This reflection accompanies ‘The care home lab: a case study’ and explores the role of residents in the care home lab and the use of Talking Mats to facilitate engagement. On reflection, the experience lab process set unrealistic expectations on a group of residents, some of whom were living with dementia, and didn’t allow for them to be included in a meaningful way. We hope that this case study serves as an example of how co-production is not a ‘one size fits all’ process.
Social Service Labs and Co-Design
Social Service lab methodology relies on a co-design process that actively involves people who access support. In the care home lab, Peacock Care Home took on responsibility for recruiting residents which proved challenging. For some residents, the involvement wouldn’t have been meaningful because they lived with dementia, and others simply weren’t interested in the concept. However, the home managed to select a group of three residents to join the care home lab co-design group.
How we planned to include residents in the co-design of the Care Home Lab
We had planned to support the residents to be active participants in the co-design group. In the lab, we wanted the residents to either role-play scenarios or take responsibility of noticing and feeding back in scenarios. On reflection, we learned that the lab methodology just wasn’t accessible and easy to make sense of, particularly for residents living with dementia.
What actually happened - “Ahm no one for speaking up” (A resident)
With hindsight, it was clear that the lab process set unrealistic expectations on a group with dementia, and was not a methodology that was able to include this group in a meaningful way.
There were practical barriers to working together in a group. Some of the residents were hard of hearing and the group conversation, where sometimes people talk over each other, made it even more difficult to hear. This meant that some of the residents weren’t always able to participate in the topic of conversation, sometimes speaking about an unrelated topic, not speaking at all or falling asleep. We also noticed that the jargon of outcomes didn’t seem to connect to residents lived experiences. It was clear that this approach wasn’t helping us to engage with residents in a meaningful way.
This was the first opportunity that the residents had been given to participate in open discussions about life in the home and some residents reported that they didn’t want to be too critical. One resident in particular shared their experience of having made a complaint in the past and said “I don’t bother with it now”. This may have have been another barrier to engaging with the project.
Despite these challenges, the residents were able to share some of their stories and experiences which helped the group understand power relationships in the setting. For example, when discussing freedom and choice, one resident spoke up about wanting to stay up late to watch the football, but being ‘put to bed’ by a member of staff. This helped the group start to explore how an outcomes-focussed approach might have been different.
Trying a different approach
After noticing some of the challenges in the first co-design session, we chose to take a different approach which we hoped would be more inclusive of the residents. The Iriss facilitator met with residents separately for two hours before the second co-design session to see if interacting in a quieter environment supported them to participate more. In this smaller group session the residents tried to ‘imagine the future’ together and discussed the lab methodology and roles in the upcoming lab. Having a quieter group with a more structured conversation (focussed on specific topics and not going off on tangents like the larger group did), made a real difference to the residents opening up. The anecdotes and personal experience shared in this smaller session were later used as our lab scenarios. Consistently, the residents spoke positively about being given the opportunity to share their experiences and tell their stories.
The smaller session was much more successful in terms of participation, but it was clear the language/jargon of outcomes and the process of the lab was still not clear enough to be meaningful for the residents. In this smaller session, we learned that the residents were unsure about what they wanted their role in the lab to be. They were uncomfortable about being ‘actors’, but also weren’t sure they wanted to be ‘noticers’. On reflection, the lab process may have been too rigid in that there were set ‘roles’ for residents. Perhaps they should have been encouraged to create their own roles.
How were residents involved in the lab
The residents did not directly participate in the experience lab for a variety of reasons. The learning from our first co-design session was that the groups struggled with role play, with the residents in particular preferring to discuss their own personal experiences rather than assume a role. The lab would not have been able to achieve a safe space to try (and possibly fail) new ways of working without an element of role play to achieve separation. There was a fear that if residents were talking about their true experiences, it would have been added pressure for staff to ‘get it right’.
Also, the residents weren’t confident about their role in the lab. The language and process of the lab wasn’t made clear enough or explained in a way that would support their understanding. We wanted to make sure that the residents were informed before consenting to participate on the day, but we couldn’t guarantee this.
What are Talking Mats?
Talking Mats is a tool used to support communication. It is an interactive resource that uses three sets of picture communication symbols – topics, options and a visual scale – and a space on which to display them. This can either be a physical, textured mat, or a digital space, for example a tablet, smart board or computer screen. The resource can be used to facilitation discussion on a range of topics and to support decision making.
How we used Talking Mats
Residents really valued telling their stories and experiences from living in the home, and staff and management were vocal about how important these experiences were. With this in mind, we asked for the support from the Talking Mats ™ team who were experienced in working with people living with dementia (Murphy and colleagues, 2007)
We hoped that Talking Mats would help to guide conversation and explore residents’ understanding of outcomes. We expected that the Talking Mats conversation would complement learning from the lab to build a fuller picture of residents’ experiences.
Talking Mats was available in print and on IPad, but the residents chose to use the physical mat rather than the IPad App:
“Hopeless with them, with these mobile phones”
Three residents with varying degrees of cognitive ability were involved in a Talking Mats group discussion using three different topics – ‘Activities in the home’, ‘Activities outside the home’ and ‘The environment in the home’. The conversation with residents using Talking Mats seemed much more focussed and allowed for an in-depth conversation about their views on activities and the care home environment. The residents responded positively to the use of Talking Mats in helping them focus:
“It helps you… to get your details…”
The residents took the opportunity to discuss the things that mattered most to them, and new activities they would like to explore such as gardening, attending clubs in the community and looking after animals. The Talking Mats also allowed them to explore options that they hadn’t thought about before, and the images helped spark new ideas.
What did we learn from the Talking Mats conversation?
Talking about improvement is tough
“The question is: How good can you make it? I don’t think you can make it any better.”
The residents said they found it hard to talk about improvement and change in the home. Residents considered the home ‘good’, but when questioned if it was ‘better or best’, one resident remarked “I never said that, I don’t know any of the others”. Not having an experience to compare with made it tough for residents to think about what could be better.
Evidence suggests that, in general, older people are much more likely to express satisfaction with services than younger people (Bauld and colleagues, 2000). In this setting, this may be because people have a close and ongoing relationship with staff, and one resident spoke specifically about “getting a staff member in trouble” and what he experienced as the fallout from that.
Residents wanted to do things that were meaningful
The residents were not just choosing activities based on their preferences, but were able to identify why something was important to them. Several themes that came up in discussion were:
- History/Memory - Reconnecting with the past or continuing old routines
- Purpose - Having a sense of purpose, for example, keeping some hens in the home to have something to do and help residents feel like they have a reason to “get up in the morning”
- Learning - Still feeling like you had opportunities to learn and try new things.
|Quality of Life||Process||Change|
I feel safe and secure
I see people
I have things to do
I live in a nice place
I live life as I want and where I want
I stay as well as I can
I belong to a community
I am treated as an individual
I am valued and respected I am listened to
I have a say in decisions about my care and support
I am supported to live well and plan for a good end of life
My family and friends are involved if I want
I can trust staff and rely on them to respond
My privacy is respected
My skills are improved
My confidence and morale are improved
My mobility is improved
My health has improved or my symptoms are reduced
I have settled in to where I am living
Choice and Power
While the residents sometimes struggled to speak about improvement, conversation sometimes turned to issues of choice and power.
For example, when looking at the symbol for ‘television’, the facilitator asked “who chooses what is on the TV?” which led to a discussion about power and choice. One resident actively spoke up about his feelings on the subject:
“Some people think they can just switch the telly whenever they like.. but the telly is for the people, for the residents. They shouldn’t have anything to do with it”
The theme of power and control appeared in the discussion on several occasions, although it wasn’t directly addressed in those terms.
What were the outcomes of using Talking Mats?
Although the conversation using Talking Mats was a lot easier for residents to engage with, we are unsure of whether or not it supported an outcomes-focussed conversation. The Talking Mats helped explore issues of power, choice and preference. However, outcomes-focused conversations can be challenging, and though there was discussion of what things could change (environmental factors such as brighter lighting and activities like going to the cinema), these weren’t always linked through to the individual outcomes for residents. The images were at a fairly superficial level and the residents struggled to explore what their own personal outcomes were.
At an evaluation held eight weeks after the lab, we found it challenging to evaluate the impact of using Talking Mats to discuss outcomes. One member of the Talking Mats group made the choice not to attend the eight week evaluation and another member of the group had no recollection of participating in the Talking Mats, despite being prompted with a visual of the mat and some stories specifically referring to him. The third resident remembered the mats and spoke positively of the experience as a whole, saying it “helped us focus”.
It is important to note that this was the first time that the residents used the Talking Mats tool, so they may have benefitted from familiarising themselves and having a series of conversations.
Ultimately, the lab experience was made more meaningful for staff because of the involvement of residents in co-design sessions, but this involvement may not have impacted on the residents themselves. It is important learning for all members involved that all participation needs to meaningful, and that trying to apply a ‘one size fits all’ approach to co-design was ineffective.
Three lessons learned
- Staff, family members and management benefitted from having the residents involved in the lab, but the residents may not have experienced the same positive outcomes.
- Talking Mats may help support a more focussed and participative conversation; however while the discussion did help unearth what could be changed in terms of the environment and possible activities, it did not necessarily help understand why these things were important for delivering outcomes for individual residents.
- The process of co-design needs to be fluid and change depending on the needs of the group.
Peacock Care Home is exploring the wider use of Talking Mats in the home, for new residents and for planning meaningful activities. Evidence suggests that the use of Talking Mats should encompass more than occasional use, and that it can be a challenge to embed training(Macer and Murphy, 2009).
Peacock Care Home will continue to strive to involve residents in future developments, but in ways that are accessible and meaningful.
More information on talking mats is available here: www.talkingmats.com
Bauld L, Chesterman J, and Judge K (2000) Measuring satisfaction with social care amongst older service users: issues from the literature, Health and Social Care in the Community, 8, 316–24
Cook A, Dunbar G, Eastwood K, Polding-Clyde S, Social Care and Social Work Improvement Scotland and JIT Action Group(2011) Talking Points: personal outcomes approach framework of outcomes important to people living in care homes
Macer J and Murphy J (2009) Training care home staff to use Talking Mats with people who have dementia
Murphy J, Gray C M and Cox S (2007) The use of Talking Mats as a communication resource to improve communication and quality care for people with dementia, Journal of Housing, Care and Support 10(3)21-27
Murphy J, Gray C M, Cox S, Van Achterberg T and Wyke S (2010) The effectiveness of the Talking Mats Framework with People with Dementia, Dementia : International Journal of Social Research and Practice 9(4) 454-472