CASE STUDY 2 - Collaborative Practice Learning Team

Aim: Developing a long-term relationship with dementia care within REH through exploring ways in which families and their relatives, nursing staff and artists can work together as a team, learning from each other in order to make positive change within the wards.

Context:Artlink has been working at the Royal Edinburgh Hospital over several years providing a range of participative arts opportunities and artists placements. The longer-term nature of the involvement allows relationships with patients and staff to evolve over time and creates opportunities to link in with specific NHSL led quality improvement initiatives.

In partnership with Charge Nurse Frank Charleston we identified Pentland Ward at the Royal Edinburgh Hospital, a long stay ward for men with early onset dementia, as the best possible place to take a longer term (12 to 18 months) learning team approach. It was also the focus of a Quality Improvement initiative led by Frank and Frances Aitken, NHSL Practice Improvement and Development and therefore had the added benefit of understanding how arts activity can contribute to creating positive ward environments which contribute positively to staff development and tackles absenteeism and high staff turnover which has a negative effect on quality improvement efforts.

It was decided that the learning team should consist out of NHSL staff, relatives, Artlink producer and artists, and patients. Pentland Ward was selected to ensure a continuity of involvement for both patient and family members. Selecting a long stay ward allowed us to take time to establish strong working relationships and follow through work with the same people from beginning to end.

From the outset, we identified that it would be important to bring in other collaborators/ organisations to increase both the reach and scope of the project, as well as provide the additional funding opportunities that our collaborators would bring e.g Edinburgh University & TCV.

Response: We established two approaches to working together to change the ward environment to ensure that people could input in ways that were relevant to them. The first was to create a Learning Team which brought people together to talk through ideas and problem solve and the second was to provide practical workshops to ensure the patients’ involvement through activity that allowed them to take part on their own terms and in their own time.

The joint aims of the project were to: To use the arts to improve the patient and family experience of care in hospital for people with

Dementia, reducing worry and feelings of anxiety, helplessness Create new magical moments, enable opportunity for memories, encouraging people on the

wards to change the space they worked or lived in Improve staff morale, confidence and job satisfaction, reduce staff sickness rates Improve patient and family experience on the wards, ensuring that lived experience would

inform changes in the ward environments Encourage positive collaboration across staff, patient and relative groups. Positively evidence that collaboration through the creation of beautiful garden space that is

‘owned’ by staff, patients and family alike

When Artlink first started, family members were impatient to see change happen. Even though Pentland ward and its nursing team, led by Frank Charleston and Frances Aitken were doing a great job, initial conversations were largely negative. Family members focused on historical things that hadn’t worked well, rather than the positive changes that were happening. To positively change the nature of the conversation and to manage expectations, we established regular meetings with the Learning Team to talk about and agree short, medium- and long-term goals. These meetings were minuted (see examples - Appendix 1) and shared with all. We also set out the ‘ground-rules’ on which the work would operate. All had responsibility for making each other feel welcome and treating everyone fairly and with respect. We made sure that everyone knew what they are supposed to be doing. Most importantly we created a safe environment so we could take risks, listening to and constructively challenging each other to share ideas and problem solve.

Although the process of the Learning Team meetings and the workshops were different, we didn’t really see them as separate, and used the combined conversations to feed into our overall understanding of where we wanted to end up.

a. Transforming the garden The garden on Pentland ward was overgrown, with planting left over from previous usage of the space that was not dementia friendly. They were so overgrown that they blocked views from the communal eating and sitting room into areas of the garden, an aspect that was problematic for staff as a visual connection with patients was imperative.

With the Learning Team we collated a data base of dementia friendly plants, i.e. plants that were neither toxic nor sharp. We then shortlisted plants through looking at connections to memories for patients i.e. they perhaps had the plant in the garden of their open home or were plants their husband/wives knew they liked. We also decided to limit it to a dementia friendly colour palette, i.e. colours which research indicated were still recognisable to individuals with advance dementia.

When we had established the ‘planting plan’ we knew that we would not be able to achieve this within existing budgets or with the small team we had established.

We then sought further funding from external funders and secured a grant from the Mushroom Trust to purchase the plants we needed. We then worked with The Conservation Volunteers (TCV) to clear the site (we only left plants that were dementia friendly) as well as working with TCV to dig over and enrich the poorly nourished soil, before planting the agreed planting scheme.

Over time we also maintained and repainted the existing garden furniture to establish a beautiful space for family members to sit outside with their loved ones. The garden became a bright, colourful, interesting space for everyone to use.

b. Creating unique artworks: While we wanted to create something unique for the garden, we knew we wanted to achieve this by working with patients from the ward. Artist James Mclardy introduced gentle, repetitive processes which enabled him to work side by side with patients, establishing a connection and relationship with those patients over a long period of time. They worked on the gardens, they weaved with a simplified spinning Jenny and they built a geodesic dome, re-awakening skills from their younger selves i.e. some of the men had worked in the building trade.

‘’Using repetitive processes that bring the act of making into focus, has delivered the best results. It’s often not an understanding of a full process that makes things work anyway - it’s those intuitive moments of interaction along the way; a moment in the process that stimulates another reaction and allows you to keep moving forward. Its a conversation of sorts, a way of sitting in quiet togetherness, making, moving forward, and continuing to make.’’ James McLardy Artist

‘’ The success of Artlink’s input into our team was the catalyst for changing my hopes and dreams for the ward into a reality. I could tell you of the wonderful changes to our environment, the creation of our dementia friendly garden, the painting of the benches, the building of the raised beds, the rope weaving, the Geodesic dome…… But, this does not show you the development of the men beginning to smile, of them returning to participating in day to day activities that were familiar to them in their healthy state, it does not show you how dirty they got when they were weeding the garden and it does not let you hear the laughter. But that is what working together as a team has achieved.’’ Frank Charleston, SCN Pentland Ward.

Impact on patients is best illustrated through ‘Toms Story’, a poster campaign used on the wards to illustrate the impact of involvement, using one man’s experience of the workshops. (See Appendix 2 - Tom’s story)

The Geodesic Dome has become a destination in the garden and is also used as a site for singing and garden party events.

c. Additional collaborations

i. Exhibition Our work on Pentland ward became an exhibition in the Tent Gallery, Edinburgh College of Art. This allowed us to disseminate the work to a much wider audience as well as creating opportunities for discussions with students at ECA (see appendix 3). During the exhibition we gave presentations to students around art and ethical care, where we met and started a conversation with Fiona McLachlan, Professor of Architectural Practice.

ii. Research Through subsequent conversations and meetings we established a research project on Pentland Ward with Fiona McLachlan and her students to address various issues, particularly ‘sticky areas’ in ward corridors where patients with dementia would become more confused. Through observation and conversations, Fiona McLachlan developed an approach which was implemented on the ward by her students. (see attached research publication – appendix 4).

Outcomes: A transformed garden space for patients, family members and staff A unique and beautiful garden structure created by James McLardy and patients, and used by

patients and staff for garden events A successful collaboration by patients, relatives, NHS staff The involvement of many different organisations i.e. The Conservation Volunteers (TCV),

Edinburgh College of Art (exhibition), Edinburgh School of Architecture and Landscape Architecture (research) and Artlink. This increased the scope and reach of the project

Additional funding to achieve outcomes (Mushroom Trust - £9,000) A motivated and engaged nursing team on Pentland, which reduces staff sickness and helps

balance ward budgets Practical research by Edinburgh University on ways to respond to architectural issues within

building that house people with advancing dementia. Happier patients and families who feel they can have a positive impact on the ward. Pentland was nominated and shortlisted for several NHS awards

Longer term impacts of this type of partnership working can be seen throughout Lothian hospitals: The start of a working process with Frances Aitken, who moved from the REH to Practice

Improvement and Development across Edinburgh and Lothian Hospitals. We are now working with her on stress and distress training in other Edinburgh and Lothian hospitals

The approaches developed as part of the Learning Teams informed how we approached involving staff and patients in making changes on the wards. e.g. Staff and patients on all of the wards at the new REH involvement in the Vitrines project, work with patients on Stroke wards at the NRIE

Inclusion in research material published by Edinburgh University and ongoing relationship with Edinburgh University in our work

A greater understanding of the importance of involving staff and patients in the development of artworks, allowing them to have greater ownership of the ideas and the artworks produced

Case study visuals:

Appendices:1. Tom’s Story2. Tent Gallery Exhibition

We will become like (a) familyArts as part of ethical care

Last year, it was estimated that 70,162 people in Scotland have dementia.  If current trends

continue, the number of people with dementia is forecast to increase by 40% over the next

12 years.  Whether these projections are accurate or not, we need to ask the question how can the arts have any impact on ways of caring within this population?

Over the last year Artlink has been exploring partnership work with staff, relatives and

patients of Pentland Ward at the Royal Edinburgh Hospital.  It, very simply, uses problem

solving through arts activity to bring people together, encouraging the sharing of ideas which

enable new perspectives to emerge.  By working together as part of a Learning Team, they

can positively shape and influence the quality of the caring environment for the benefit of

everyone involved, much more than they can do by individual efforts.

There are 10 collaborators on the Pentland Learning Team, who meet to make decisions on

the way forward in relation to two strands of activity on the wards. One focuses on how

patients, relatives and staff contribute to the improvement of the outside space of the ward.

They also inform an ongoing programme of workshop activity led by Artlink artist James

McLardy, supported by Pentland activities co-ordinator Donna Morton. These workshops are

designed to ensure that the patient gets involved on their terms and in their own time.

’’ Using repetitive processes that bring the act of making into focus, has delivered the best

results. It’s often not an understanding of a full process that makes things work anyway - it’s

those intuitive moments of interaction along the way; a moment in the process that

stimulates another reaction and allows you to keep moving forward. Its a conversation of

sorts, a way of sitting in quiet togetherness, making, moving forward, and continuing to

make.’’ (1)

‘’ The success of Artlink’s input into our team was the catalyst for changing my hopes and

dreams for the ward into a reality. I could tell you of the wonderful changes to our

environment, the creation of our dementia friendly garden, the painting of the benches, the

building of the raised beds, the rope weaving, the Geodesic dome…… But, this does not

show you the development of the men beginning to smile, of them returning to participating

in day to day activities that were familiar to them in their healthy state, it does not show you

how dirty they got when they were weeding the garden and it does not let you hear the

laughter. But that is what working together as a team has achieved.’’ (2)

Our continued hopes for our unit are that we will treat everyone, our patients, relatives and each other with kindness. We will become like ( a ) family. Like any other family, when we have troubles and difficulties, by working together and communicating with one another, we will have the ability to work it out, resulting in a fun, happy but ultimately therapeutic environment. Care filled with purpose. (3)

This way of working and the changes we have achieved so far would not be possible without

the energy and continued input from everyone on the Pentland Learning Team, we are

extremely grateful to everyone involved.

This exhibition displays some of the collaborative processes that have emerged from

working on this very busy dementia ward. In the exhibition, the artist, James McLardy

presents sculptural forms (a geodesic dome, and a rope weaving Nancy) designed to

encourage communal activity and participation. The workshops are a safe space for

patients, staff and families to talk and share ideas. A space where it is possible to take time

out away from family worries, from the stresses of caring, just for a few minutes, and start to

make some positive changes to the physical environment.

This is a work in progress.

(1) James McLardy, Artlink artist

(2) Frank Charleston, Senior Charge Nurse Pentland Ward

(3) Pentland Learning Team

ECA Tent Gallery Exhibition – Photo Albie Clark

ECA Tent Gallery Exhibition | Geodesic Dome and Spinning Jenny by James McClardy and patients – Photo Albie Clark

ECA Tent Gallery Exhibition | Spinning Jenny by James McClardy and patients – Photo Albie Clark

ECA Tent Gallery Exhibition | Spinning Jenny detail by James McClardy and patients – Photo Albie Clark