Guidance for using the Observation of CareFeedback Tool

This Observation of Care Tool is for people with severe cognitive impairment and disability who are unable to participate in other methods of giving feedback about their care and the service delivery they receive.

This tool serves to close that gap through the interpretation of behaviours based on a detailed record of how an individual normally behaves when they are calm and content to very agitated and distressed.

This tool captures the experience, at a point in time, of vulnerable people in our care who for one reason or another cannot completely express their needs and wishes. Observation is a simple and effective intervention that, along with other data can contribute to a snapshot but holistic view on service/care experience.

Observation allows care teams to step back and watch what is going on from the position of an observer. It provides an opportunity to see the differences between what we think we do, or what we think is happening, and what we actually do or what is actually happening.

Use of the tool is in 4 stages: initial gathering of information, the observation of care itself, the interpretation of what is observed, and action taken as a result.

Practical application of ‘Observation of Care’

Prior to any period of observation, information about how the patient behaves under different circumstances needs to be gathered. This information needs to be gathered from the person who knows the patient best, usually their main carer prior to admission.

There are 2 records to be completed:

• Behaviours I display• Things that happen around me

There are 3 lists of prompts and reminders to help the carer complete the 2 records above:

• Generic reference list of behaviours• Generic reference list of external stimuli• Generic list of occurrences that may have an impact on a person

Completing ‘Behaviours I display’

Using ‘Generic reference list of behaviours’ as a guide, write in the boxes the types of behaviour displayed by the person under the different circumstances.

Contented behaviours should describe the person’s behaviour when they are calm or their behavioural baseline is the nearest to calm.

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Signals of changing behaviours are descriptions of behaviours that a person may display when they start to shift from a calm state to agitation or distressed state.

Distressed behaviours are descriptions of behaviours when a person is clearly unhappy and distressed.

Completing ‘Things that happen around me’

This document is to record any sort of behaviour, external stimuli or occurrences that affect the person positively or negatively. Use the ‘Generic reference list of external stimuli’ and the ‘Generic list of occurrences that may have an impact on a person’ as a guide. You may also use the Generic Reference List of Behaviours to describe carer/peer behaviours.

Behaviours and environment that best support the patient are those things that best help the person maintain their wellbeing.

Behaviours and environment that trigger and prolong distressed behaviour are those descriptors that outline what behaviours/interactions from a carer and environmental factors could cause the person distress.

This information can also be found in a hospital/communication passport and/or one page profiles.

Use clear concise information avoiding acronyms, abbreviations or jargon.

The descriptions must represent the person as they present now or recently and not how they used to be prior to their disorder.

You may add behaviours that are not listed.

Once these record sheets are completed they should be placed in the person’s notes. The Observer should not study these before observation.

Preparation for Observation

You need to have a question that you want to answer before commencing and this question should be written on the start of the Observation Record. Examples of questions might be:

“Do you feel safe on this ward?”

“Do you enjoy this activity?”

“Do you like the food?”

Bear in mind that this cannot be done in abstract. The observation needs to take place during the activity or meal that the question is directed at. You will not be able to generalize so you can be quite specific in your question and name the activity or the meal.

Before commencing the observation of care, it is important that the care team are aware of the observation being undertaken and what to expect. Sometimes it feels this openness may bias the care the individual receives, however experience tells us that very quickly, because of the complex nature of care giving and necessary activity and demands there are in the care setting, staff quickly forget the observer’s presence. Page 3

Think about the location of the observation, one which will gather the richest information about the service/care experience the individual is receiving.

The observer must now open themselves up to be an observer. This means to relax and settle down comfortably to focus in become attuned with the environment, to resist any temptation to join in, to be patient, not make judgements and to be open to see what is there.

The Observation

Use the Observation Record to record your observations. You will be writing your observations of the patient (behaviours they are displaying) and the environment (things happening around them) on the same record. You can use the pages of descriptors or you can use your own.

Watch and then write down what you see. You might also make note of things you don’t see that you think should be happening. Note verbal and non verbal communications and reactions. During these interactions you may want to make notes of conversations, write down what is happening in the environment – is it noisy, busy, quiet or chaotic.

There is no set length time for an observation, it depends on what the patient is doing, what your question is, and whether you think you have enough information to answer it.

Interpretation of information

Once observation is completed, interpretation can take place.

The first step is to compare the Observation Record with the information on the two assessment records: ‘Behaviours I display’ and ‘Things that happen around me’ which are filed in the person’s notes.

Cross reference the written observations with ‘Behaviours I display’ by inserting a √ in the relevant red, amber and green boxes on the left.

Cross reference the written observations with the ‘Things that happen around me’ by inserting a √ in the relevant red or green box on the right.

If more ticks are in the green box this may indicate a positive response to a situation but if there are more ticks in the amber or red boxes this may indicate a more negative response to a situation. However see section Feedback as the staff/carer will have further information that will inform the observer further.

Use the Summary of Observation sheet to summarise your interpretation. Page 4

Feeding back

You now need to feedback your observations to the care team and together reflect on these observations. This should be carried out in a private area and should take around 20 minutes. You should openly share your written notes.

Giving feedback should be a two-way open process, allowing both the opportunity to explore what was witnessed.

The observers offer their feedback in a descriptive non-judgemental way. Staff members will then be invited to expand on what they were doing – to ‘make sense’ of what was happening in the area at that time. Staff may feel defensive at this stage, trying to rationalise and justify why they behaved in a particular way. It is therefore important to be explicit that the purpose of this exercise is not criticism; but to think about, and understand, the reasons behind what has been observed and to help make sense of the observation. This understanding is vital, because the observers won’t always have the full picture.

It is helpful to ask the team if they want to make any additions to the observations you have made. There will be times when the practice that is observed isn’t very good. If this is the case, how the observers handle the feedback is key in helping staff to commit to improve these areas.

Once the feedback has been completed the observer will then rate the overall observation of the patient experience witnessed.

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Behaviours I Display

Page 1 is to be completed before any observation takes place. It must be completed by a carer or someone who knows the person well.

Name of patient:

Page 7 is areference list of

behaviours to helpyou complete this page.

You can also use aperson’s profile /

passport orcommunication

Contented state of behaviours:

Signals of changing behaviours:

Distressed behaviours:

Physical Verbal

Emotional

Physical Verbal

Emotional

Physical Verbal

Emotional

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Things That Happen Around Me

This is to be completed before any observation takes place.To be completed by a carer who is familiar in supportive and unsupportive behaviours for the patient.

Behaviours and environment that best supports the patient:

Physical Verbal

Emotional

Behaviours and environment that could trigger distressed behaviour:

Physical Verbal

Emotional

Use the genericreference

list of external stimuli on page 8 to help you complete the sections

below

Page 7

Generic reference list of behaviours

Please note these are just a guide and there may be other descriptions you would like to use

Physical

Verbal

Emotional

Other specific behaviours

Initiate social contact

Approaches others

Avoids others

Smiles

Frowns

Grimace

Vacant expression

Grinds teeth

Bites lip

Maintains eye contact

Grabs

Fiddles

Repetitive movements

Pulls / pushes

Avoids eye contact

Eyes closed

Touches appropriately

Hugs

Hits out

Self slaps

Slaps others

Withdraws from touch

Gestures with head

Gestures with hand

Squeezes / presses

Curls up

Restlessness

Adjusts clothes

Cowers away

Rocks / sways

Dances

Upright posture

Offers assistance

Withdraws from others

Rubs / holds self

Winces

Leans left / right

Shuffles

Paces

Bangs objects

Hand wringing

Pinches

Initiate conversation

Makes wishes known

Speaks clearly

Speech slurred

Mutters

Swears

Screams

Makes sounds

Sings

Hums

Sighs - negative

Sighs - positive

Covers mouth

Calls out

Laughs / enjoys humour

Giggles

Cries

Smiles

Aggressive

Affectionate

Seeks reassurance

Enjoyed

Elated

Alert

Attentive

Curious / inquisitive

Winces

Trembles

Anxious

Fearful

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Generic reference list ofexternal stimuli

Please note these are just a guide and there may be other descriptions you would like to use

Location of observation

Activities taking place

Day time

Night time

Staff / peers

Staff if more than one describe by using A,B,C

Peer if more than one describe by using A,B,C

Manual handling

Staff entering the room

Staff leaving the room

Peers entering the room

Peers leaving the room

Objects being moved around the room

Food / drink trolley being pushed through a doorway / room

Busy with people

Layout of furniture – organised / disorganised

Fan extractor on

Temperature: hot / cold

Being given food

Being given drinks

Cleaning - mopping

Cleaning - sweeping

Cleaning - polishing

Items being carried by others

Quiet / loud

Chaotic noise

TV loud / quiet

Radio / music loud / quiet

People muttering

People swearing

People screaming

People shouting

People singing

Hums

Sighs - negative

Sighs – positive

General talking

Calling out

Laughs / enjoys humour

Giggles

Cries

Smiles

Aggressive

Seeks reassurance

Enjoyed

Elated

Alert

Attentive

Winces

Trembles

Anxious

Fearful

Curious / inquisitive

Food

Drink

Perfumes

Sprays / cleaning

Faecal

Urine

Reacts to liquid / food

Bodily

Physical / Environment

Verbal / Noise

Emotional

Smells / Tastes

Other specific behaviours

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Person Observation Externalstimuli

Observation Record

Space for your own question…

Page 10

Summary of Observation

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