Junior doctor dementia champions in a district general hospital (innovative practice)

Abstract

Dementia is a common condition in the UK with around 25% of patients in acute hospitals having dementia. In the UK, there is national guidance on the assessment of cognitive impairment in acute hospitals. This article is a qualitative study of junior doctors' experiences as part of a dementia and delirium team involved in changing the care of patients with dementia in a hospital in the UK. It draws on data from a focus group and follow-up questionnaire in two hospital trusts. We examine what drives doctors to become involved in such projects and the effects of this experience upon them. We suggest a typology for getting junior doctors involved in projects generating change when working with patients with dementia. Being more actively involved in caring for and developing services for patients with dementia may represent the crossing of an educational threshold for these junior doctors.

Keywords

care CQUIN dementia junior doctors threshold concepts

Introduction

Dementia is a common condition in the UK with around 25% of patients in acute hospitals having dementia (DOH, 2012). On certain wards, such as those in elderly care departments and hip fracture units, the presence of patients with dementia or other forms of cognitive impairment may be up to 40%. The presence of dementia is associated with an increased length of hospital admission, more inter-ward bed moves, higher rates of readmission and an increased likelihood of a cognitive deterioration in the form of acute delirium. In addition, the Care Quality Commission, the independent regulator of all health and social care services in England, identified that patients with dementia are 30% more likely to come to hospital with potentially avoidable problems (CQC, 2013).

In 2012/2013, the Department of Health in England introduced the national Commissioning for Quality and Innovation (CQUIN) payment framework with regard to dementia care in hospitals. This set out to pave the way to improvements in the identification of, and care for, patients with dementia in acute hospitals. The national CQUIN consisted of three parts (DOH, 2012):

Case finding with over 90% of patients aged 75 and older being asked a screening question within 72 hours of admission.

The diagnostic assessment and investigation of over 90% of those patients who have been assessed as ‘at-risk’ of dementia from the dementia case finding question.

The appropriate referral of over 90% of those for specialist diagnosis of dementia and appropriate follow-up.

In many acute trusts, the screening question has been included in the clerking pro-forma used when a patient is admitted to hospital. These are often completed by junior doctors when they admit a patient.

We feel that, in order for this process to be completed accurately and efficiently, the junior doctors have to be involved in its development. Foundation year one (FY1) doctors are doctors in their first pre-registration year following medical school they start working in hospitals in August. At the FY1 induction in Trust A in the August of 2012, the idea of having junior doctors as hospital ‘dementia champions’, to promote the work set out in the CQUIN, was raised. A small number of junior doctors volunteered to take part; with a consultant and registrar, they formed the dementia and delirium team (DaD). Initially, they collected data about the CQUIN achievement and then, over the year, set up structures to improve care, including the design and implementation of a ‘forget-me-not’ scheme on all wards in the hospital. The forget-me-not scheme became a multifactorial intervention surrounding the care of patients with dementia. There were information leaflets for relatives, a car parking permit, a hospital passport, patient identifying stickers for the ward patient lists and an ‘8 things about me’ form for completion in conjunction with patients and relatives. The first foundation year doctor champions set up the dementia screening and forget-me-not scheme on the wards in which they spent their initial four months, and then as they moved job roles within the trust (every four months), the scheme was handed over to a new ‘dementia champion’ on the original ward and the junior doctor went on to set up the scheme with their new team. Over the course of the year, the CQUIN achievement increased with almost 100% compliance in all domains (Wilkinson & Lee, 2014). This high level of assessment has been maintained to date.

The enthusiasm of the original core group of FY1 doctors was essential to the initial success and sustainability of the scheme. We feel that this is an example of an activist form of professionalism (Wilkinson & Lee, 2014). In order to achieve long-term sustainability, the reasons why this group of doctors were so successful need to be understood. To this end, a focus group was convened within Trust A to assess the program from the junior doctors' points of view. Following this, the key themes were explored with a follow-up questionnaire to junior doctors in a neighbouring trust (Trust B), in order to explore the drivers for involvement in another population of junior doctors. In this study, we present the analysis of this focus group session and the subsequent questionnaire. The following analysis aims to answer two questions:

(1) What influenced the junior doctors to become dementia champions?

(2) What impact did being a dementia champion have on the junior doctors?

Method

This was a focus group performed with six of the dementia champions in Trust A – a district general hospital – in South London, UK. The focus group was run on a voluntary basis but with purposeful sampling from the pool of junior doctor dementia champions (i.e. all dementia champions were invited to participate but non dementia champion junior doctors were not). The group was held in a quiet room in the postgraduate centre in the hospital during working hours. All of the participants were towards the end of their first foundation year. Four doctors had been dementia champions for 11 months, one for 7 months and one for 4 months.

The focus group design was conducted by IW and SM using the principles suggested by Cousin (2009) and Rubin and Rubin (2004) to develop a semi-structured discussion. The group all gave consent to have the session recorded from start to finish and the data to be used thereon. The recording was transcribed verbatim by IW and SM with all names being anonymised. The transcript was checked by SM and IW, and the transcribed text was uploaded to the ‘Dedoose’ qualitative analysis software.

The questionnaire design used the initial results from the focus group around the impact of being a dementia champion on the junior doctors and then explored these areas in a novel group of doctors. Answers were a mixture of scenario-based multiple choice questions and open-ended questions, prompting a longer written answer designed to facilitate a qualitative analysis of the answers. Questionnaires were sent to all junior doctors working in a neighbouring trust which did not have junior doctor dementia champions but did have an active junior doctors forum (JDF) through which a junior doctor-led change could happen. Anonymised questionnaires were sent electronically with a link to a ‘google form’ for completion to all junior doctors working in Trust B (two district general hospitals in SW London). A reminder was sent two weeks later. Twenty forms were completed and analysed using ‘Microsoft Excel’.

An interpretive phenomological analysis (Biggerstaff & Thompson, 2008) was performed with a view of understanding the reasons for volunteering to be, and the impact of actually being, a junior doctor dementia champion. The focus group text was coded line by line by IW. The coded data were then analysed separately by IW and SM to generate themes which are presented below. The questionnaires were analysed in a similar way by IW and AC.

Results

What influenced the junior doctors to become dementia champions?

There were three themes that encompassed the reasons that junior doctors volunteered to become part of the DaD team. These are: ‘prior experiences’, ‘peer involvement’ and ‘desire for knowledge gain’.

Prior experiences

The first doctors who chose to volunteer had experience in looking after relatives or other people with dementia.

I’ve always been more interested in dementia because my granny had it… I remember when she was in hospital and my Mum panicking at home about it, you know ‘Will anyone know? Will anyone help her eating?’ and you know my Mum rang the ward and said ‘Can I come in to help with eating?’, rather than, than… you know. So when I heard about it, for me, I could just imagine if it had been there for my granny when she was in hospital, how much nicer it would be for our family at home, to know that there was… such a scheme in the hospital. (Participant 5)

And you know I did see it occasionally in surgery you know, people with memory problems, and you think, ‘Are they getting the best care? Are we doing everything we should? Would I want that for my grandparent?’ And I think that was the sort of a push for me. (Participant 3)

This personal involvement from both of these doctors was very influential in the development of the enthusiasm needed for the initial core group of champions to develop.

I think, I really like patients, and I realise not everyone feels that way about patients; and I think you have to really like patients to want to be a dementia champion. (Participant 4)

Peer involvement

From this point on, the initial doctors’ enthusiasm and the sense of a ‘group coming together’ led to the snowballing effect that was seen. The fact that the process was led by their peers seemed to lead to an increased interest in the team's work over the year.

So when XX [FY1 doctor] got involved she sort of told us about it didn't she, just in sort of, I don't know it just came up. And then, because we both like medicine and geris specifically as well, we approached Dr XX [Consultant]. (Participant 5)

So then when I started on the elderly care firm I think it was much more, I heard people [junior doctors] talking about it and I hadn't really known about the scheme and it was sort of, Dr [Consultant] had, or I think it might have actually been you [to participant 4] that emailed me… and I thought I'm quite interested… (Participant 2)

Peer involvement also came through from the questionnaire. The influence of the JDF formation in the second trust was a key driver for a number of junior doctors to become involved in service development through quality improvement projects and allowing the junior doctors access to the management meetings taking place in the unit.

We have founded a Junior Doctors Forum with great connections with the Trust management and representatives sitting on 13 Trust committees. Our forum discussions are disseminated to many consultants and managers, and we are leading a project on improving the quality of discharge summaries - something that the JDF initiated and we're working with the Trust executive to see changes happen. (Questionnaire answer 7)

Desire for knowledge gain/knowledge deficit

Some of the junior doctors felt that they did not have the practical knowledge required to look after patients with dementia. The necessary completion of the CQUIN served as a prompt which identified the gaps in their knowledge. Becoming dementia champions helped them gain the knowledge they felt they were lacking.

Just because we needed to know how to do everything, we needed to know that the AMTS needed to be done for those patients, and most of our patients were over the age of 75 so the AMTS needed to be done, the confusion screen needed to be done, the collateral history needed to be done, CT's and the blood tests needed to be done and then the referral needed to be done. So because we were auditing so many patients and we needed to know how to do everything. So I think becoming a dementia champion made us enthusiastic about doing it really. (Participant 6)

They were aware of the large numbers of patients with dementia under their care; this also served as a driver to gain more knowledge. Membership of the team served both as a means of recognition, that this feeling was not unique to them, and also provided a way of gaining added skills and experience in this area.

XX[FY1] and I were probably the next to volunteer as the second and third people. But it was mainly because we had so many people suffering from dementia on the wards, that… we thought it would be nice to have a bit more [knowledge]. (Participant 6)

When they moved through the hospital posts, their prior experiences during the year prompted the junior doctors to question the standard of care they delivered (as stated by Participant 2 during her placement in surgery). When then given the opportunity to take part, they grasped it. When directly asked, 65% (n = 13) of the junior doctors felt that they had the skills needed to provide a good standard of care for patients with dementia. The vast majority though, 90%, (n = 18) felt that the standard of care to patients with dementia would be better on a specialist unit, and 85% (n = 17) felt that the standard of care delivered to patients with dementia was less good than that delivered to patients with other conditions. This suggests a need for ongoing specialised training of junior doctors in the management of patients with dementia. We then went on to ask what the doctors would like to gain from a training session – designed to increase their confidence and skills with people with dementia. The two key topic themes were: the further development of appropriate communication skills and how to deal with the common practical scenarios faced on the ward (i.e. nutritional difficulties, behavioural and psychological symptom management and end-stage disease management).

What impact did being a dementia champion have on the junior doctors?

Analysis of the impact of being a dementia champion on junior doctors was seen in three themes: ‘gaining of knowledge and skills’, ‘understanding of their role in patient care’ and finally ‘leadership and career development’.

Gaining knowledge and skills

The opportunity for deeper involvement with patients with dementia led to a clear improvement in the transferable skills that the junior doctors felt they gained over their foundation year. They all felt they all learned more than just about the dementia CQUIN or how to investigate and manage cognitive impairment in acute hospitals. Understanding a patient's cognition in order to add weight and value to the history was a commonly gained understanding, as was an improvement in confidence and skill in communication with patients' relatives.

So clarifying their cognition on admission will always help their acute condition as well as their cognitive state. And I think being a dementia champion puts that at the front of your mind… It's the process, so with every single patient you keep exactly the same routine. So you examine their chest, you examine their abdomen, you do an AMTS and you examine their neurological system, and it should just be something that you automatically do. (Participant 6)

I think it has made me a better doctor in that I am much more confident in talking to patients' families now… having to do lots of collateral histories and … I am a lot more at ease in that situation that I was when I first started. (Participant 4)

Understanding of their role in patient care

The junior doctors felt that, at the start of their year, they had very much a ‘secretarial’ role to play in patient care. However, as they became dementia champions their comments changed to include a wider aspect of delivering care to patients and their families. There are two empowering factors in this change. One factor was undoubtedly the fact that they were ‘the dementia champion’ on a given ward and that therefore their more direct role in care was ‘sanctioned’.

I think it has probably made me better as well I think in sort of going onto other jobs it has kind of made me realise what the standard of care should be, you know this is obviously particularly about dementia but I think you know it does make you think you know there are you know important standards …as a champion just to have a chat with a relative you can be so reassuring and I think relatives really like it…and sort of saying you know we want to get to know about your father or something we want to help them and make sure they get the best care must be a huge relief…(Participant 3)

…and like taking collateral history it means that you are more involved with family and so different members of the family come and you said, 'Oh your sister is arriving from Australia next week and she is coming to visit 'and they think 'Oh how did you know that? You have obviously looked after my parent really well'. (Participant 6)

The second important factor seems to have been the senior support for the scheme from the consultant lead – something found in other studies of junior doctor development (Brennan et al., 2010) and in the questionnaires. The junior doctors felt empowered by this support to go and make changes and talk to patients with dementia and their families.

I think Dr XX's influence has been huge because she have made this seem like what every patient should have, a sort of natural course of events for patients and I can almost not imagine going to another hospital where they don't have this sort of set-up. (Participant 1)

The results of the questionnaire showed that, in a hospital with no dementia champions, there was less evidence of junior doctors being willing to provide hands-on care to patients. There was recognition that the junior doctors themselves could change their behaviour with regard to specific interactions with patients with dementia. Despite this though there were a number of perceived barriers to actively delivering care to patients (a scenario was given with a patient who needed encouragement in drinking and questions based on how to deliver this during your ward round). Being too busy was seen as a barrier by 74% of the doctors, 21% felt that more active care would not be supported by the rest of their team and one doctor felt that it was part of the nurse's role.

Leadership and career development

As dementia champions, the junior doctors were aware that they were potential role models for other doctors. In fact, they were often asked for advice from other teams about the CQUIN assessment and recording process. They offered support for both other junior doctors and also nursing staff caring for patients with dementia.

I don't know what you find but I find that other people ask me about it, as in other F1's. Because at the moment it's only me in orthopaedics out of us four, and the others, they do all their own stuff themselves but if they don't know something they'll say “you're the dementia champion, should I be doing this?” or like “where is the folder kept for this?” or ummmmm….. I dunno, like “Should I get a CT Head, or should I speak to, say, Dr XX, or should I……..” so I think probably that's because the other guys know that I am a dementia champion and I'm more involved. (Participant 5)

The project was an opportunity for the junior doctors to develop their leadership skills and present their work at a number of forums around the country, bringing a sense of achievement and valuable experience prior to application for further training. This experience they felt has instilled the confidence to go on to further leadership projects in the future.

…. I've been able to go to conferences and go to present it and I think because I needed that extra, sort of,… support to get on with projects, like that, initially, because I had never done it before, it's been really useful for that. And so I, right at the beginning, and you as well XX [FY1 Doctor], right at the very beginning we said we want to try and present this, we want to try and write it up to try and get some stuff on our CV. And I had a lot of support doing that, and help along the way, and now I feel way more confident about doing projects next year. I wouldn't feel like I need half as much support next time - I know how to write a project. (Participant 5)

Results of the questionnaire in Trust B demonstrated the clear importance of quality improvement projects as a means of helping career progression. The doctors had completed twenty-six of these between them, however, only one involved patients specifically with dementia. This reflects the JDF's focus on a range of issues regarding inpatient care as opposed to the DaD team's focus on dementia care alone.

Limitations

This is a result of one focus group conducted with a single group of doctors at the end of their FY1 training. Over the course of the year, a number of important formative events will have taken place. It is recognised that the transition from medical student to junior doctor is likely to offer a number of transformative learning moments; being a dementia champion is potentially one of these opportunities which has led to the change seen in these doctors.

The cohort of junior doctors was especially motivated to improve dementia care at a time when there were a number of national strategies being launched to improve dementia care in acute hospitals. However, each trust is different and as such, their experiences may differ from junior doctors in other hospitals.

The questionnaire represents a small sample of doctors drawn from all the junior doctors in the trust. Exploring a different population removed the potential bias of including doctors who had had some contact with the dementia champion scheme. At Trust B, there were moves to set up a dementia champion scheme but this had not happened as yet.

Discussion

The fact that prior experiences were so instrumental in the development of a motivated group of junior doctors is not surprising. Within medicine, there is much stress placed on reflective practice being a large part of how we learn and develop. Much work has been done on this, developing from John Dewy's initial thoughts (Simpson, Jackson, & Aycock, 2005) to Kolb (1984) and more recently, Jarvis (2009). Each of these theorists comments on the importance of an event upon which to reflect that leads to some form of development. Events which create more reflection will likely lead to a greater change and influence going forward. Participation in the DaD team was a means of getting the development that these junior doctors felt that they needed. Being part of a team then allowed them to develop a community of practice with shared beliefs and goals (Wenger, 1998). Being part of such a community cements the feeling of identity and helps explain the snowballing effect that we saw in Trust A. It also underpins the change in understanding of the scope of one's role as a junior doctor that they experienced. The support and encouragement gained from senior doctors ratified this feeling of involvement in a community developing practice, allowing it to develop further and promoting the active delivery of care as the norm by removing some of the barriers identified in the questionnaire (namely, unsupportive seniors and short rotation lengths – the DaD work continuing throughout their rotations). As can be seen in the quotes above, the presence of a supportive senior person in the team is imperative. It seems that although the senior colleague may not actually be the person delivering whatever change is being made, their support gives credibility to the changes suggested and implemented by junior doctors and provides an absolutely key motivator.

With regard to being too busy to deliver the active care – which was felt in Trust B – a number of comments in the focus group from Trust A identified that actually spending the time to get to know patients saved them time in the long run. This may seem counter-intuitive to many busy junior doctors. Coupled to the fact that it led to a transformative change in the junior doctor dementia champions' attitudes to their patients, their colleagues and their personal skills, this raises the probability that delivering personalised care in a hands-on manner is a threshold concept (Meyer & Land, 2003).

A threshold concept, first suggested by Meyer and Land, 2003 is a concept that, by its nature, is troublesome when initially faced and is transformative in some manner for the student leading to a change in subjectivity – or an ontological shift – they change for now knowing this information. Threshold concepts are also likely to be key integrators of other key concepts and irreversible once grasped. The active hands-on delivery of dementia care, being the threshold concept for the junior doctor dementia champions, would certainly explain the transformative nature of their experiences and suggests that these skills, once learnt, are likely to remain with them for their ongoing career.

These findings echo the transformative change seen in other healthcare workers’ attitudes to care seen by Clouder (2005), and a change through the domains of care from ‘caring about’ to ‘caring for’, and particularly moving into ‘care-giving’ in Toronto's framework of care (Toronto, 2001). Nell Noddings (2013) in her ethical consideration of care acknowledges that caring takes effort, and we need to remember this when teaching and training junior doctors and colleagues, and is split into the ‘I must do something’ versus the ‘something must be done’ standpoints. The junior doctors in Trust A aligned much more to the former statement, personally feeling they wanted to or needed to improve care standards.

Conclusions

The junior doctor dementia champions in this focus group felt that they had been involved in a project that led to a change in the standard of care delivered to this vulnerable group of patients in their hospital. Three themes emerged as potential drivers for doctors volunteering to be a dementia champions and these are: having had seminal prior experiences (often with a family member with dementia), of being involved with a project run by their peers and feeling that they would gain knowledge and skills in the care of this large group of patients. These areas need to be harnessed if the motivation of this group of doctors is to be replicated, and teams should look for these characteristics in groups of doctors set up to improve dementia care in acute hospitals.

The junior doctors felt that they personally gained a lot from being part of this process. Additionally, they felt a team-wide satisfaction in achieving sustained improvements in the dementia CQUIN results. They gained the development of new skills and knowledge (particularly surrounding communication with patients with dementia), the understanding of the holistic nature of their patients' needs and became involved more actively in their care. During the project, the junior doctor dementia champions underwent a transformative change – initiating the change to delivering hands-on care and routinely gaining detailed personal information about their dementia patients. It is likely that this is a threshold concept in geriatric medicine and, more widely, in the training of all doctors working in secondary care who are likely to be responsible for the health of older people.

Finally, the project enabled the development of leadership skills and provided valuable career development for these junior doctors. In order to embed a change in the way in which junior doctors care for patients with dementia, we suggest that these drivers for their involvement and gain from being involved in projects such as this one are harnessed by teams looking to improve the quality of the care delivered to patients with dementia. A key factor in doing this is having a motivated senior doctor who trusts and allows the more junior doctors to make changes in the way patient care is being delivered.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Dr Iain Wilkinson was a Specialist Trainee in South-West London and is now a Consultant geriatrician at Surrey and Sussex Healthcare NHS Trust with a special interest in orthogeriatrics and medical education. He is a Joint Clinical Lead for the hip fracture enhancing quality program in Kent, Surrey and Sussex's Academic Healthcare Science Network. His research interests centre on the concept of ‘care’ and the educational threshold concepts in geriatric medicine.

Dr Anna Coates is currently an FY2 at Surrey and Sussex Healthcare NHS Trust after graduating from Nottingham University Medical School. She hopes to undertake an out of programme year in 2015, working with a charity she has been involved with for some time called AMECA. Following this, she looks to enter ACCS training, with a view to a future in Intensive Care Medicine.

Dr Sophie Merrick graduated from the University of Manchester in 2011, following which she completed her Foundation Training in London. She then had the opportunity to pursue her interest in medical education while working as a Clinical Teaching Fellow. Dr Merrick is currently completing her Core Medical Training in the London Deanery and continuing to gain experience in medical education.

Dr Chooi Lee is a Consultant Geriatrician at Kingston Hospital NHS Foundation Trust. She has a special interest in orthogeriatrics and is clinical lead for dementia care and the forget-me-not program.

References

Biggerstaff

Thompson

(2008) Interpretative phenomological analysis (IPA): A qualitative methodology of choice in healthcare research. Qualitative Research in Psychology 5(3): 214–224.

Brennan

Corrigan

Allard

Archer

Barnes

Bleakley

Regan de Bere

(2010) The transition from medical student to junior doctor: Today's experiences of tomorrow's doctors. Medical Education 44: 449–458.

Care Quality Commission (CQC) (2013) The state of healthcare and adult social care in England, London, UK: HMSO.

Clouder

(2005) Caring as a ‘threshold concept’: Transforming students in higher education into health (care) professionals. Teaching in Higher Education 10(4): 505–517.

Cousin

(2009) Researching learning in higher education – An introduction to contemporary methods and approaches, UK: Routledge.

Department of Health (DOH) (2012) Using the commissioning for quality and innovation (CQUIN) payment framework – Guidance on new national goals 2012/13, London, UK: Author.

Jarvis

(2009) Learning to be a person in society. In K. Illeris (Ed.), Contemporary theories of learning – Learning theorists in their own words, Abingdon, Oxon: Routledge, pp. 21–35. .

Kolb

(1984) Experiential learning: Experience as the source or learning and development, Englewood Cliffs, NJ: Prentice-Hall.

Meyer

Land

(2003) Threshold concepts and troublesome knowledge: Linkages to ways of thinking and practising. In: Rust

(eds) Improving student learning – Theory and practice ten years on, Oxford, UK: Oxford Centre for Staff and Learning Development (OCSLD), pp. 412–424.

10.

Noddings

(2013) An ethic of caring. In Ethical theory: An anthology, Chichester, UK: Wiley and Sons, pp. 699–711.

11.

Rubin

(2004) Qualitative interviewing: The art of hearing data, London, UK: Sage.

12.

Simpson

Jackson

Aycock

(2005) John Dewy and the art of teaching – Toward refelctive and imaginative practice, London, UK: Sage Publications.

13.

Toronto

(2001) An ethic of care. In Ethics in community-based elder care, New York, NY: Springer Publishing, pp. 60–69.

14.

Wenger

(1998) Communites of practice – Learning, meaning and identity, Cambridge, UK: Cambridge University Press.

15.

Wilkinson

Lee

(2014) The dementia and delirium team – An example of activist professionalism. Age and Ageing 43(suppl 1): i5.