Relationship Activated Care:
The 360 Standard Framework Defining and Transforming Care Cultures
Patricia Duff OBE, MSc, BA, RN, RM, PGCEA
Rosemary Hurtley MSc, Dip COT, FRSA
Rosemary Hurtley MSc, Dip COT, FRSA
College of Medicine, Summer School 2013
Using measurable outcome standards to exemplify
and protect Human Rights in care settings
360 Forward provides : Diagnostic assessment
Consultancy, education, coaching &
training services
Working with managers and staff at all
levels
Health and social care
Our aim is to establish dynamic,
sustainable person centred cultures in
their organisations in line with the
philosophy and principles of The 360
Standard Framework.
Patricia Duff OBE, MSc, BA, RN, RM, PGCEA
Rosemary Hurtley MSc, Dip COT, FRSA
What is the 360 Standard Framework?
A diagnostic assessment framework that shows care organisations how
to establish and maintain person-centred cultures from the perspective
of the cared for person, their families and carers
An outcomes based practice development framework for achieving
continuous improvement
Dementia: complex interactions
between five main factors (Kitwood)
Dementia = NI + P+ B+ PH+ SP
• Neurological impairment
• Personality
• Biography (life changes, events and experiences)
• Physical health (senses, hearing, eyes, pain)
• Social psychology (the social dynamics that surrounds the
person)
Restoring the Image
Activating
Restoring
Developing
Communicating
Enriching
Releasing
Empathising
Connecting
The 360 Standard Framework
creates cultures where:
- people want to live
- staff enjoy working
- relatives enjoy visiting
…. and where managers and leaders
facilitate relationships and
community building with high
quality care
Defining and Transforming
the Care Experience
Assessment Framework –
Residents' Measures
1. Receiving person-centred care
2. Opportunities for social/occupational activity
3. Influencing meals and drink
4. Meeting spiritual needs
5. Resolving concerns and complaints
Staff and Relatives’ Measures
Staff measures
4. Feeling valued as a staff member
3. Equipped to do the job
2. Having time to deliver good care
1. Finding the work fulfilling
Relative measures
2. Communicating with staff and
managers
1. Welcoming ambience of the home
4. Seeking to resolve concerns and
complaints
3. Being fully informed
5. Contributing to the care of the
family member and the community
of the home
Domiciliary Care: Clients
Main themes for clients:
Control over decisions
Receives consistent care and support
Care and support is delivered in acceptable ways to acceptable standards
Positive relationships
Empathetic and effective communications
Able to resolve concerns and complaints without fear of retribution
Domiciliary Care: Staff and Relatives
Main themes for staff:
Finding the work fulfilling
Support to do the job
Equipped with the knowledge and
skills to do the job
Feeling valued as a staff member
Main themes for family carers:
Involvement in decisions about the client’s care and support
Consistency and continuity of support to the family carer
Standards of personal care and support to the client
Relations and communications
Concerns and complaints
Managers making it happen
• Enabling /facilitative management style - clear channels of
communication, positive relationship building, collaboration with
other professionals and agencies
• Pivotal leadership role in change management
– Operational management
– Practice development
– Quality improvement
– Business planning
Example : Resident Standard 3:1 The resident has a choice of culturally acceptable food and drink that meet his/her dietary
requirements
Structure Process Outcome
Characteristics
of the 360 Standard Framework
Delivers continuous quality improvement and demonstrates
measurable change
A Standard of excellence in relationship activated care for
person-centred outcomes
Involves the cared-for person, relatives and staff
Incorporates evidence from research and empirical studies
Underpins all other service and practice standards
Diagnostic with measurable outcomes
2 -
Preparing
and
Planning
1 - Client
Decision
4 - Data
Analysis
5 -
Feedback
3 - Data
Collection
8. Internal
Evaluation
9. 360
Foundation
Commitment
Award
10. 360
Foundation
Outstanding
Progress Award
6. Action
Plan
7. Internal
Implement
Action Plans.
Routes : The 10 Step Cycle
Scenario: the Problem
Scenario Effects on
Resident
Effects on
the Relative
The
problem
Effects on
Staff
Heirarchical
work-load
allocation
Lack of continuity and consistency –
insecurity and passive acceptance –
(institutionalised)
Disaffection – lack of relationship,
lack of authority
Poor job satisfaction, reduced
motivation, loss of confidence in
decision making, lack of
responsibility taken in care staff
leadership, lack of practice
development
Loss of confidence, did not feel staff
knew resident not knowing who was
who & some collusion
Success
The Solutions
Devolve authority
/accountability to appropriate
competence levels (S)
Revise job descriptions to define new
roles/responsibilities (S)
Provide training for new roles and
responsibilities and develop managers in
facilitating changes, involving everyone
(S&P)
Reorganisation of work allocation –
Named Nurses, Key workers – life
assistant responsibilities (S)
Benefits to the Organisation
If the resident’s and relatives outcomes are achieved
Improved reputation leading to increased occupancy and income
If the staff outcomes are achieved
Higher job satisfaction resulting in reduction in sickness, increased
recruitment, lower turnover, decreased use of agency and efficiency
savings.
Why is the 360 Standard Framework
important to the NHS?
Good patient outcomes - Create a patient-centred NHS
Quality Improvement - Focus on improving their
experience and their health outcomes
Value added benefits: effectiveness and efficiency
Leadership and management enabling tools - Empower
professionals – end top-down control
Benefits to the organisation • Prevents the experiences that bother older people and their relatives
(concerns/complaints)
• Achieving continuing improvement, meeting statutory requirements and beyond
• Able to demonstrate measurable improvements in reputation
• Offer nurses a career path – attracting more into the sector as a positive option
• Demonstrate efficiency savings, less reliance on agency staffing, lower absence, reduced staff turnover and highly motivated workforce and increased effectiveness of delivering PC outcomes
Work-based Learning Key topic areas
For delivering compassionate care
• Understanding ageism in society
• Understanding chronic conditions and their effects on the
person –identity, significance, continuity, purposefulness,
belonging and being understood
• Building positive relationships –the triangle
• Specialist communication skills
• Understanding transition, loss and adapting
• Understanding and preventing institutionalisation
• Inter professional co-operation and collaboration
The Elizabeth project
Rosemary Hurtley
Director, 360 Forward
Karin Tancock
Background
• Developing a career pathway for people working with
older people
• From apprenticeship to post-registration nursing
• Mid Staffordshire and other incidents of unacceptable
care
• Over the years older people have been moved out of
hospital into residential care and as a result the health
input has diminished
The Structure of the pathway
•Post apprenticeship course
•Elizabeth practitioner – Foundation degree
•Elizabeth Nurse – Post qualifying degree
• Increase in complexity of care – dementia, long term
conditions
• Need to have higher standards within the sector
• No dedicated career pathway for older people
• Need to give the sector and their staff more status
and recognition
Why is this needed?
Why training is essential:
• 65% of people in hospital are over 65. 80% of people in care homes have dementia or cognitive impairment (Alzheimer’s Society, 2013)
• Residents of care homes have complex healthcare needs, reflecting multiple long-term conditions, significant disability and frailty.(BGS, 2011)
• All health and social care providers need training in the complex management of people with multiple long-term conditions (BGS, 2013)
• People living in a care home and suffering from dementia are more likely to go to hospital with avoidable conditions such as urinary infections.(CQC, 2012- Care Update)
• The social care model is central but insufficient to meet residents’ health needs.(BGS, 2011)
Personal & Professional Development 15 credits
Research for Professional Practice (Dissertation) 30 credits
Learning through Professional Practice- Compassion in Care 15 credits
Extending Professional Practice- Delivering Person Centred Outcomes 30 credits
Valuing Work Based Learning 15 credits
360 FWD MGT Module Or University of Surrey Management Modules
Independent Learning 15 credits
• Maximising Independence • End of Life Care • Dementia
OPTIONS MODULES
BSc (Hons) Professional Practice (The Elizabeth Nurse)
Learning outcomes for compassion in care:
1. Staff that can communicate sensitively and acknowledge each individuals, personal experience of dementia.
2. Daily routines, activities and an environment that supports and meet their emotional and social needs.
3. Staff that can apply techniques and strategies to approach situations creatively.
4. Be supported to achieve quality of life in the least restrictive ways.
5.Their experience of care is supported and evaluated through person centred outcomes.
Benefits to people living with dementia:
1. Staff that can communicate sensitively and acknowledge each individuals, personal experience of dementia.
2. Daily routines, activities and an environment that supports and meet their emotional and social needs.
3. Staff that can apply techniques and strategies to approach situations creatively.
4. Be supported to achieve quality of life in the least restrictive ways.
5.Their experience of care is supported and evaluated through person centred outcomes.
http://www.youtube.com/watch?v=gF99CPs9veo
First Steps to creating
the Therapeutic Relationship • Your goal is to – GAIN the person’s TRUST - Create a safe environment both
physically and psychologically.
• Understanding and knowing the individual's life long achievements and failures that have
shaped their lives.
• Listen, observe, explore, imagine, verbalise – we must focus on what the person is trying
to express. • Learn the needs that underpin much of the words and actions of the person with dementia
(Kitwood 1997 , Nolan 2006). To feel safe and to make sense of their environment To give love and/or receive love To communicate a personal need and/or wish To belong and feel included To feel useful, purposeful and fulfilment Maintain identity, control and significance to brings back feelings of self
continued - First Steps to creating
the Therapeutic Relationship-
• Learn what the person with dementia may be struggling with (adapted Feil 1983)
Relive past memories to restore sense of self worth and control.
Resolve past conflicts by expressing feelings through actions and words
Relieve boredom by stimulating their own senses in order to feel useful.
Retreat from painful feelings and feelings of usefulness.
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Enabling the Willis and Francis Report Recommendations
The culture of healthcare provider organisations is routinely assessed
More family and user involvement in education
Streamline communication skills to provide dignity for people with dementia, mental health and chronic disease
Flexible education programmes for nurses and carers, people and their families
Work-based learning
New status of nurse for older people (Francis Report)
Someone who listens Someone to talk to Kindness and understanding Someone to laugh with “Me” to see “me” a lot I like to be liked I like to please I like to know what pleases you So that I can pass it on to someone else
Doing things, loving people Letting them know you are thinking of them I like to see the light come into their face Because I have said something that really makes them happy, … …because I had so much unhappiness as a child It is not so much about what people do But about relationship
