Case study – Taking a holistic approach to improve understanding and support for patients experiencing stress and distress: July 2026

Implementing CEASE (Comfort, Environment, Activity, Social Contact, Engaging) care planning to improve dementia care in Ward C4 at Dumfries & Galloway Royal Infirmary

A structured, holistic approach to understanding the causes of stress and distress has enabled Ward C4 at Dumfries & Galloway Royal Infirmary to significantly reduce stress and distress and embed sustainable person-centred approaches. The ward has seen a marked reduction in psychoactive medication administered when required (PRN) and positive feedback from patients and unpaid carers.

Situation

Ward C4 is a medicine of the elderly ward: patients are over 75 years of age, and a high proportion are living with dementia or cognitive impairment. Patients on the ward are split between those with acute care needs and those with delayed discharges, most of whom are awaiting care home placements or large care packages. Staff routinely encounter patients presenting with stress, distress, delirium and heightened confusion exacerbated by being in an unfamiliar, hospital environment.

The team recognised that patients experiencing stress and distress were not being identified and supported early enough and there was need for a more structured clinical approach to understand the causes and better support distressed behaviour. The team wanted to better meet the needs of both patients and families during hospital stays, recognising that hospitalisation and changes in environment can significantly increase confusion, even within a modern, purpose-built hospital with single-occupancy rooms. This led to the decision to look at improving dementia care practice across the team.

Approach

Aim: By December 2025, Ward C4 DGRI will strengthen cognitive screening processes and embed dementia care practices, ensuring 100% of patients identified at risk of stress and distress are recognised promptly and have an individualised stress and distress care plan in place.

The team began by completing the Reducing Stress and Distress self-evaluation tool to develop a clearer, shared understanding of existing practice gaps and identify early opportunities for improvement.

They prioritised achievable quick wins to improve care and build momentum with staff. AMT4 (a tool that assesses cognitive impairment in elderly patients) and 4AT (a bedside tool for rapid delirium screening) were often not completed on admission and this was highlighted as an improvement priority to enable earlier identification of those most at risk of experiencing stress and distress. Nurses took responsibility for completion by embedding the questions into routine patient conversations during admission to the ward. Completion of the assessment tools for all patients within 48 hours of admission to the ward quickly reached 100%, demonstrating the impact of improvement activity and energising staff.

The team then introduced the CEASE care planning model for patients identified at risk of experiencing stress and distress. This model is used to better identify and understand the range of factors that could contribute to stress and distress. The Dumfries and Galloway IDEAS team provided training on CEASE which strengthened staff capability, knowledge and skills.

Following initial testing, the 2-page CEASE documentation was modified to create a CEASE checklist to simplify care planning and guide staff in assessing each domain. Once the checklist was completed, a focused, individualised care plan was developed for each patient which identified a range of interventions to reduce and support stress and distress.

When looking at patient comfort within CEASE the team acknowledged pain as a major contributor to stress and distress. They also recognised the challenge of fully assessing pain in patients who may have limited or no use of spoken language, including those with cognitive impairment. They identified the Abbey Pain Scale (APS) as a practical, reliable tool to support assessment with these patients. The team piloted the paper-based Abbey Pain assessment tool with a single patient to evaluate its use before rolling it out with all patients at risk of stress and distress. If pain was identified, staff requested the medical team to review medication to manage the patient’s symptom.

Following initial testing the CEASE checklist and APS were implemented with a broader group of patients before spreading incrementally across the whole ward, where patients at risk of stress and distress were identified. Development of an SBAR (Situation-Background-Assessment-Recommendation) paper and inclusion of the tool in patient notes and daily safety huddles ensured consistent use.

Results

The combined approach of improving completion of AMT4 and 4ATs and introducing CEASE care planning has transformed practice in Ward C4. The completion of AMT4 and 4AT assessment within 48 hours of admission to the ward has reached 100% compliance for all patients, ensuring earlier identification of cognitive impairment or delirium.

The completion of the CEASE checklist, for patients at risk of stress and distress, reached 100% compliance within 3 months and this has been sustained. This has ensured improved understanding of the factors that contribute to stress and distress and the development of person-centred care plans to better support patients.

The implementation of CEASE care plans in the ward is evident by the range of activity and interventions now being supported. Staff are prioritising nonpharmacological interventions and are developing personalised approaches to support stress and distress for example distraction, meaningful activities, reminiscence, music, and keeping active.

As a result of this change in practice, there has been a reduction in the number of stress and distress incidences on the ward.

Wider impact of this improvement in practice has also been anecdotally recorded, this includes:

Reduction in administration of PRN psychoactive medications such as lorazepam and quetiapine.
Positive feedback from patients and unpaid carers
Staff feel more confident and better equipped to support patients living with dementia
Senior leaders have recognised the ward as demonstrating best practice.

Importantly, the impact of this project has spread beyond ward C4. The CEASE Checklist and APS documentation is now included within the enhanced observation care plan and has been spread across Dumfries and Galloway Royal Infirmary, Stranraer Community Hospital and other local community hospitals.

Key learning

The Reducing Stress and Distress self‑evaluation tool helped create a shared understanding of current practice and focus on a clear improvement aim. Through the use of quality improvement methods, the team was able to evidence their progress, secure staff buy‑in and support sustainability.

Top tip:

Starting small enabled success. Testing the Abbey Pain Scale with one patient then a small group of patients allowed the team to learn quickly, adapt their approach based on feedback, and build confidence before spreading the change to the whole ward.
Quick wins built momentum. Improving AMT4 and 4AT completion was a simple, low burden and highly visible change, helping to get buy-in from staff early and demonstrate the value of improvement work.
Ensuring assessment tools are user friendly. Moving from a full CEASE model to a CEASE checklist reduced duplication, increased uptake, and ensured care planning was focused on individual need. The CEASE checklist was easy to use and supported staff to develop a more holistic understanding of the underlying factors that contribute to stress and distress
Embedding new tools into existing systems supported sustainability. Aligning CEASE, APS and cognitive screening with enhanced observation care planning, staff handovers and SBAR processes normalised new ways of working.
Influencing the wider system. The work supported spread across DGRI and into other community hospitals, with the ward becoming a local source of learning and support.

What was challenging:

Maintaining momentum during staffing pressures. Sickness absence and limited protected time for improvement activity made it difficult to sustain the pace.
Wider staff ownership took time. Initially, knowledge and confidence sat with a small improvement group which led to reliance on a few staff.
Access to training. Competing operational pressures limited opportunities for staff education despite its importance for spread and sustainability.

What they would do differently:

Plan earlier for spread and training, including a train‑the‑trainer approach from the outset.
Protect time for improvement and learning to develop staff resilience.
Collect data earlier, particularly around administration of PRN psychoactive medication, to further strengthen the evidence for change.

Next steps

Ward C4 will continue refining CEASE care planning, supported by ongoing training and expanded dementia care education. Work is underway to improve the ward’s dementia-friendly environment through new colour schemes, artwork and a formalised “wellness walk,” along with introducing music therapy and recruiting an activities co-ordinator.

This case study demonstrates that starting by improving understanding and identification of the underlying causes of stress and distress can lead to wider cultural and practice change. The approach used in Ward C4 – small tests, early wins, team training, and a focus on person-centred assessment – provides a clear, adaptable blueprint for wards wishing to reduce stress and distress and strengthen dementia care. Wider regional and national spread is now both possible and encouraged.

Microsoft Copilot was used to assist in generating parts of this content. As AI-generated text may contain inaccuracies, all information has been checked and validated by Reducing stress and distress improvement programme team prior to inclusion in this case study.