1. Audit of ‘This is me’ and ‘Forget me not’ on wards Semi structured Interviews with volunteer relatives Observation of care Undertaken over a 24 hour period 2.Strategies for Change A triangulation of audit, interview and observation (Fig.1) were implemented in order to gain a perspective on the range of issues relating to the experiences of those patients living with dementia, their relatives and carers. Background: PHT Dementia screening Jan–Aug 2014 46% of patients admitted to the Orthopaedic Trauma Wards aged 75 years and over were living with dementia Fig 7. A summary of the comments highlighted from the ‘Observation of Care’ undertaken 1.Aim  To identify and develop interventions that will promote activities and social interactions for those patients living with dementia whilst on a trauma orthopaedic unit. Team Members: R. Sherrington*, G. Baldwin*,P. Cheesman*, A. Gillon*, L. Heath*,J. Kynes*,C. Moore*, W.Rongavilla* *Orthopaedic Unit, Queen Alexandra Hospital, Portsmouth. When I wander don ’ t tell me to come and sit down. Wander with me. It may be because I am hungry, thirsty, need the toilet, or maybe I just need to stretch my legs. When I call for my mother (even though I’m ninety!) don’t tell me she has died. Reassure me, cuddle me, ask me about her. It may be that I am looking for the security that my mother once gave me. Background: Our inspiration taken from the poem ‘When I Wander’ When I shout out please don’t tell me to be quiet....or walk by. I am trying to tell you something, but I have difficulty in telling you what. Be patient. Try to find out. I may be in pain. When I become agitated or appear angry, please don’t reach for the drugs first. I am trying to tell you something. It may be too hot, too bright, too noisy. Or maybe it’s because I miss my loved ones. Try to find out first. When I don’t eat my dinner or drink my tea it may be because I’ve forgotten how to. Show me what to do, remind me. It may be that I just need to hold my knife and fork I may know what to do then. When I push you away while you’re trying to help me wash or get dressed, maybe it’s because I have forgotten what you have said. Keep telling me what you’re doing over and over and over. Maybe others will think you’re the one that needs help! With all my thoughts and maybes, perhaps it will be you who reaches my thoughts, understands my fears, and will make me feel safe. Maybe it will be you who I need to thank. If only I knew how. Norma McNarhara Fig 2. Development in ‘Observation in Care ‘ 3. Changes and Improvements Identification of the significant findings led to the following cluster of themes:- Self awareness of practice by reflecting on observations Coping with challenges Doing the right thing for the individual Promoting success through activity interaction The following improvements were implemented aligned to the project aim 3a. The promotion of ‘This is me’ A simple and practical tool developed by the Alzheimer's Society helping to provide a ‘Snapshot’ of the person living with dementia. The use of the ‘This is me’ tool was initially audited at the start of the QI project. Audit data in 2 week period 24/11/2014-05/12/2014 identified 8 patients had been admitted with a formal diagnosis of dementia, all failed to have a ‘This is me’ and only 50% had a visual identifier using a forget- me not symbol. Improvement By providing the 'This is me’ document in an upright holder located on the patient locker side increased accessibility and allowed information about the patient to be shared in social interaction(Fig3). To encourage engagement, the Ward Staff developed abbreviated post card sized versions of ‘This is me’ of themselves which helped engagement with the project. 2a. ‘Observations of Care’ Tool (RCN Workplace Resources for Practice Development, 2007) The observations were undertaken in pairs on wards where at least one person living with dementia was present. During the observations notes were taken to build a picture of events, which took into account verbal and non verbal communication, actions, events and people, in order to develop a greater understanding about what was happening (Fig 2). The tool was selected for its effective approach and uncomplicated design. A total of 36 observations (30 minutes) were undertaken to ensure each hour over a 24 hour period was covered. A total of 24 staff from a broad range of staff groups participated in the observations including Ward Managers, Registered Nurses, Health Care Support Workers and Student Nurses. The observations were feed back to the staff involved to identify learning and action points. This encouraged the ward staff to feel part of the process with the Quality Improvement Team. ‘ I want to come back again’ ‘Lots of memories coming back’ ‘Reminds me of songs my mum used to sing to me’ 5. Achievements and Future Plans Achievements:  Broaden staff engagement and awareness by promoting the use of ‘This is me’ as highlighted from the interviews and visual identifier using the ‘forget-me-not’ symbol.  Education Boards on each of the wards.  Staff boards with photos and their hobbies.  Activity Trolleys for each ward Future plans:  Every month: Re audit of the utilisation of ‘This is Me’ every  Complete weekly ‘Observation of Care’ around the use of Activity Trolley with a broad range of staff (Fig 2) with observations of care particularly with those offered the opportunity to participate with activities.  Complete weekly interviews those participating with activities and relatives. Continue to listen to feedback from friends and family and action as required 2b. Interviews Seven in-depth semi structured interviews were conducted to investigate values, reason and meaning held by relatives of those patients living with dementia to gain an authentic understanding of their interpretation and concepts. The qualitative data was analysed using the whole of the transcribed interview and the notes made from the observation of care. Impact These offered a range of activities (Fig.4) that could be adapted to the individual. This empowered the staff with the ability to adapt their approach to individuals with the implementation of activities to increase stimulation and social interaction. 3b. Introduction of Ward Activity Trolley Fig 4. Staff & patients engaged in activities Fig 3. Illustration of the ‘This is me’ located in the holders on the patient’s locker and the Staffs abbreviated post card sized versions. 3c. Improvement Music Activities Musical aptitude and appreciation are the two of the last remaining abilities in the patients living with dementia (Alzheimer Society 2015). Fig 6. Musical activities being undertaken to increase stimulation and social interaction 3d. Impact of ‘Observation of Care’ The observers involved described the opportunity to step back and see what happens in their area as an opportunity they had not been afforded before. Helped develop self awareness of behaviour. Helped to develop their observation skills and develop their skills of giving and receiving feedback. This lead to a direct impact on care by working with their colleagues to share good practices and identify ways to improve care (Fig 7.). Equipment held on each of the Wards Activity Trolleys Reminiscence Picture to share books Percussion set Chatterbox cards Aquarium Gel Sensory Pad Colouring cards Shape sorting Square puzzle CD & song books Fig 1. The Triangulation of approaches used 6. Lessons Learned: Fig 5. Illustration of the range of activity equipment held on each trolley Improvement To help improve the patient experience and journey, the Quality Improvement team developed three Activity Trolleys located on each of the trauma orthopaedic wards. Impact: Improved Patient Experience Reflected by comments below regarding the music activities and the comments summarised from the observations of care (Fig 7). Such activities appears to evokes emotions that bring memories, shift mood, manage stress and stimulate positive interactions.  Opportunities to listen and observe are essential in order to gain an insight of ‘the person in the patient’.  Staff thrive on constructive feed back.  Involving a broad range of staff is key for sustainability. Impact Empower staff with the ability to know the individual, through the promotion of the ‘This is me’ scheme.