Intro to the series
Step Change Design focuses on encouraging care settings to take a fresh look at their care culture and care practices in order to engage actively and meaningfully with their outside spaces with their residents. In this monthly series we explore ways to make the most of the outside spaces around your care setting and help your residents benefit from stepping outside and enjoying meaningful activities there, as and when they choose. www.stepchange-design.co.uk
What do we mean by ‘legacy of fear’? In simple terms, we are talking about something that happened a long time ago that continues to impact negatively on the behaviour or activities in the care setting, particularly in relation to the outside space. We noticed this phenomenon at work in one of the care homes we visited as part of our research study. It helped to shed light on the various ways that care homes interpret and apply health and safety guidance and how these different approaches were a reliable indicator of where the care setting was located on our Care Culture Map.
A traumatic accident that happened to a resident in a particular area of the garden had created a reluctance to go to that part of the garden with residents. Consequently, a new habit or ‘rule’ had been allowed to take hold which meant that residents should be kept away from that part of the garden to avoid the risk of a similar accident befalling another resident.
Over time, this rule became the normal way to engage with the garden. When we arrived in this garden, it became obvious to us that a significant area of the garden was not being used and yet we couldn’t understand why. What was normal to the care setting appeared to be very abnormal to us. This is when we were told about Fred’s accident and fall in that same area. When we enquired further about how he was doing (thinking that it may have been very recently), we were told that it was about five years ago and sadly Fred had passed away in the interim period.
So for five years, every garden visitor (whether staff, resident or family member) had been prevented from engaging fully with the whole garden because of the fears that had been allowed to take hold amongst the staff after that unfortunate accident. Instead of tackling the root cause of Fred’s fall, to fully understand what led to the accident and correct the problem, the response was to discourage visitors from going to that part of the garden at all. It appeared that the garden got the blame during the accident investigation. This was interesting to us as it indicated that this home was practising a risk assessment approach that assessed the feature for its safety (in this case the garden) rather than Fred’s (and other residents’) ability to engage with it safely.
This was confirmed in a later conversation at the same home when we asked why a rotary washing line had been hidden behind a wall getting rusty. The reply we received was that it represented a ‘ligature risk’. When we delved further to find out for whom specifically it was a ligature risk there was no reply. The manager had risk assessed the item alone without any reference to her residents’ individual abilities or desires to engage with the familiar outdoor activity of hanging out the washing. For a particularly fearful care setting, and one in which Health and Safety practices risk assess things rather than from a resident’s perspective, you could argue that anything has the potential to harm, maim or even kill.
It’s worth taking a deeper look at the emotion of fear and how it manifests both individually and in organisations. Fear is a powerful emotion. It can make us doubt ourselves, question our abilities, and create a sense of feeling unsafe or insecure. One of its principal effects is to cause us to stop, delay or avoid doing something. In other words, its effects can be that of reluctance or resistance.
Fears at an organisational level are also very subtle. Because fear is not seen as a desirable trait, and yet it is nonetheless a perfectly normal human emotion, it can be very well disguised. In management practice this can manifest in different ways: putting off decisions about installing new garden items (reluctance), making excuses (blaming), closing down conversations that challenge the reasons for not doing something (avoidance) and timidity in trying something new or supporting (or funding) even very modest experiments or trials (resistance).
Fears can also be found in organisational policies too. Look out for the tell-tale signs: very complicated and often contradictory rules and procedures that are expected to be followed. This can often be found in Open Door policies as we described in an earlier blog (number 7). Once fears become embedded in policy and practice they can be very hard to address, despite the situation that may have caused the original fear being a long time in the past. Complexity is a sign of a very fearful organisation that is trying to cover every eventuality. Instead, the organisation should be seeking to address these fears directly by remaining objective, being proportionate and tackling root causes.
One of the care homes in our research project informed us that because there was a broken paving slab just outside the door to the garden, it would not be possible to use the garden at all that summer and therefore the home would not be able to take part in our data gathering exercise. We contrasted this response to a home where a broken manhole cover was discovered in the garden alongside the household with residents living with advanced stages of dementia and it was fixed within 24 hours because the home believed that engaging with the garden regularly was of utmost importance to these residents.
Why had the first home not simply repaired the broken paving slab? Why did it appear that they used this as an excuse not to go out into the garden at all that summer? Could the broken paving slab have been conveniently used to disguise a bigger fear: that the home believed the garden was a dangerous place for its residents?
If there is a belief that the garden is dangerous then this is likely to manifest as reluctance or avoidance to engage with that outdoor space and over time it becomes normal not to use the garden at all. Beliefs have a big impact on our behaviour and our practices, whether or not the belief is actually true or not.
The outdoor space acts like a mirror of the care organisation’s care culture and can reveal a great deal about any fears that may be holding back or inhibiting staff across the whole care setting. Additionally, we noticed that these traits were more likely to show in care settings that were lower down on our care culture spectrum. These care settings generally held fearful attitudes towards Health and Safety and a culture of unquestioning compliance to outdated or plainly wrong interpretations of good risk assessment or health and safety best practice.
In the case of Fred’s fall, a thorough investigation of the area where this accident happened (alongside awareness of Fred’s then current physical and mobility abilities) would probably have revealed the raised edging bricks as a potential trip hazard and likely contributing factor. They could then easily have been removed or re-laid flush with the path surface, solving a problem very practically and quickly. A more responsive care setting would seek to learn as much as possible from the incident and to focus subsequent actions away from blaming the garden to encouraging and supporting staff and garden visitors to look objectively at how to fix any physical elements. This is a more person-centred approach to garden visits, ensuring the garden is accessible to everyone but tailoring supervision and support according to individual needs in different parts of the garden.
How did this home reduce the fears in their care settings? The simple answer lies in the quality and frequency of information-gathering about their residents and making sure it is shared widely and regularly. A characteristic of homes practising person-centred care is their emphasis on remaining curious and interested in their residents as individuals, constantly alert to new information that sheds light on behaviours or preferences.
The key difference then between the fearful homes and the more progressive ones in our study was around risk assessment practice. Homes practising person-centred care and beyond were risk assessing their individual residents’ abilities to engage with an item, garden feature or activity safely, as opposed to the item (or garden) itself.
Staff in this home now understand that fear takes hold in the absence of information and experience and so they have greater awareness of those residents who may need extra assistance in particular areas of the garden (risk assessing their residents’ abilities to engage safely with the garden), ensuring that residents who wish to go into the garden are supported to do so according to their current level of need.
Be inspired by Step Change Design’s new infographic that shares key statistics from their study to help you step outside with residents more. https://bit.ly/2WZQ240
Connect with Step Change Design on Twitter Debbie Carroll @stepchgdesign
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