La codificación léxica

Absent on both Netherton and Rivermead were what we termed vertical and horizontal networks linking the action on PIE beyond the immediate environment of the ward to wider networks of support on dementia, as in Seaford. In part, this reflected the absence of an external driver who could provide such a link; it was also affected by the perceived lack of congruence between the direction pursued within the Trusts on the immediate priorities for action on dementia and focus of PIE on ward level practice change.

There were other dementia improvement initiatives being carried out in City and Ironbridge Trusts. Unlike in Seaford, these operated in parallel with PIE and there was no interchange between them. In both Trusts, recruitment of ‘dementia champions’ was a key element of the dementia strategy; and the champion model broadly operated in similar fashion in both.

In Ironbridge, focus was on developing a dementia champions network with two champions in each area (clinical and non-clinical). The requirement on them was to attend a minimum number of meetings a year and to raise awareness of dementia within their work spheres. The aim was to generate interest among staff at all levels, thereby building awareness of dementia in small steps from what was considered to be a low base of understanding. Staff on Netherton expressed impatience at the evolutionary nature of the approach: improving ward practice needed to be addressed and focus on enhancing general awareness would not achieve this. As the Seaford Trust experience indicated, there is no necessary conflict between adopting parallel approaches (practice change alongside enhancing general awareness). For Netherton staff, the lines of difference were an expression of what they viewed as the low priority attached to patients with dementia with high level needs. In City, the vision conveyed by the matron who played an important enabling role in the dementia champions initiative was that once the ‘champions’ were in place on each ward, they could use PIE to improve practice. This initiative too was affected by organisational upheaval and there was little indication over the course of fieldwork of diffusion of the dementia champion’s network and its reach into wards to improve practice.

Organisational context

In comparison with the other ‘partial implementers’, the organisational context in Netherton and within which PIE was being introduced, was relatively stable and benign. A process of integration of the Elderly Care Directorate and Community Services was underway during interim data collection, and although it involved senior ward staff in additional work, it was perceived as a welcome development.

130

Micro-system change at ward level, was a perceived shift in the patient profile from baseline. During interim data collection a persistent topic of staff informant conversations and interviews was that the patient profile had become more medically acute and physically dependent. As an ongoing presence on the ward, the researcher was conscious of the level of emotional and physical work undertaken by staff to maintain a pro-active and responsive approach, to relieve and manage distress and agitation among people with delirium and dementia, and to sustain a relatively calm environment.

Patient data collected at interim supported staff perception of a change in the patient profile. The age and gender profile was similar for the two time periods, as was the prevalence of dementia (93% and 98% respectively) and delirium on admission (80%). At interim, however, a fifth of patients were admitted from long term care, double that at baseline. The mean length of stay had also reduced from 42 to 31 days. These indicators would tend to suggest a more dependent patient profile; a picture that was supported by research observation. Thus, few patients were seen routinely walking about on the ward compared to previously. Staff perceived that more of their patients were presenting challenging behaviour (acting out in anger at staff, shouting, and unpredictable in their actions and interactions). Such a change was not discernible from fieldwork: at baseline also, staff were working with many patients with delirium and dementia whose agitation and distress escalated during late afternoon and at night. Further, although the staffing complement was unchanged between baseline and interim, fieldwork indicated that during the morning and afternoon shifts, actual staffing was frequently down by a nurse; typically moved to support a neighbouring ward. Qualitatively, many staff projected weariness in their body stance; unnoticed during baseline. This might have reflected timing of data collection phases: baseline occurred between mid-August and early November; interim fieldwork began end of November to the beginning of February, a period of heightened demand on beds.

As indicated above, the problem of leadership as it impacted PIE implementation in Rivermead was shaped by turbulence in the Trust. By summer 2014, organisational changes resulted in high work pressure on the ward as the effects of ward closures (30 beds across care of older people wards) percolated to ward level. Across the Trust, the level of admissions was regarded as unprecedented. For ward staff and middle managers it meant an absence of ‘headroom’ for reflection and planning as ‘firefighting’ consumed the working day: “we’re so focused on the basics today that we have no

time to look at tomorrow”. Work pressures contributed to reduced morale. It was also observed

that sickness and staff vacancies had resulted in more extended use of Bank staff. In informant interviews, staff expressed hope that PIE would be picked up again when timing was more

131

favourable. Work pressures persisted on Rivermead through interim data collection between January and March 2015; and several staff left, exacerbating staffing difficulties.

A further full CQC inspection in October 2014, reporting in April 2015 resulted in an overall assessment of ‘requiring improvement’. Governance and staffing levels were identified as issues to address. A re-organisation of middle and senior manager tiers was aimed at addressing the former; the persistence of recruitment difficulties contributed to further bed closures and ward re- organisation. In summer 2015, a decision was taken by senior managers to close Rivermead with immediate effect; the manager being informed the week before it was to take place. Over several weeks, concerted opposition from clinicians resulted in revision of the plans: the merger of two wards. As a strategy to retain staff with perceived expertise in care of older people and a resource built up over several years, it was unsuccessful. Many staff had already moved to other posts and what had been a stable ward team, dispersed. The end of Rivermead ward brought the research here to a conclusion.