La actual colaboración ILG-RAG

Based on their response to PIE, we characterised non-implementers as: ‘tentative’’: wards that expressed continued interest in PIE but timing for change was wrong; and ‘disengaged’, wards which did not engage with PIE after re-assessment of the decision to proceed, ’true’ non- implementers..

Tentative implementers

The three wards in Central Trust were ‘tentative’ implementers Although two of them – Rose and Beech – took faltering steps to PIE installation; and the third – Denton – made no progress beyond the exploration and adoption stage, the factors which shaped their varied responses were the same. Denton, a dementia ward, was established in early 2013 to provide support to people with dementia who were ‘medically fit’ but would benefit from ‘enhanced recovery’ (Chapter three). From a performance perspective, an additional objective was to facilitate timely flow of patients from the acute wards of those deemed ‘challenging’ and either ‘unsafe’ to return home or likely to need long term care placement. The staff team had been recruited for their knowledge and interest in working with people living with dementia; and care delivery, similar to that on Netherton, was person-centred. From the outset, staff were enthused by the potential of PIE to enhance care of people admitted to the ward. Shortly, after fieldwork began, it became evident to the research

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team that its continued existence was uncertain. From one week to another, the site researcher was apprised of varied accounts of the future of the ward oscillating between closure, expansion and permanence. By Autumn 2013, the dominant narrative was closure, ostensibly because of the lengthy stay of patients admitted. Although work practices were directed at supporting individual patients, and staff in their own time pursued fund-raising initiatives to enhance what they could offer, a consequence of the lack of a clear strategic vision for the ward at hospital and trust level was that goals for improvement were immediate to short term. Even so, the ward manager assumed the role of PIE ‘champion’, advocating with peers on Beech and Rose wards to engage with PIE and took the lead in organising and facilitating PIE workshops.

Both Beech and Rose ward managers were open that knowledge of dementia among staff and care of people with dementia on their respective wards, required improvement. Additionally, both wards were in transition. The Rose manager was new in post and building relationships with the team; her Beech ward colleague, although very experienced, had assumed leadership of a new ward model and staff group. For her, forging a team ethos and ward culture was regarded as a work in progress. Both expressed interest in being actively involved in PIE.

These three, along with three staff from Rose, Beech and Denton wards respectively took part in a joint PIE workshop in early November 2013. The event sparked interest in using PIE. At its conclusion, all three ward managers arranged to meet and discuss how to work jointly to take PIE forward. They anticipated working collaboratively to support each other. There were potential difficulties: Beech had moved physical location and the manager had been informed that the ward purpose was changing from an acute medical facility to a step-down assessment unit. The perception of managers on these wards, and conveyed in informant accounts was of decisions being discussed and pursued at Trust and senior management levels, and involvement of them at the point when decisions had been arrived at. Further that changes could not be communicated to their staff until the decision was actioned. Although the research remit did not extend to decision-making beyond the ward, staff on all three, conveyed in interviews and informant conversations, their sense of being continuously ‘acted upon’ with regard to changes in their work roles and environments in which they had little input to shape. For the Beech ward manager, the proposed change in ward model was the third in as many years.

In some respects, Beech and Rose wards were unlikely implementers in that the scale of change required to improve practice was considerable. Even so, PIE was regarded as a lever to effect improvement. Following the workshop, Denton, Beech and Rose managers working in pairs undertook several practice observations on Beech and Rose respectively. The research team offered a further workshop on action planning which was difficult to organise: Beech was in transition

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between an acute ward and step-down unit, maintaining both functions with a lower staff complement, and Denton’s future was uncertain. In Spring 2014, the Denton ward manager confirmed that the decision to close the unit had been definitively made, Rose ward was also planned for future closure, and further changes to the Beech ward model were being planned. Staff on all three wards were reported to be demoralised and looking to move on: they were unable to continue with PIE..

Non-implementers: Re-visiting the exploration and adoption stage

In Valley Trust, the senior nurse for older people and intended ‘driver’ of PIE on both Ambridge and Oak wards moved to a new post during baseline fieldwork. Although the research team sought to involve a staff member at a similar level, no-one was identified to provide it. Facilitation support at ward level was not forthcoming either, in part reflecting staffing shortages on both Ambridge and Oak wards. Two of three introductory workshops organised for staff on both wards during January and February 2014 were poorly attended; a third was offered but cancelled on the day as staff could not be released. No senior ward staff were able to attend any of the workshops.

Feedback from the workshops posed the question as to how those attending perceived PIE: as an approach to engaging them in a process of change; or as training in dementia care. The first part on the dementia experience was perceived as valuable; the second, on implementing PIE was not viewed as salient to their current concerns, namely getting through daily tasks with patients. For some participants the gap between current practice and ‘person-centred’ care was so wide that improving care required basic knowledge and skills in dementia care to move forward; for others, the care they provided was as person-centred as it could be with the resources at their disposal. Further attempts to organise workshops were unsuccessful, including pursuing negotiation at directorate level for support. Both ward managers indicated that PIE implementation was not possible; it was ‘out of time’. The current constellation of factors, staffing difficulties on both and senior staff moves on one of them, indicated that if circumstances changed, pursuing PIE might be possible. The research team agreed to contact ward managers later in the year. Over the following six months, the research team made several attempts to re-engage senior ward staff on both Oak and Ambridge: some had moved on; staffing difficulties persisted; and Trust priority was on dementia training with staff.

Similar to all recruited wards, ‘buy-in’ to PIE had been negotiated and ‘readiness’ criteria met. The departure of the senior nurse who was to drive PIE curtailed further engagement. Attempts to pursue PIE occurred, first, through discussion at directorate level on how to identify a replacement ‘driver’; and then by returning to the stage of ‘exploration and adoption’ with ward managers.

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Neither were successful. Although the senior nurse had acted as a ‘change champion’ through the initial exploration and adoption stage, there was no-one willing to assume this role on her departure. Whereas change ‘champions’ can play a pivotal role in facilitating innovation, their effectiveness also depends on whether they can harness networks of support to carry it through.80,112 _{Regarding PIE,} those networks did not survive the ‘champion’s departure, although here too there appeared a lack of resources at ward level to pursue a service improvement process requiring ‘headroom’ to action. Cedar ward in City Trust, the companion ward to Rivermead, was the outcome of ward re- organisation, an amalgamation of medical and orthopaedic beds resulting from reduction in beds within the hospital. A late entrant to the study within weeks of its creation, the task for senior ward staff was to construct a team and develop systems and mechanisms to deliver care to a new patient group.

Although a number of staff from the original older people’s ward had attended the PIE workshop, there was no further engagement at any level in PIE. As with Rivermead, the PIE driver had no capacity to lead the work and the same demand pressures and organisational change at City Trust which impacted on Rivermead also affected Cedar ward directly. Reflecting back, the ward manager considered that the decision to take part in the research had underestimated the level of work involved in forging a new team, which coupled with demand pressures meant that ‘timing’ was not right. Although, the ‘timeliness’ of an intervention is a feature of context receptivity in adoption, it has not been an explicit focus of research interest.80 _{We suggest that although ‘timing’ is a relevant} ‘readiness’ criterion in site selection, it does not determine successful implementation in absence of a facilitative organisational context.

Summary

Only the Seaford trust wards had all the conditions in place to effect PIE implementation. In essence, interaction between micro-level features at ward level and a facilitative organisational environment created the conditions for a receptive context for change on these wards. Elsewhere, organisational turbulence impacting in multiple ways at ward level, resulted in an organisational environment which was unreceptive to change.

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