British Geriatrics Society

Improving the experience for dementia - Taunton and Somerset undation Trust -

In the third of our growing series of case studies, we feature the Taunton and Somerset model for improving care for dementia patients.

Launched in 2000, Enhancing the Healing Environment (EHE) was one of five major grant programmes that The King’s Fund launched to mark the Millennium. Since 2003 the Department of Health has funded the extension of the programme in England and the aim of these grants is to encourage and enable local trust teams to work in partnership with patients to improve the environment in which they deliver care. This case study outlines the work that Taunton and Somerset NHS Foundation Trust did at Musgrove Hospital as part of the programme to improve their wards for people with dementia.

Background

The Dementia UK report found that the number of people with dementia in the UK is growing. 700,000 people have dementia and this is forecast to increase to 940,000 by 2021 and 1,735,087 by 2051 – an increase of 38 per cent over the next 15 years and 154 per cent over the next 45 years. People with dementia over 65 years of age are using up to one quarter of hospital beds at any one time. Forty-two per cent of individuals aged over 70 years with unplanned admission to an acute hospital have dementia, rising to 48 per cent in those aged over 80 years. People with dementia stay longer in hospital than people without dementia.

Challenges

The physical environment has a major role in the care and support of people with dementia. A ward designed to meet the specific needs of this group helps them to retain their function and skills, reduces their anxiety and can enhance the healing process. A ward environment suitable for the needs of people with dementia will often also benefit other older patients.

Solutions

The England Department of Health has conducted two independent evaluations of the EHE programme. The Medical Architecture Research Unit (MARU) was jointly commissioned by NHS Estates and The King’s Fund to undertake an evaluation of the acute and mental health schemes in London (Department of Health, 2003). MARU found that the projects brought a ‘sense of normality’, created a ‘sense of welcome’ and provided social spaces that presented dignified and comfortable areas for relatives and friends away from the clinical environment. The other evaluation, by the York Health Economics Consortium, found that the schemes had increased staff, patient and user satisfaction and improved use of space. It also found that redesigning the wards had affected the way in which clinical care was given: for instance, the nurses in the discharge lounge refocused their management of patients within the lounge, delivering more education and advice.

The key changes undertaken at Taunton and Somerset were:

Redesign of the nurse station: the nurse station is an area to which all ward and visiting staff gravitate. It can be noisy and intimidating to visitors as well as patients. People with dementia often like to walk around the ward, which can be fraught with obstacles and people. Removing the nurse station has created a large open space with a warm and friendly ward entrance and a seating area for patients and their carers. To make the area less clinical and enhance the social ambience, non-standard hospital chairs (tub type) in bright yellow were chosen.

Use of colour: Colour contrast rather than the colour itself and creating a more familiar, less clinical feel is the important concept here. Deep colours are better than pale or pastel colours because through the older person’s eyes, deep colours create a better contrast. (Try looking through a yellow plastic/acetate film to see the difference). The flooring is a wood effect laminate, giving a warmer, less clinical feel to the ward.

Importantly, in the bathrooms and toilets, colour contrast is used, together with more familiar fixtures and fittings. Many bathrooms and toilets in hospitals are all white - a white toilet against a white wall, with a white dispenser holding white toilet roll - all of which makes it difficult for an older person, especially with dementia, to see bathroom furniture clearly and to use it effectively.  The aim of these changes is to enable people with dementia to maintain their skills.

Signage and orientation: changes have been made to improve way finding. The four bays on the ward are distinctively colour coded using wall paint and matching furniture. Clear signage is used on the bathroom and toilet doors. New hand rails in a strong contrasting colour have been added to the main ward area and the entrance corridor.

Art work has also been used extensively throughout to stimulate conversation. The corridor walls on the way to the ward are decorated with beautiful large quilts, each representing a decade from 1940-70, made by a group of local volunteers. The hospital’s Art for Life group provided cheerful black and white photographs dating from the post war years. Around the ward lie photo albums holding an array of vintage postcards of favourite UK beauty spots and sea-side resorts, collected by ward staff – many a honeymoon has been fondly recollected as a result.

A quiet room: by creating the sitting area in the centre of the ward, the old small day room has been released to create a much needed quiet room in which sensitive conversations with patients and families can be held.

Lessons Learnt and Changes to Practice

The project is in the early stages of evaluation. Removing the nurse station has necessitated a change of practice for nursing staff. Along with members of the allied health professional team, they are now spending more time in the bays with patients. The social seating area has proven to be popular with patients and their relatives as well as staff. Patients are using the area extensively at all times of day, and those who wander often use the area at meal times and will sit to have snacks and drinks throughout the day. At night, the sleepless confused patient can sit comfortably in the centre of the ward where nurses pass by frequently.  There has been positive feedback from all visitors who report that the ward now feels warm and friendly.  Patients have said the ward feels ‘cheery’ and ‘homely’. There may have been an impact on the rate of in-patient falls but it is too early to tell at this stage.

The reception desk is working well but there is limited space for the doctors, which has caused some congestion. Installing another computer and telephone for nursing staff away from the reception has improved this a little. The reception desk was designed for wheel chair access, and this has resulted in the loss of storage space. This area has not been used and if we were to change anything, the need for wheelchair access to the reception desk would be reviewed.

Storage space is now very limited and whilst this forced us all to de-clutter, the lack of storage difficulties has not yet been fully resolved!

Next steps

The next steps are to complete the evaluation and disseminate the learning throughout the trust and wider community. We are also looking at occupations for patients on the ward and are working with the trust’s Art for Life co-ordinator to introduce a variety of activities.

Contacts: Dr Lucy Pollock, This email address is being protected from spambots. You need JavaScript enabled to view it.