Elderly patients with dementia are at higher risk of falls and pressure ulcers and this is compounded during a hospital admission, which could trigger distress, confusion and delirium.
Our dementia care lead at the time, Alison Thayne, came to me a few months before we applied for Q Exchange funding, describing a need in the dementia ward for ways to help our often young staff members to better interact with older patients.
The idea was that blending entertainment with therapy could help to improve patient-staff communication and the patient experience, reducing behavioural problems, falls and, ultimately length of stay and mortality.
We wanted to evaluate the use of touch screen technology in reminiscence therapy, using mixed methods to understand patient and staff experiences of using this technology.
What we did
The project was a chance to pilot the introduction of RITA (Reminiscence Interactive Therapy Activities) for inpatients living with dementia.
A relatively new tool in the fields of nursing and health care, RITA is an all-in-one technology offering digital reminiscence therapy. It can assist patients with remembering and sharing events from their past.
This might include listening to music, watching news reports of significant historical events, listening to war-time speeches, playing games, singing karaoke, watching films and accessing websites such as YouTube where playlists can be tailored to the individual.
The Q Exchange funding enabled us to bring not only the RITA devices onto our Older People’s Medicine and Trauma & Orthopaedic wards, but also to employ four health care assistants as RITA champions to spend time with patients while using them. It also enabled us to evaluate the project.
We rolled it out over four PDSA (Plan, Do, Study, Act) cycles. Our project team included the dementia lead, head of quality improvement, research & evaluation associate, the ward managers of the two selected wards and our RITA champions.
During the three-month implementation period, the RITA champions would identify admitted dementia patients on a daily basis and engage them in a one-to-one period of reminiscence therapy using the devices. They would then write a brief reflective report of their interactions.
Where possible, ward staff were also shown how to use the devices. In later PDSA cycles, the project was handed over to our safeguarding team to embed in their day-to-day work.
In the final phase of the project, other parts of the hospital were starting to ask for RITA through the safeguarding team, so we widened the scope of patients that were able to access the devices.
Results of the project
The RITA devices and content really helped to bridge the age gap between staff and patients, with old films, news clips and TV series that helped to open up conversations between them.
Patients began to look forward to the time they would have with the champions and the RITA devices and staff saw a real difference in terms of engagement from patients on the ward.
The RITA champions reported that the devices and programming had patients singing on the ward and created ‘a noticeable difference to the ward atmosphere.’
Our evaluation revealed four overall themes: person-centred care, facilitated meaningful activities, improving staff morale and other benefits to patients.
Enabling person-centred care
There was wide acknowledgement that the impact of the project was as much linked to the presence of the RITA champions, as much as the device itself.
RITA champions described how they used RITA as a channel to open up discussion. Patients felt they were speaking to someone who’s job was to listen, rather than purely providing personal care or medication.
One stakeholder said:
‘RITA staff have come to the ward and sat with a patient who was extremely anxious and upset. They came and sat with him played the games on the screens, had a cup of tea with him and helped him to feel more relaxed. They were able to find out more of his interests and to do activities and watch films that made him happy.’
Patients said that having the visit from the RITA champion made their day.
One patient said:
‘Everything on there..I enjoy…wonderful, chat..super. It picks me up.’
Gemma Lister, safeguarding team lead, described the difference RITA made:
‘When you work on the wards with complex patients it can be really challenging. It’s really important to know your levels of resilience so having that as a tool to deescalate situations is really good.
‘I had this one gentleman who was really agitated – he was an Arsenal supporter and he was at one of the games and we managed to find a clip of the game he was at and he watched it over and over again.’
Field notes showed that RITA also helped staff to encourage patients to drink more fluids. It also provided opportunities for group activities such as Bingo.
Improving staff morale
RITA champions reported that using the devices with patients resulted in an uplift in their own mental wellbeing, through being able to calm patients who had been agitated.
One staff member said:
‘Really rewarding seeing the improvement on the patients and one of the patients before they left the care home and the data they left when I got there, they actually remembered who I was and I was so happy.’
Lister said:
‘It’s improved patient experience and contributed to improvements in staff morale – and that’s definitely around the fun factor. We’ve given staff the tools to make things a little more interesting and they’ve embraced that… It does actually make enhanced supervision fun and you can build meaningful therapeutic relationships with the patients.’
How was the project evaluated?
When we began the project, we’d hoped to be able to show that the use of RITA stopped the escalation of conditions and reduced length of stay in hospital. We’d planned for a mixed method evaluation including quantitative and qualitative data. However, in reality, there were barriers to measuring all of these things.
The national situation for the NHS, Adult Social Care and Community Health and Care meant that patients were unfortunately spending longer in acute care than required, so length of stay was not representative. We also had a small cohort with no falls recorded during the project, so it wasn’t possible to collect meaningful data on this.
Other circumstances making quantitative data difficult to collect were:
- some patients were transferred between wards, so they only had intermittent access to RITA devices
- relying on busy staff to manually update forms for fluctuating behaviours proved challenging
- Covid 19 and other complex system problems impacted on length of stay
- Covid 19 infections limited access to the wards, meaning RITA champions could not always provide a regular service.
Instead, we conducted semi-structured interviews amongst a sample of key stakeholders on the geriatric ward and a trauma orthopaedic ward to understand patient and staff experiences and acceptability of the intervention.
In addition, we wanted to explore the experience of patient’s relatives and staff who were using the device. This was done by conducting surveys, interviews and analysing observation field notes and activity logs. This data was then thematically analysed using Braun and Clarks 6 step analysis.
Challenges and tips for other improvement projects
As with any project that involves the implementation of new tools, the main challenge anticipated was the integration of RITA as part of day-to-day practice. This was one of the driving reasons for employing the RITA champions for the initial embedding in of the devices.
Another challenge that we anticipated was the need to involve digital teams from the beginning, enabling us to get sign off on the information governance before we started implementation.
For some patients with advanced dementia the use of RITA didn’t make any difference to their engagement or communication. The nature of dementia and the fluctuation in patients that comes with that did prove a challenge for evaluations.
COVID also meant we couldn’t go onto some wards and some of the evaluation we had planned just wasn’t possible.
I’d encourage other projects to make sure they have enough time to plan and to line up all the right people from senior support to safeguarding, data analysts and digital teams.
Finally, it was amazing to have the opportunity of Q Exchange funding. Our evaluation colleague found the action learning sets with Q really useful. The Q team were really supportive and it was great to have other hospitals getting in touch to contribute, as well as a platform to showcase what we were doing.
What are the plans for RITA now?
RITA has now been embedded into the work of the safeguarding team for support with most vulnerable and complex patients. These staff also talk about the RITA devices as part of their safeguarding training of other teams in order to increase their use across the wards.
The four original devices are mostly used in old person’s medicine, acute medicine and on the gastro ward for patients with eating disorders, where they’re really helpful in de-escalation.
They’ve been used to support patients with learning difficulties and to assist with communication with non-verbal patients and patients who don’t speak English.
Any staff member can now request a device and the team keep track of where they are.
Another six RITA devices have been ordered for use across the wards, with the aim for the safeguarding team to eventually have one on every ward.
Ideally the team would be able to get out and about with the devices on a daily basis, but Lister recognises that current staffing levels won’t allow for that.
While they miss the benefits of having the RITA champions as an additional resource on the wards, the project has enabled staff to see the benefits of these devices for patient experience, staff morale and day-to-day care.
Find out more
Learn more about the project: Improving patient experience, communication and care through digital technology – RITA