Finding time and space

In the climate of poor communication, uncertainty and lack of understanding, welcoming the group and showing value of their work and experience was a vitally important start to the study. I acknowledged the difficulties the group faced in trying to manage this chaotic situation.

………it’s not an easy world out there. It’s complicated, it’s chaotic, there are loads of different people in the team and we’re dealing with expectations of the public versus expectations of the national standards As a result of responding to priorities and trying to balance everything care has become a bit uncaring and impersonal but the national standards are sort of driving that to get things done quickly, to get people through the system as fast as possible (Reflections)

The group were willing to find the time and space to be together and to try and address some of the problems experienced by the patients and those close to them. The old adage ‘a problem shared is a problem halved (Ev workshop)’ was used as a reason to try to work together to overcome the difficulties.

4.3.2 Valuing experience

There appeared to be much hidden knowledge and understanding that needed to be uncovered and used effectively if the evidence of person-centred practice was to be gathered.

I believed that there was untapped resource in teams of the groups’ knowledge, skills and clinical experience and we needed to work effectively together with the time and resources that we had (Reflective diary).

Early in the action meetings an introductory task enabled the group to work together to agree an understanding of person-centred practice and evidence- based practice. I had a hunch that the group knew about these ‘buzz words’ that were commonly used in the policy context of improving healthcare experience. Taking this time out was an opportunity to value their ideas.

I acknowledged that the group had a very important part to play in the patients’ experience of [hip fracture] care. There was a lot of listening and a lot of thinking so it seemed slower in this sort of group than work would normally be. I asked the group to be patient with that as this was their time out to think. I recognised that this may seem frustrating when there were a lot of clinical issues to sort out and a lot to do in practice; it was quite normal and very difficult (Reflective diary)

The participants worked together to share their ideas. Despite the views of the managers it became apparent that not only did the group understand person- centred practice but they had strong views about the subject. The findings (Fc4) in Figure 5 not only told me what they knew but also reinforced the ground rules that we had discussed previously.

Figure 5 Post-its identifying themes arising from person-centred practice EMPATHY TRUST PERSON-CENTRED PRACTICE COMPLEXITY RELATIONSHIP OF NEEDS Reliability – do it if you say you will i.e. I’ll be back in 5 minutes

Reliability – resulting in trust

Truthful expectations not hiding anything from

patients and relatives (what they can and want to know

Remembering to do what you said you would do Acknowledge fear

and loss of control

Addressing fears Listening and giving

information – taking and giving

Time to listen time to speak, time to go back and check all is ok Listening and hearing what said, non-verbal actions, communicate content of communication – the truth, give written information, involving patient in

discussion about the care Treat the patient as you

would like to be treated same as relatives, respect for person and self

Slowing things down Empathy

Breaking complex issues into manageable steps

Understanding the importance of your role in the patient perception

Good written records i.e. unitary notes, records that follow the patients to prevent duplication

Discharge planning negotiation between relative, consultant & team to achieve outcome

Applying appropriate services at right times i.e. home visit at weekends if that suits patients/relatives

Professions taking responsibility - take charge but ensure

appropriate balance More private facilities

rather than commode in the ward

Provision of all relevant

information and then time to think Involvement in care i.e. going to x-ray

on (x) date & allow for repetition

Continuity of profession dealing with case/care Looking at the

persons needs

The group’s ideas about evidence-based practice (Fc5) are in Figure 6.

Figure 6 The groups’ ideas about evidence-based practice

Standards, best practice guidelines, pathways, national frameworks, protocols, performance indicators, targets, risk management, expectations, tells you what to do

Professional standards, accountability, ‘covering your back’ Baseline starting point, goal setting, time consuming

Productivity, efficiency, cost effectiveness, clinical experience, audit, measurement, outcomes

The themes the group developed during this exercise showed how the values underpinnings person-centred practice potentially conflicted with evidence- based practice and performance targets. The main issues are outlined below.

4.3.1.1 Developing a relationship based on dignity and respect

It was not always easy to ‘treat the patient and relatives as you would like to be

treated’ while showing ‘respect for [the] person and [for] self’ (Fc4). Developing

a relationship based on dignity and respect could be challenged by both internal and external factors. The examples given were the lack of ‘continuity for the

professional dealing with the case or care’ (Fc4) and the need for ‘more private facilities rather than a commode on a ward’ (Fc4).

The group recognised that ‘understanding the importance of your role in the

patient perception’ (Fc4) was vitally important. It was suggested that the

professions [needed to be] taking charge [while] ensuring [an] appropriate

balance (Fc4) between creating dependence and enabling the injured older

4.3.1.2 Assessing the complexity of needs

The group reported that finding out the complexity of the needs following hip fracture involved ‘looking at [assessing the] person’s needs, acknowledging [the] fear and loss of control’ that was naturally present following injury and then ‘addressing [any] fears (Fc4)’. The healing process was slow and ‘time

consuming’ (Fc5). This conflicted with the fast pace demands of service

delivery driven by ‘standards, best practice guidelines, performance indicators

and targets’ (Fc5).

A full assessment provided a ’baseline starting point’ (Fc5) then an individual plan was developed by ‘breaking complex issues into manageable steps (Fc4) and ‘goal setting’ (Fc5.). It was very difficult ‘slowing down’ (Fc4) and ‘taking

time’, giving people ‘time to think’ and ‘providing relevant information’ (Fc4)

when the drive was to get ‘more [people] through (4.142 Radiographer).

‘Meeting with the MDT’ [multidisciplinary team] (Fc4) and ‘discharge planning negotiated between relatives, consultant and team [was essential] to achieve

[successful] outcomes’ (Fc4) for all involved. ‘Applying appropriate home

services at the right times i.e. home visit at weekends if that suits patient and relatives (Fc4) was one example given of being person-centred. However, this

involved a flexible approach to working hours and a level of autonomy that was not considered an option in the service at present.

4.3.1.3 Building trust

Building trust involved giving ‘truthful expectations [and] not hiding anything

from patients and relatives (Fc4)’. This was clarified further in finding out ‘what they can and want to know’ (Fc4). There was some indication that this was time

related. The group were aware that due to the pressures of work they were not always able to carry out everything they wanted to do within a reasonable time scale. Examples of reliability that resulted in trust were ‘do it if you say you will

i.e. I’ll be back in 5mins’ and ‘remembering to do what you said you would do (Fc4). In reality the group recognised that they did not always achieve this.

4.3.1.4 Showing empathy

The group understood that showing empathy involved ‘non-verbal actions’ (Fc4) and ‘listening and hearing what was said’ (Fc4). They noted that the patient and those close to them should be given ‘time to listen’, ‘time to speak’ (Fc4) and then the healthcare professional should find ‘time to go back’ (Fc4) to ‘check all is ok’ (Fc4). They believed the ‘content of communication’ (Fc4) involved ‘giving the truth, giving written information and involving the patient in

discussions about the care’ (Fc4). However, they had to balance this with the

expectations of the organisation in terms of the ‘risk management’ (Fc5) agenda which involved additional paperwork.

The group recognised that practitioners were torn between understanding the demands of their employer versus the needs of the person they were caring for. Rather than being proud to have the knowledge, responsibility and authority and They often felt defensive and ‘accountability (Fc5)’ was described as ‘covering

your back’ (Fc5). ‘Good written records i.e. unitary notes, records that follow the patients to prevent duplication’ and provided evidence of ‘productivity, efficiency, measurement [and] outcomes were essential as well as good

communication that demonstrated the values underpinning care.

Overall, there was a stark comparison between person-centred practice and evidence-based practice. The group suggested that perhaps ‘more caring and

less measurement may be better’ (Ev2). On reflection by working together and

building trust through understanding the group were able to share their expertise, experiences and values and in turn build up their group strength to recognise the challenges ahead.