Observation as an evaluation tool for people with advanced dementia

The Purpose: The purpose of this activity was to explore the use of observational method with people in the late stages of dementia in day care and support services provided by Alzheimer's Society. 

Preparation:

The team identified services that had outcome-areas for people with dementia that had the potential to be observed to varying degrees - people with dementia

• are supported to engage in activity that is meaningful to them.
• are supported to maintain existing skills and try new activities
• have opportunities to socialise with staff and other service users 
• are supported to be independent
• are treated with respect.

The team chose to use the Quality of Interactions Schedule (QUIS). This tool was designed to evaluate the quality of care provided by two residential units where the people with dementia were unable to give verbal feedback about their experiences of care. The tool was further developed and adapted by City University, Dementia Care Matters, and used to evaluate a number of care homes and day centre services. 

What happened:

The team's approach to evaluation involved carers and people with dementia by:

• piloting the QUIS observational tool alongside the day support managers

• piloting a carer questionnaire

A team member observed with the day support manager, sitting where they could see and hear conversations without being directly in the group.

• Staff and service users were told what was happening on the day.

• Notes were made for each five minutes of observation. These were about what was happening during that time.

  • The quality of interaction between staff and service users was scored and coded immediately using the QUIS coding categories. Coding was based on the dominant feature of that particular five minutes. This provided an at-a-glance way to start to appreciate whether the service was meeting its service outcomes.

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• The experience could only be understood meaningfully when combined with the notes about the verbal, and non-verbal, engagement observed that led to these scores being given.   

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What happened as a result:

Observation highlighted missed opportunities to meet service outcomes by providing a good experience, such as to provide activity more suited to the range of skills and interests of the people with dementia being observed.

The team found the QUIS categories effective in gaining an insight into how people with dementia experienced the service, with some limitations too: 

• carer insights about an observed person would be valuable to understand further about what they had observed and what might be made better for a particular person with dementia. 

• it was sometimes difficult to distinguish between categories for positive social interaction and positive personal care.

• The service managers felt the tool was beneficial:

  • to understand if changes need to be made to a service, such as choice of activities

  • to highlight which service users may not be getting as much from an activity as others

  • to highlight which service users may be bored or dominating and group dynamics overall

  • to give an idea of who service users gravitate towards and what makes them feel comfortable, providing day support staff with an opportunity to improve person-centred care.

  • to capture the experience of service users who do not have the verbal ability to respond to evaluation questions.

Learning points:

Observations are a snapshot of a service. The aim of the tool is for care to move into positive social interaction as much as possible. Repeated observations over time could demonstrate and support progress.

If there's a large group then it is not possible to observe the whole group all of the time, which could risk positive and negative examples of experience being missed - and could risk not being able to demonstrate how well outcomes are being met for the whole group.

Some service users will want to engage with the person observing them. As the tool is designed to be used in five minute intervals there are opportunities to pause and continue at another point. 

Some managers found it difficult to observe and not step in to offer suggestions or advice to staff there and then, rather than take notes and have a conversation with the staff later.

It is important to reassure staff about why the observation is being done and how this may help the service.

The observation complemented, and gave a richer picture than just feedback from carers. The carers tended to give overwhelmingly positive feedback, whereas observation highlighted areas for improvement too. 

Key contact to find out more:

Evaluation and Impact team, Alzheimer's Society. Email: [email protected].

Useful links

Downloads for using Quality of Interaction Schedule, Observation Tool (2011)