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Homely environment reduces aggression on the ward

Improvements to the ward environment have seen reductions in patients’ physical and verbal aggression – and in antipsychotic drugs and staff sickness
Geraldine Rodgers

‘Before this project I would not have known how a change to use of space and the environment could be so beneficial – relaxing and uplifting at the same time.’

Geraldine Rodgers (right), with a patient
Nurse consultant Geraldine Rodgers (right) says: 'Just by talking we saw a dip in aggression'. Picture: Nathan Clarke

Matron Lorna Mess says that the transformation of a ward at Goodmayes Hospital in Ilford, Essex, has reduced violence and aggression, and therefore staff burnout. ‘The end result is incredible,’ she says.

Nurse consultant Geraldine Rodgers’ project to create a more homely environment on the older people’s mental health ward has led to a fall in restraint and use of antipsychotic medication, as well as staff sickness levels. The money saved on agency spend has more than funded the changes.

Geraldine’s achievements were recognised at the prestigious RCNi Nurse Awards, where she won the Nursing Older People category.

Geraldine, who qualified as a general nurse in 1993, knew from early in her training that caring for older people was ‘where my heart lay’. Her career has included posts such as ward sister for medicine and older people, nurse specialist for Parkinson’s disease, community matron, and now nurse consultant for frailty and long-term conditions.

She says: ‘I wanted to qualify as a nurse from the age of three and winning the Nursing Older People category is one of my highlights so far. 

‘This project has demonstrated that enhancement of the therapeutic environment on a ward has a positive impact on patients and staff. There has been validated improvement to the patient experience, and positive outcomes such as patients feeling safe, having greater confidence in staff and improved staff morale.’

The ward had a high proportion of patients with dementia, exhibiting increased disorientation and anxiety. Only 29% stated that they felt extremely safe. ‘We wanted to dig deep to find out why and find a solution,’ says Geraldine.

She used an adaptive leadership style, working as a role model to motivate the team. She says: ‘I encouraged team building through a more democratic style of leadership. In this project, it was important to obtain an understanding of inner dynamics. 

Setting goals

‘A co-productive approach with patients and staff when setting goals, and meeting with the team weekly, initiated and maintained momentum and enthusiasm. It has proved that leadership skills are fundamental in getting the team to own the project locally.’

The team performed retrospective reviews of all violence and aggression data over the five months before the project started and during its implementation. Staff sickness and the prescribing of antipsychotics were compared between periods as balancing measures. The team contrasted staff and patient views of the ward environment, which set a benchmark for measuring the effect of change on the ward.

A focus group was formed to explore why patients felt unsafe, and identify what needed to change. Three workshops were held involving doctors, nurses, patients, carers, therapists and support workers.

‘Every department was touched by the project,’ says Geraldine. ‘Just by talking we started to see a dip [in aggression].’

She improved signage and used door colours chosen by patients to create a home-like environment – making the ward feel less institutionalised.

Geraldine says: ‘A coloured toilet door had an immediate effect, with four patients becoming independent at toileting within 12 hours. 

‘We created an indoor sensory garden [see below], engaging all the senses, where one-to-one interaction is enjoyed by patients and staff. Patients said they wanted it to be touchy-feely and a special place. They did smell tests and chose fragrances and music. It is grown up and sophisticated.’ 

There are also more activities available on the ward and patients can choose what they do. ‘There was little social activity in the dining room, so we changed it,’ Geraldine says. ‘It is now a social area where patients like to sit and chat.’

The effect on violence and aggression has been impressive. There were 47 incidents of physical aggression and 81 of verbal aggression in the six months before the environmental improvements, which fell to 28 and 33 respectively; a 40% and 59% reduction. 

Before the project, less than 30% of patients said it was ‘extremely likely’ they would feel safe on the ward. This has more than doubled to 64% of patients. 

The balancing measures – including confidence in staff, use of antipsychotics, staff sickness and use of restraint – also showed a marked improvement.

The average monthly number of episodes of staff sickness fell from 3.8 days to 2.2 days per month, a 42% reduction. Days lost to sickness fell 64% from 26 a month to 9.3.

Ward manager Debbie Chown says: ‘The impact on staff has been amazing and the project has made me realise how many ideas and innovations are out there to help our patients’ experience in hospital be more positive and less limiting. And the whole team is looking forward to being part of many new projects.

‘The process was multidisciplinary and staff were encouraged to give honest feedback. Geraldine spent time getting to know staff, patients and carers on the ward in an unobtrusive way so she got a true reflection of the experiences, strengths and challenges we face on a daily basis.

‘The staff felt involved throughout, from the more formal focus groups to informal voting for toilet door colours and choosing which lavender themes we wanted.’

For Geraldine, changing the attitudes, beliefs and values of the ward team and creating an environment with a culture of openness was vital to securing patients’ confidence. 

She says: ‘The new transparent working environment allowed patients to observe the innovative changes being implemented and their impact. They recognised themselves to be at the centre of the change process, listened to and valued by staff, and as a result their original apprehension was replaced by confidence.’

Other successes include a 26% reduction in antipsychotic prescribing and the use of restraint calculated as a percentage of the number of incidents fell from 37% to 21%. No physical restraint was used in the second quarter after the project was complete. Results from the Friends and Family test showed 100% of people who completed the survey stated it was ‘extremely likely’ that they would recommend the ward.

And the project has already saved money. In terms of staff sickness alone, by March it had already recouped its cost and netted £10,000 in savings. 

‘There had been real concerns about the level of agency spend on the ward,’ says Geraldine.

Consultant Saheem Gul says: ‘We are all aware that with ageing, and particularly in dementia, a number of sensory changes occur that alter perception of stimuli. There are many studies showing the beneficial effect of a soothing environment in older adult patients, which can reduce problematic behaviour and reduce burdensome symptoms without resorting to medication. On the ward we noticed the positive impact that these changes had.’

The RCNi Nurse Awards judges were impressed by the project and Geraldine’s leadership. They said: ‘Geraldine is a splendid role model. The impact on care and experience is really impressive. It is evidence based and sustainable and has superb stakeholder involvement.’

Geraldine continues to review data to ensure the ward continues to improve.

‘We are looking to spread this on older people’s wards through this proven methodology,’ she says. ‘We are also looking at replicating it on mental health wards and on a male ward. 

‘We came a long way in a very short period of time – it took just six months. We said “this is possible and we can make a difference”. And we did.’

The garden room

Extensive consultations and focus groups with staff, patients and carers identified that nature and the outdoors fostered calmness and relaxation. 

Ward sister Debbie Chown says: ‘The garden room is open to all and we include it in patient care plans. It’s a great place for patients to have one-to-ones with staff in a non-clinical environment where they are not going to be disturbed.’

Patients chose everything from the décor to the smells and sounds. There are pictures of tulips on the wall, a sandwich picnic basket and an old radio for music.

There is bird song, gardening books and artificial grass, and the room smells of lavender. The corridor leading to the room is also scented in lavender to highlight the entry to an oasis of calm.

Debbie says: ‘The garden room has made the biggest difference in terms of immediate impact. It is such an unexpected thing to see on a hospital ward and really gets people talking. 

‘Daily I see patients, relatives and staff enjoying spending time there and benefiting from getting a glimpse of the outdoors – indoors – especially when the weather is bad or the patient is too unwell to go outside.

‘I see and hear the reactions from people who come to the ward. Comments include: “It makes coming to the ward less intimidating”, “It shows that staff care about their environment and are about making things nicer for the patients”, and usually, “It’s so lovely!”’

Matron Lorna Mess agrees: ‘The impact of the room has been instant. The space is calming and tranquil. We are so proud of it. 

‘I have seen patients with anxiety go into the room and either do some relaxation exercises or just sit with a nurse and come out less anxious – avoiding medication.’

Build relationships

Staff use the room to interact with patients who have different levels of cognitive impairment. They report that it helps build relationships. A remark in the comment book reads: ‘In the afternoon, the patient was upset and agitated looking for her husband (who had died some time ago). I took her to the garden room and sat with her. We chose some music; we talked and looked at the garden books. The patient became so much calmer, chatted about her life and family. She enjoyed being there and I enjoyed my time with her.’

A patient wrote: ‘What a haven, which smells lovely. I like this place.’

Another wrote: ‘The room is pleasing to the eye. It looks just like a garden. I love my garden at home; the grass looks great – beautiful. How wonderful it made me feel.’ 

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