Differentiation:.

During baseline data collection, verbal handovers and informal exchanges between staff regarding patients with dementia allocated to constant observation focused on summaries of medical needs, risks and behaviours likely to lead to harm to the patient or others. There were few examples where staff shared a patient’s emotional and social needs and little evidence that these needs were documented in care records. Staff supporting implementation (ward managers and implementation champions) discussed how the intervention could provide a framework for incorporating psychosocial information as part of their everyday work. Several staff commented that the inclusion of the suggested strategies for working with patients’ different needs and risk-related circumstances provided a framework for extending the range of information considered to systematically improve awareness of different needs and attempting alternative approaches.

“before this [using the intervention], we were all just doing what’s best for the patient, but this has actually given us a guide to actually do it in the right way, and it’s actually helping to make sure that every need the patient needs has been met. (Nurse, C2_10)”

The components of the intervention that legitimised staff decisions to apply what they knew about a person to their care increased their confidence and valued the skills of the team. It introduced a method that endorsed and supported staff when they focused on the quality of their care work. This was not usual practice.

Communal specification:.

Staff rotas, shift patterns, annual leave, ward closures (due to COVID-19) and sickness meant it was difficult for researchers to inform and train all staff in the use of the intervention, maintain awareness of the study and promote consistent use of the intervention on the wards throughout the 12 weeks. Regular visits from the researchers with the staff responsible for supporting implementation helped to maintain commitment. Meetings with ward managers and implementation champions from wards A1, C2 and team A5 focused on how implementation of the intervention occurred outside of research team visits. However, equivalent meetings with staff in wards A2, B1, B2, C1 were difficult to plan and were often cancelled or interrupted. Researchers perceived that their visits to these wards were often an inconvenience and could lead staff to avoid contact with researchers. During interviews conducted at the end of the 12 weeks, these staff provided explanations for their limited capacity to support use of the intervention, recognising how this impacted use of the intervention by ward staff:

“Recently we’ve had a lot of difficult things going on in the ward, like our patient group and infections and then sickness, and there’s lots of things that probably prohibited it being more effective.” (Ward Manager, A2_19)

With the exception of wards A1 and B2, who volunteered to be involved following conversations with the research team, all wards were nominated to participate by Senior Management. For at least one ward (C1) recent changes to the ward leadership combined with the ward characteristics meant their capacity and readiness to support implementation was not fully appreciated by Senior Management and only became apparent to researchers once implementation had commenced.

Individual specification:.

Staff allocated to constant observation discussed how the intervention facilitated approaches that could be incorporated into their work monitoring risk and enhance a person’s care. Using the resources meant they were more likely to understand the person’s needs, share that information with colleagues and use what they had learned to adapt care practices to suit the person:

“I think it is useful because it can make you think a little bit more about the patients and what can be done and what can’t be done to help them. So, you can say ‘we tried something like putting on classical music and that didn’t work, so we tried this one instead.’” (Clinical support worker, A2_03)

These staff also recognised how application of this knowledge could help to form connections with the person, reduce distress and be an opportunity to invite the person’s supporters to have more understanding of the care they were receiving. For other ward staff who were involved with constant observation on the periphery there was less clarity about the value of the intervention for patient care, with the intervention seen as additional work that was not their responsibility to take on.

Internalisation:.

Contrary to assumptions of the intervention that it could provide continuity and support for staff who were only occasionally involved in constant observation, it had most uptake by those who had experience of doing this work and could see that risk reduction alone was insufficient to support patients well. A prerequisite was an awareness that practice needed to be improved. These staff reported a prior interest in dementia care or having received additional training. They understood the potential for constant observation to be used in a therapeutic way and the intervention validated their commitment to a person-centred approach. In contrast, staff who reported ad hoc involvement with constant observation were less able to articulate how the intervention benefitted their daily work. Their irregular allocation to constant observation limited their exposure to the intervention, making it difficult to incorporate consistently in their work.

“I was doing a one-to-one, a couple or three weeks, two weeks ago so then I saw that poster and I was reading it… so I think I applied it straightaway to my patient… But that was weeks ago… it’s not all the time. That’s one of the weaknesses, because it’s not all the time that we can use it [the intervention].” (Clinical support worker, B1_23)

At sites A and C, where constant observation was often provided by staff who were not permanent ward staff, whether temporary staff or staff who provided constant observation to patients across the hospital, this had the unintended consequence of the intervention being seen as someone else’s responsibility. In these circumstances, patient-centred conversations between staff about the people receiving constant observation were less likely to occur.

Initiation:.

Ward managers and implementation champions responsible for driving use of the intervention with their teams needed to prompt, persuade and enthuse their colleagues to incorporate the intervention as part of their work. How successful they were reflected their status and influence. For example, on two wards (B1, B2) both implementation champions were clinical support workers and appeared to be the only staff who used the intervention. Interviews with them suggested they had talked with colleagues about the intervention and made sure tools were located with other relevant documents. However, they appeared unable to persuade their colleagues to use the intervention. Over half of ward staff interviewed from these wards (n = 7 out of 13) reported they either did not know about the intervention or did not realise they could use it. While implementation champions from B1 and B2 reported using the intervention regularly as part of their work and finding the materials helpful, a lack of wider encouragement and support within the wards, particularly from senior staff, hindered use of the intervention. In contrast, implementation champions on ward A1 and team A5 reported and were observed to actively engage their colleagues to use the intervention, spending time going through the resources with individuals and in small groups, making suggestions for their use and referring to the resources during their shift. A combination of their motivation, the influence they had with the wider team due to their seniority, and the support they received from senior ward staff helped to maintain the momentum for use of the intervention:

Discussing experience of acting as CONNECT implementation champion: “[Ward Manager] has been great with it, and so have the Band 6s [senior nurses]. I think, depending on who you’re working with, they will help and support you along each side of it.” (Clinical support worker, implementation champion, A1_01)

Enrolment:.

Along with the hospital-wide team, at least one ward at each site had been involved in co-design of the intervention (n = 5). Despite a strong sense of commitment to the co-design process and assertions that the intervention would be useful to staff, this did not guarantee ongoing commitment to the work of implementing the intervention.

“I say, ‘if you are happy to be an implementation champion, this folder is for you’. I detect a slight intake of breath and see that she feels obligated (from her ward manager and also probably as she’s engaged in the co-design process under her previous ward manager).” (Field notes, C1)

The intervention had been designed to be used across the care team, including with family supporters, but the work of initiating its use was seen as the responsibility of those providing and supervising constant observation. Other staff reported referring to information captured in the Patient Comfort booklet to support their interactions with the person. However, there was limited evidence of the intervention being used or referred to in care planning beyond discussions with staff from team A5.

Legitimation.

Evidence of use of the intervention beyond written completion of sections of tools was limited. Aspects of the intervention that required staff to interact with other staff or family supporters to share information were reported as being difficult to instigate or were avoided. Routine handovers continued to be dominated with discussions of medical and physical needs. Staff explained that they found it hard to initiate handovers to busy senior staff that focused on information of personal relevance to the patient they were working with. Some staff also found it difficult to engage in conversations about their work with family supporters during their visits. These staff worried that discussing why they had been allocated to constant observation with family members was not appropriate for their paygrade or might provoke a negative response:

“[Clinical support worker] feels that speaking to relatives is essential but that some staff don’t have confidence to do this. I asked if they felt confident in contacting family, they said maybe if they had the full picture but there is a worry that relatives could misinterpret the reason for contact or might complain. The staff member references she’s ‘only a clinical support worker’, and explains she feels it’s not her place to talk to family, particularly if medical.” (Fieldnotes, Ward A1)

Their concerns included raising expectations for the level of support a person would have throughout their stay on the ward, upsetting family members by discussing distressed behaviours and being blamed for a person reacting in that way. The resource legitimated what staff knew to be important and how they wanted to respond, but this did not legitimate what they did with that information as part of their work in the ward where other priorities took precedence. As a result, visiting family supporters did not know the person was receiving additional support in hospital and were unable to share information about the person that could improve how staff worked with them because they were not talked to.

Activation:.

Implementation champions and senior ward staff described how they made the intervention easily accessible, visible and linked to current practices and systems through assembling and locating the intervention in logical places.

“My ward manager made up a pack. In the pack they came with the one to fill out, the leaflet and then the one that we fill out. I put the plastic wallet into the nursing notes so that everyone can see.” (Clinical support worker, implementation champion, B1_13)

This activity alone was insufficient to encourage use of the intervention. However, when these strategies were combined with encouragement, such as reminders to use the intervention or directly handing out the intervention to staff, use of the intervention was more likely. Two senior staff spoke about using the intervention to guide and supervise staff providing constant observation by checking what staff knew about the person they were working with and helping them to think through how they would use this information to enhance the person’s care.

[discussing use of the intervention] “When I’m doing my rounds, I will always ask ‘Where is this assessment and care plan? What are you doing about this? What is your involvement into this? Have you engaged the family?’.” (Senior nurse, Site A)

These senior staff discussed how the intervention complemented their work and were able to easily incorporate it as part of their current practices.

Interactional workability:.

Clinical support workers and staff temporarily assigned to the ward to provide constant observation found it difficult to use the intervention with their colleagues unless senior staff facilitated opportunities.

“…that [Making a Difference document] was very useful, because sometimes I don’t get a single bit of information about my patient… I’ve got to approach a nurse. They just are more busy about getting into their handover and they go, oh, yeah, you’re looking after bed so-and-so, and they just give me a number.” (Temporary Constant Observation Staff, C1_15)

Those providing constant observation were reluctant to share information about a person unless it was related to immediate risk or medical concerns. This prioritisation of medical and behavioural information was reinforced through routines on the ward, such as the structure of morning and evening handovers. Personal information and strategies used to reassure and comfort distressed patients, if discussed, were part of separate handovers with senior staff who had specific responsibilities in overseeing constant observation and allocation. For staff, this underlined how clinical care and person-centred care were separate activities.

Relational integration:.

Staffs’ sense of confidence in working with people living with dementia identified as at risk of harm to themselves or others was highlighted through how they used the intervention. Staff discussed their reluctance to use the intervention in a way that identified them as accountable or exposed their work, for example by writing down their observations of how a person responded in different situations. This meant that strategies that had been attempted, regardless of whether or not they were beneficial to the person, were not documented:

“We discussed the reason for constant observation. [Patient] likes to walk around ward but is not waiting for support from staff. The team lead explained that reassuring the patient that staff are there to provide support with walking did not always work. The team lead noted Patient Comfort booklet had not been used to communicate this as they not found something that has worked.” (Field note, Team A5)

Staff did not document potentially informative patterns of behaviour when constant observation was first initiated, instead stating that patients needed time to settle into the routine of the ward before committing to writing down observations. This observation of the typical patient trajectory for those receiving constant observation impacted the learning and care planning potential of the intervention at a time when it was critical that a person was supported in ways that accommodated and understood their needs. Staff explained not recording this information as they considered it would quickly become obsolete. Instead, staff used the tools during quieter times and when they felt confident that the information recorded aligned with other care partners’ understanding and observations.

“The nurse explained patient was in a good frame of mind to talk so she sat down and had a chat with him and was able to initiate conversation and add to the booklet.” (Field note, Ward A1)

Of itself, use of the intervention to structure conversations with a patient with dementia was considered helpful to staff and beneficial to patients.

“It started conversation starters, which then built a relationship with my patients.” (Clinical support worker, implementation champion, B1_13).

Skill set workability:.

The intention of the intervention was to build a picture of a person across the duration of them needing constant observation to support care and care planning. However, there was no evidence the intervention was used in this way; tools were completed at one time point and were not added to. In part, this was linked to how the credibility of what was documented would be established:

1. Participant 1: “The problem is, if I fill in a little bit of it, and then you fill in a little and then [colleague] puts in a little bit, then the ward staff put in a bit and then the family…”
2. Participant 2: “… and put your name.”
3. Participant 1: “But what’s the point of putting our [name down]…”
4. Participant 2: “it’s just like a collective… so the reliability of who puts it in.” (Joint interview with clinical support workers, Site A)

Similar discussions related to whether information about a person was representative of their typical way of being. This demonstrated a tension for staff between recording what they observed or learnt about the person through conversations and interactions with them and what those who knew the person well reported. The intervention was creating a different way of recording behaviours that did not align with established practice for documenting patient experiences.

Contextual integration:.

Often the staff providing constant observation did not have access or had restricted access to the electronic notes systems. This limited what they were able to view and update meaning their knowledge of the person relied on what they were told by other staff, what they learnt during their work and impacted continuity of information available to others providing constant observation. Staff temporarily assigned to the ward felt the intervention was beneficial to themselves and the ward team, providing continuity across those involved with the person’s care. However, some ward staff considered introducing the intervention to temporary staff was time consuming and of limited value because of their transient involvement.

“I think ward staff aren’t thinking about them [temporary staff] using it [intervention]. But it’s really important that they are, because they’re the ones that are providing that enhanced care [constant observation].” (Clinical support worker, implementation champion, C2_01)

This was despite some observed and reported consistency in the temporary staff who worked on the wards and provided constant observation.

Systemisation:.

A number of staff reflected on their experiences of using the intervention, commenting on the benefits of the tools to themselves and for the patients they worked with.

[discussing patient with limited verbal communication abilities and who is in isolation for COVID-19] “for this patient, having the Comfort booklet has been very useful for the staff to get to know her and how to reassure her… staff have been able to include the name of the son when they talk to her… she likes to sit quietly and listen to the radio, so the staff put the radio next to her and that’s keeping her happy and calm.” (Clinical support worker, implementation champion, B2_12)

They reported that the Patient Comfort booklet was the most used. The similarity of this tool in terms of gathering personally important information to existing patient profile tools meant staff were able to transfer current practices to this component of the intervention. However, this meant that the ambition for the document to be a dynamic record of staff observations that gleaned useful information about what did and did not work for the person was not achieved.

Individual appraisal:.

Interviews suggested most staff narrowly interpreted ‘use’ as completing the tools rather than also including times when resources were referred to for informing their own or colleagues’ work. The potential of the intervention to encourage a shared sense of responsibility for constant observation was not recognised. However, staff who had referred to tools’ content but not added to them reported that information had been useful for starting conversations with patients, particularly if they were beginning to become distressed by their surroundings or provided tips to comfort them at times of increasing distress.

“On a nightshift a couple of weeks ago, there was a patient who had Alzheimer’s, and they kept on getting a little bit agitated. And then that’s when I’d refer to the documents and have a quick look through to see if there’s any information that can benefit me, and in making sure that they’re okay, and making sure that everyone around them isn’t then worried about that patient.” (Clinical support worker, C1_04)

This suggests evidence of incremental changes triggered in situations when other help might not have been available.