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The Royal College of Psychiatrists Improving the lives of people with mental illness

National Audit of Dementia


Person, Interaction and Environment (PIE)


What is PIE?

PIE is an observational method which aims to:

  • describe the culture for person-centred care experienced by people with dementia or confusion in general hospital wards
  • help the ward team reflect on and develop their approach to working with people with dementia


What does it involve?

  • Following a one-day workshop, two members of staff carry out PIE on a different ward within the hospital that admits people with dementia or communication difficulties (elderly care, stroke rehab, acute medical or surgical).
  • Real-time observations of 5-10 people with dementia or cognitive impairment, delirium or communication difficulties take place over at least two key times of the day in 2-hour time periods (4 hours in total), one in the morning and one during a meal-time.
  • Background information about the people receiving care and the ward are recorded as well as comments about their care made by patients or their relatives/ friends.
  • Patients, visitors and staff should be informed beforehand and given the opportunity to have any questions or concerns addressed, with an on-going process of consent. The observers can intervene in a crisis but should otherwise aim to be as unobtrusive as possible and respect patient privacy.
  • Verbal feedback to the host ward team should be given as soon as possible after data collection.
  • An action plan to develop practice will then be agreed with the ward team.
  • Ideally, both observers will spend a shift of 7.5 hours to undertake PIE in each ward. This is required for introductions to the ward team, data collection including 4.5 hours observations (4 hours plus a practice of 30 minutes), reflection on the findings between observers and feedback to the ward team.


What is observed?

The following prompts may help us to consider the culture for person-centred care for people with dementia in the ward at any given moment. These are (following the PIE acronym):

  • P – Person: whether staff are using what is known, or not known, about the individual patient as a person to personalise their care; observing what the patient is doing and how they are affected.
  • I – Interactions: a person-centred care culture is particularly evident in the context of relationships, or more specifically, through day-to-day interactions with staff.
  • E – Environment: this looks at the modifiable ward environment and its impact on the people receiving care.


What happens to the findings?

  • The main impressions formed about the culture for person-centred care will be discussed with members of the ward team.
  • Although members of staff may benefit from one-to-one feedback, the focus is not on individual staff competencies per se, but on the shared responsibility for the ward culture experienced by people with dementia.
  • Key action points will be derived to develop person-centred care practice and improve patient experience, e.g. to engage people with dementia more often in conversation.
  • The main impressions and action plans for each ward will be submitted to the Royal College of Psychiatrists and an overall thematic analysis of the results from the participating hospitals reported at the national level.
  • The findings are expected to complement those from other parts of the clinical audit, e.g. patient/carer questionnaire.


What are the potential benefits of using PIE?

For people with dementia and their carers

For hospital staff

Give a voice to people who might otherwise find to difficult to convey their experience

Provide a means by which staff can reflect on the culture of care from the patient as well as staff perspective

Assess aspects of care which matter most to people with dementia and their carers’ in acute care, particularly their interactions with staff

Raise greater awareness in the staff team about the impact that their way of working has on people with dementia, including what is done well

Raise awareness at the local and national level about the quality of person-centred care received by people with dementia in general hospital wards

Empower staff to make small but significant changes to everyday practice in their ward

Improve the experiences of people with dementia in general hospital wards

At the national level, share elements of best practice and share solutions to problems



Where next...



National Audit of Dementia, 4th Floor Standon House, 21 Mansell Street, London, E1 8AA    

Fax: 020 7481 4831   



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