The ward environment has provided a challenging context from which to progress a Microsystem. The competing clinical demands of being a 24/7 inpatient service have at times made it difficult to have consistent and representative attendance from across the MDT. This challenge has meant that changes have perhaps taken longer to implement and embed. The team has continued to show real determination and have persevered with the Microsystem approach and are starting to see the fruits come to bear. Many of the changes have been planned and led by the Support Worker team and the Activity Co-ordinator who have been supported to do so by the leadership team.
The assessment stage allowed a sense of ownership to develop across the team, enabling them to identify areas for improvement by assessing the available data, current processes, views of professionals and patients. The assessment was underpinned by a common purpose agreed by the whole team and used to guide future changes.
Six themes for improvement emerged from the assessment:
- Referral process
- Admission process
- Discharge process
- Staff wellbeing
- Therapeutic Activities
The team decided to focus on therapeutic activities as the priority theme and hoped to achieve the following:
- Patients being more occupied whilst on the ward
- Reduced patient agitation, fewer incidents and seclusions
- Building therapeutic relationships through meaningful activities
- Equipping individuals with long term skills and interests
- Helping people to maintain their interests whilst in hospital
A fishbone diagram was used to help focus the team on some of the core issues preventing the delivery and access to activities on the ward and this helped to inform potential changes which might address these. The team wished to address the following question:
‘Why aren’t people on the ward accessing beneficial activities?’
Following the diagnosis the team wanted the initial changes to address:
- Processes and policies which prevented activities happening
- The lack of activities after 6pm
- Not maximising the available space
- Linking activities to care plans
Change 1: Regular Cooking Groups
The team wanted to start regular cooking groups whereby staff and patients could cook and eat together.
To enable this change a food hygiene course, specifically designed for staff on an inpatient ward, was held for three of the support workers within the team. This course has now been extended to the wider team and there are plans for it to be delivered on the ward so that it is more accessible. The intention is that cooking groups are not reliant on a few individuals and can be delivered by the wider team, meaning that they can become more spontaneous and take place when the opportunities arise.
The team have reflected on each cooking group and have evolved their approach and have:
- simplified and clarified the process for reimbursing staff when they buy ingredients
- changed the process for planning a meal (see change 2)
- written a recipe book which provides instructions for meals that work well in a group
- started keeping stock ingredients that don't spoil so that meals can be more spontaneous
Cooking groups have now become a regular feature on the ward and often happen after 6pm.
the activity was enjoyable and the food delicious
everything was delicious - keep it up
I participated in making and the food was enjoyable
superb – absolutely delicious vegetarian alternative
would love to participate in the creation next time
Change 2: Planning Activities
It can be difficult to plan a group activity on an inpatient ward given that acuity, staffing and observation levels are subject to change. In the past this has resulted in planned activities not going ahead. To address this the team are now planning activities for the short term and taking stock of the known conditions which will affect an activity going ahead. Through discussion with the ward manager and shift co-ordinator a decision is made as to whether, if all things remain equal, an activity can go ahead with the facilitator kept out of the 'ward' numbers. This approach has helped to make the activities more responsive to the conditions on the ward with a greater chance of a planned activity going ahead.
Change 3: Regular Film Evenings
The team wanted to trial having regular film nights on the ward to help address the of activities after 6pm.
Having reflected on each film night the team have evolved this into a successful activity with:
- the film no longer shown in the communal area and instead making use of the equipment in the MDT room
- patients being given a choice of film so it replicates the choice people get at the cinema
- an interval during the film where patients have snacks together
- the wider team being trained on the equipment so that anyone can set up and host a film night
The film nights are now well attended and with fewer interruptions and distractions people are choosing to watch the entire film. The film nights are scheduled to happen on alternate Thursday's and Saturday's but due to their popularity the team may look to make this more frequent.
Change 4: Recording Activities
As group activities were being progressed the team started considering the ways in which activities are recorded. The activities provided a very different context for conversations to take place and valuable insight in to somebodies recovery. This information is often observed at the time of an activity but isn't always shared with the wider care team and may not inform care plans or MDT discussions.
As a result the team are now:
- Having time factored in at the end of the activity to briefly write in the patients notes
- This note is being copied and pasted in to the MDT review form so that it informs care planning
- A folder is kept on the ward to record any feedback or learning from activities
- Patients are really enjoying the activities and their involvement continues to increase each time an activity group happens (i.e. more patients are helping to prepare, eat and wash up in the cooking groups). Through the activities some patients have achieved significant personal milestones which have helped in their recovery.
- When the activities take place there is less boredom on the ward. Those participating in the activity have said they value the time away from the main ward environment, whilst those not participating in an activity have reported that the ward is a nicer place to be whilst activities are taking place.
- Staff participating in activities have found that the more relaxed setting has encouraged therapeutic conversations to take place. One of the main benefits has been staff and patients sharing in an experience (such as eating a meal together) and this is helping to enhance therapeutic relationships.
- The team are feeling empowered and are developing a greater sense of ownership in relation to ward activities. They are leading on and taking forward more and more ideas and these are being progressed through the Microsystem Meeting.
Through the ‘Ward Activity Folder’ the team are recording:
- Group activities which have taken place
- The number of people attending the activity
- Lessons learnt from each activity
The teams aim is to have a regular group activity every other evening
There are many benefits associated with these changes - some of which will be informed through:
- The impact on restrictive practices and incidents
- Patient and staff qualitative feedback