Abstract
When people with dementia are admitted to hospital, both they and their carers and families have crucial roles to play. They should be positioned as the only true experts in the unique individuality of the person and brought into the nursing process as an equal partner in care. ‘Care to Talk’ is a conversational model developed through Appreciative Inquiry to facilitate this way of working. The model, its development and outcomes are discussed.
Introduction
Think about a time when you, or someone you know well, received outstanding care and support. What contributed to that exceptional moment?
This is not the type of question we expect to hear when reviewing services or making plans for organisational improvement. Normally, we tend to focus on problems on the basis that if we fix these, everything will be fine. The irony is that whilst there is growing recognition that we need to appreciate the strengths and assets within individuals, when it comes to developing and improving services, we tend to revert back to traditional deficit based approaches.
Failures in the care of vulnerable older people with mental health problems show us that a new way of thinking about care and the relationships that exist between all involved is required. In doing so, care traditions and cultures may have to be challenged. The ‘Care to Talk’ framework introduced here is constructed around a belief that health care professionals are not experts regarding the uniqueness of the person being admitted to hospital and it may be arrogant to think otherwise. If such expertise lies anywhere, it is with the individual and their carer or family. This is particularly so, where the context is admission to a mental health ward for people with dementia and where the individual is struggling to maintain their own sense of self. ‘Care to Talk’ positions the individual and their carers as equal partners who are to be welcomed within the nursing process.
The appreciative approach
In 2014, Betsi Cadwaladr University Health Board and Taith Ltd discussed the development of a Dementia Care Pathway for the wards provided by the health boards Older Person’s Mental Health Services across North Wales. This could have been developed as a desk-based exercise but the Consultant Nurse wanted a process that was more inclusive and meaningful. As a result, two workshops were held; one over two days with staff and the other for carers and representatives of carer groups. These workshops were facilitated by Taith and used an Appreciative Inquiry framework.
Appreciative Inquiry is a tried and tested approach that has its roots in positive psychology, social constructionism and storytelling (Academi Wales, 2015). However, unlike some other theories, Appreciative Inquiry also offers a methodology for delivery – a practical way to put the theory into practice. This methodology is called the 5D cycle (Watkins, Mohr, & Kelly, 2011). In short, this takes people through a process of planning (Define), exploration of what is currently working well and why (Discovery), aspirations for the future (Dream), action planning (Design) and exploration of issues relating to sustainability (Delivery).
The principles that underpin Appreciative Inquiry has been defined in a number of ways, however, some of the simplest definitions emerged through the work of Annis-Hammond (1998). She formulated a set of ‘8 Assumptions’ – i.e. beliefs that underpin the efficacy of Appreciative Inquiry, amongst these are the following assertions:
In every society, organisation, or group, something works, What we focus on becomes our reality, The act of asking questions of an organisation or group influences the group in some way, It is important to value differences.
After the planning sessions, the first two-day workshop took place involving a range of staff within the health board. We shared stories about ‘outstanding care and support’. We explored what contributed to these exceptional moments. We shared future aspirations (including fixing some of the problems but within a solution-focused context). We agreed actions that built on the best in order to deliver on the dreams and explored how this momentum could be sustained into longer term action.
Key themes included ‘what was provided’ (in terms of resources and activities) and ‘how it was provided’. In terms of the ‘how’, there was a lot of discussion about communication, working together and a comment about ‘more blank spaces’ and less directed support.
In the second session with the carers and carer representatives, a similar Appreciative Inquiry format was used to capture the carer perspective. This resulted in more themes including:
The critical importance of building trusting relationships, The importance of people being really listened to, Willingness to explore all options, Keeping focused on the person and knowing the person, Informed choices.
What emerged was not a traditional care pathway, rather the Appreciative Inquiry process generated real creative thinking which led to a completely different approach – namely the ‘Care to Talk’ framework.
Care to talk
The conversations that form ‘Care to Talk’.
The ‘Care to Talk’ document is owned by the carer and to emphasise this it is kept off the ward. To our surprise, many carers seem to treat it like a maternity record and keep it with them which, with obvious caveats around confidentiality, we welcome as a sign that carers are not just engaging but are to some extent rewriting the rules. Carers may instigate the conversations that the framework is built around at any time, although some are intended to happen at key points (such as admission). During or following each conversation, the carer may record their understanding of what has been discussed. It is therefore imperative that these conversations occur and that they happen jointly and clearly. Nursing staff have equal access to view the document but cannot add to or change any of the carer made entries. If there is a lack of consensus then either party can initiate a conversation.
‘Care to Talk’ ensures that important conversations happen. The process thrives on honesty, openness, relationship building and transparency. The full document, in Welsh or English, can be accessed at: http://www.wales.nhs.uk/sitesplus/861/page/84057
Feedback and outcomes
The ‘Care to Talk’ framework was taken back to those who had participated in the Appreciative Inquiry workshops to elicit their feedback. Overall, the framework was approved with recommendations that staff training be a priority and that such training encompasses the full range of communication skills required to make it a sensitive and effective tool. Many of the participants suggested ‘Care to Talk’ had the potential to empower families, carers and staff. Being owned by the family was felt to be a potent symbol of how services were repositioning the role of carers and families as active partners in care, whilst more practically providing the tool by which to do that. For staff, it offered a symbolic commitment that they were authorised to have those desirable open, honest and transparent conversations without feeling constrained by worries over saying the wrong thing. Some found the concept of such conversations challenging but were reassured that the support of training and clinical supervision would sit around practice to develop the nurse’s confidence and competence.
Outcomes were measured as part of an ongoing family/carer satisfaction monitoring programme that had commenced six months before ‘Care to Talk’ was introduced and used the 1000 Lives dementia carer questionnaire (NHS Wales, 2010). 1000 Lives is a part of NHS Wales’ aspiration to achieve excellence in care for the citizens of Wales through care bundles rooted in evidence and practical and meaningful interventions, the effectiveness of which is in part measured by asking those on the receiving end of the care. Of the four wards involved, the framework was introduced to two whilst the others acted as a control. Two questions from the 1000 Lives questionnaire seemed most appropriate to measure change: Q11 ‘I am fully involved in the care plan’ and Q13 ‘I am consulted about major decisions’. The results are presented as Figures 1 and 2 and show that introducing ‘Care to Talk’ has led to increased carer satisfaction in those wards that are using it.
% of carers feeling involved in care planning. % of carers feeling consulted about decisions.
Conclusions
If it is accepted that the experience of dementia care must become more inclusive and participatory for the families and carers of people with dementia then, it follows that there should be an effective framework to encourage this. By adopting an Appreciative Inquiry approach, we have developed ‘Care to Talk’ to facilitate open, honest and transparent conversations. Its use within one health board suggests it is acceptable to both families and staff, and can open up key parts of the nursing process to those who are best placed to represent the individual person who is admitted to hospital.
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.