element of task orientation

15. 15 Background Pilot site for the � Teaghlach� model Innovation funding New unit being developed Staff recruitment to work in the unit Staff training Research element Similar to the development of �Saoirse�

16. 16 Staffing 21 residents � 15 WTE�s 40 hours per day (24 hours) = Nursing 44 hours per day (24 hours) = Support Staff Nursing per day � 1 Clinical Nurse Manager, and 2 nurses = 28 Nursing per night � 1 nurse = 12 Health Care Assistants per day = 16 hours Multi-Task Attendants per day = 12 hours Support staff per night = 12 hours Cleaning staff per day = 4 hours

17. 17 Education and development analysis Team building To develop a philosophy of care Person centred care Physiology of ageing and associated aspects Life stories Communication Nutrition Mobility and the older person Dementia/ behaviours that challenge Pharmacology Palliative care Care plans and documentation Activities Role of the family/carers

18. 18 Education and development � to date Team building and self awareness Life story Person centred care workshop 1 � day Observation of care Discussion and very little PowerPoint!! Workshops, brainstorming

19. 19 Observations of care Workplace Culture Critical Analysis Tool (McCormack et al 2007) Staff observe the delivery of care to residents in a ward, document their findings using an agreed format, and give feedback to others following the period of observation. Areas such as the how care is organised, resident involvement, how the privacy and dignity of residents is maintained and the care environment are observed Focus on the positives and areas that need improvement

20. 20 Outcomes Clutter General noise Radio on �nobody listening Language Communication Signage Gentle language Good level of engagement with a resident Sharing a joke!

21. 21  What it is now ..�An Graig� 21 bed unit. 20 continuing care residents and 1 respite patient. The residents profile: 5 very high dependency 12 high dependency 4 medium dependency residents. 5 residents would have a diagnosis of dementia.

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23. 23 A new way of being..

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25. 25 Philosophy .. Some extracts �to provide a homely, friendly and happy environment to live and work where people are treated with respect and dignity�. �to maintain a sense of continuity with the person�s past and give them hope for the future�� �Differences of opinion are respected and a true sense of listening is the norm��� �Keeping an open mind where my way may not always be the �right way.� �Where creative solutions and thinking are fostered while at all times remembering this is the resident�s home��

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27. 27 Feedback from Staff Discussion with staff 4 months after moving in Enthusiasm is still very evident Relationships � �tolerant of each other� �Prioritise now � �not that we must�

28. 28 Feedback from staff Important of hearing the same message Relatives are more comfortable with staff Hidden talents of staff

29. 29  Residents Space � residents have a sense of their own space Life story � new learning about the lives of residents Provide areas of discussion away from the task Empowerment of families Quietness - �make not suit all� Smell Table is the focal point

30. 30 Residents �Confidence about themselves� Strong sense of home Residents �lie in� Less night sedation Continuity of staff � now address staff by first name

31. 31 Transition Not an easy journey �like everyone moving into a new house at the same time and wanting their choice� May not suit everyone More time �the rush is gone� CNM role more challenging � team and regular meetings �letting go of the old ways�

32. 32 Environment Separate entrance Quietness � day and night Efficiency improved by having facilities closer at hand

33. 33 Some learning� All staff need to receive the same message Observation of care ��insight� Leadership at management and clinical level Research to provide evidence Local ownership Importance of public awareness

34. 34 Research The aim of the study is to explore the process of cultural change, in particular the changes in working practices and relationships of care, which result from the establishment of the Teaghlach Model at the study site

35. 35 Research Methodology a qualitative phenomenological approach Sample Staff Relatives Residents Data collection Focus groups Interviews

36. 36 Preliminary findings from the phase of the research Residents The process of adaptation to long term care R1 �There has to be give and take� R7 �T�is all right� R5 � We don�t go out much� R3 � Nurses are good and they are all nice but I would prefer to be at home�

37. 37 Preliminary findings from the phase of the research Conforming R1 �it isn�t what I would like to do but what you are really left to do� R4 � I like to read every day but it doesn�t always work�because they mightn�t bring in the paper� R3 �I can�t read, I can�t sit up�

38. 38 Preliminary findings Enjoyment and quality of life was dependant on the staff R1 � A lot depends on the staff� �I get on fine I keeps well in with the women� R4 �they make you feel at home� R5 �They are great staff, kind and very nice in every way�

39. 39 Preliminary findings - relatives Emotional �no body wants to put their relative in hospital� �we are very, very lucky� �it is very emotional , exceptionally emotional and say for us we had spent over 2 years caring for mother on a 24hr basis at home and it had got to the stage we could not mind her anymore� � you do feel a failure to them after all they have done for you�

40. 40 Preliminary findings Grateful �You can see by them that they are happy, comfortable, well looked after and well cared for� �that�s it really � it is peace of mind� �Open visiting gives us all a great chance ��also gives a very transparent view because staff are not always aware when a relative will walk in� Priorities �they only go from bed to chair and back again- but it is the simple practical things like clean sheets� �they are always and neat and it is no joke to get all that done every morning�

41. 41 Preliminary findings - Staff Relationships � a lot of them don�t have any visitors� �sometime you and the support workers are the only contact and you try to make their day as happy as possible for them� �I suppose you get to know them and their ways� Routine focused �try and get as much work done as you can before 1st break� �I do a round of patients attend to all their needs, toileting needs or whatever� � I suppose our day is routine really�

42. 42 Preliminary findings Task centred approach to care �the first thing is the drug round� � I organise my care find out who has to be showered� Health and safety a priority �as regards to patient care the priority is patient safety� � there is a huge emphasis now on patient�s safety making sure they are sitting safely, are in a safe environment are not going to slip or fall�

43. 43 Preliminary findings Desired changes �not to be against the clock, to be a little more flexible, team work� �to make more a family environment because they are not going home� �To create a homely environment� � it takes time to change the habits of a life time�

44. 44 John�s Story (not his real name) John spent his days sitting in the day room. He was unable to interact with other patients as his verbal abilities are poor. It was difficult for staff to build up a rapport or understanding with John. This led to John being isolated and frequently would tear at objects especially the chair he was sitting in. One of the behaviours John had was to grab anyone who would pass his chair and this stopped people going anywhere near him. He had episodes of aggression Since moving to 2B we have found that Johns has a keen interest in watching the football on the television; he likes to be taken out to the garden, he likes watching the television if there are animals or lots of colour in the pictures and he loves patting the dog. We found out through talking to his sister that he shows his non verbal contentment when he moves his head from side to side. When one of the staff picked him flowers one day he wouldn�t let them out of his hand for the day. The staff found out that he can communicate with clear commands of �yes� and �no�. He doesn�t grab staff anymore and when staff do put out a hand to him he will hold your hand and then relax it. There have been no incidents of aggression or agitation in the past two months. The staff have changed in their attitude towards him � no longer fearful to pass his chair. His family are delighted with the change in him and say that he is much more like his old self.

45. 45 Joe�s (not his real name) story Joe, is a bachelor who lived all his life alone in a farm in West Cork. He was admitted five years ago. From time to time thoughts of his farm gave him reason to go outside � searching, spent his time alone and he appeared sad. Back in the hospital Joe, would eat his meals alone, beside his bed. Since moving to the unit, Joe chooses to have his meals at the table with a couple of the men. They talk about the �cattle� and the �land�. He has a dry sense of humour, makes his opinions known and his so knowledgeable about so many subjects. His words are few but when spoken are well worth listening to. Joe enjoys the music sessions and only last week built up the courage to sing aloud. Joe no longer looks to go out and on occasions we get a smile or a comment to let us know he is taking it all in. We as staff feel that we are beginning to get to know him. He now calls us by our name so I suppose he is.

46. 46 Thank you for taking time to listen