When we talk about controlling care we often think about the actions, words and labels that we see being used. Locked doors, ‘I’m going to do the feeds,’ ‘The Wanderers’ or ‘Have you medicated room 24?’. I’m always struck by how that even when these things are pointed out to people, they often just carry on doing them. Old habits die hard and getting rid of controlling care is a constant battle.
I’ve found running a training session on controlling care can help people to see things differently, but I often leave frustrated as I feel that things are unlikely to change much. This is even the case when they have produced their own list of ‘banned’ words and actions. Aligned with this is their struggle to come up with alternative words and actions.
What interests me is getting behind the reasons for staff feeling or being unable to provide care in a less controlling way.
One thing to look at is the influence of routines. Traditionally routines are based around the tasks that need to happen, shift patterns, drug administration and mealtimes. They are also influenced by the belief that all tasks must be completed by a certain time in order not to upset the staff on the next shift.
A place I worked with had many people living there who were clearly unhappy and showed it. I sat down with the nurses, and we went through hour by hour what was happening and why. The results were startling. Most of the activities and mealtimes were clumped together in a few hours. Medication was administered early in the morning, hours before breakfast because it was convenient to do so. For most people there was a two or three hour gap between breakfast and lunch. The kitchen put huge efforts into providing a lunch that for the most part was thrown away. More worrying was the lack of a plan to consistently offer food and drink in the gap between supper (about 5.00pm) and breakfast the following day.
The upset and waste were being driven by a routine that had remained unquestioned for years. Why had it not been tackled before? We worked out what needed to happen and how, but there was the anxiety of what change may bring, the fear of unknown consequences. Getting to focus on the possible positive outcomes was difficult. Some people even believed that the routines should not be changed, that they just needed more staff (More staff doing more of the same things that weren’t working before?).
The nurses led on re-organising the medication round, breakfast began earlier and went on for longer and lunch was pushed back. More snacks were made available during the evening and at night. It took a few weeks planning and there was nervousness on the first day of the change. It did make a difference; people were more relaxed, and the focus was shifting more towards the needs of the people living there. It galvanised them to go and do great things.
My experience has been that when staff teams question the routine and feel empowered or compelled to act, positive change will happen.
It takes courage to challenge established rules or customs. Teams won’t change unless you change the routine. We know why the status quo exists but let’s look at it from the point of view of the person living in the care setting. Are these things happening at this particular time for my benefit or for the rotas?
Consultant Learning & Development Manager