Following the workshop, at the instigation of the Netherton PIE team, the site researcher met with them to discuss the process and tasks. The ward manager suggested she would lead PIE and that they would carry out practice observations to build their confidence during December. The first PIE cycle began in earnest with observations from mid–January 2014. These were conducted over a two hour period in pairs on two occasions, at different times of the day (mid-morning and afternoon). Staff initially felt inhibited and anxious, concerned that colleagues might act differently knowing that they were being observed, similar to Seaford. Afterwards, they met to share reflections.
Observations indicated positive features of practice (staff responsive and reassuring with anxious patients; encouraging interaction between patients; offering choice of food and drink and going to it straight away; ward clean; patients in bed appearing content; others up and about in the day room and corridor). Feedback was provided to staff on shift and welcomed as acknowledging the strength of team working. Immediate action was initiated from these observations. The introduction of short, staggered staff breaks in the morning to ensure responsiveness during a period when staff were relatively invisible in the bays (observed as buzzers going unanswered, and patients being left longer than usual for assistance); and attention to the temperature of the ward for patients who were inactive by offering blankets (staff constantly in motion did not notice).
Over the following two months (February/March 2014), further observations occurred involving all seven PIE team members and practice development co-ordinator. Additional support anticipated from staff at directorate level did not materialise. Apart from individual examples of a particular
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patient being ignored or a dozing patient not being offered a drink, observation elicited a picture of responsive practice; an image with which the ward ‘outsider’ – practice development co-ordinator – concurred. A facilitation meeting between members of the research team, PIE team lead and senior charge nurse, was held in early April 2014 to support translation of observations into action plans. It was reported that plans were being developed from the second set of observations, on reducing noise in the morning and increasing activities.
By summer 2014, six months after initial implementation began, progress had stalled. Examination of action plans from previous observations by the research team revealed difficulties in moving beyond a general ‘wish’ list to identify specific steps and devolution of responsibilities to achiever them. For example, although use of volunteers to support activities such as reminiscence, exercise groups, games etc. was identified as an action, as was increasing activities provided by staff to patients, concrete steps to take these forward were vague (‘manager to pursue’). Indeed, from informant conversations with PIE team members, although they concurred with the objective of doing more stimulating activities with patients, they felt that this could not be done within their existing staff complement. Similarly, engaging volunteers was viewed as a good idea, but the steps to make it happen had not been worked through.
The research team offered a further half-day workshop to consider action planning and review , held in August 2014, when interim data collection was to start. Five PIE team members attended, including two senior staff. Anonymous ethnographic observations were used to explore practice in its organisational context. These were intended to provoke discussion of factors shaping practice that might be focus for change without ‘blaming’ individuals; and to work through action planning around concrete examples. Evident from discussion was the openness of the team to debate aspects of practice that were regarded as contentious (use of language and terms of endearment with patients). The workshop appeared to generate renewed enthusiasm as had previously occurred with Crane. It was agreed that they would develop an action plan for discussion with ward staff at the forthcoming six-monthly staff away-day in November (to which the researcher was invited). Thus, as the PIE implementation phase approached nine-month interim data collection, there was prospect of resumption.
In Rivermead, similar to Seaford wards, nearly three months elapsed between the introductory workshop and the first set of observations. In May 2014, three pairs of staff (three HCAs, a housekeeper, nurse and ward manager) conducted observations at different times of the day: early afternoon, teatime, and late evening, over two hours on each occasion. Reflections on observations occurred informally afterwards. Despite the number, range and length of observations, documentation revealed a relatively superficial portrayal of practice and goals for improvement,
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largely related to professional ‘visitors’ to the ward (pharmacists, phlebotomists, porters and medical staff). For example, positive features of practice were greeting every patient when entering the bay; contrasted with poor practice such that ‘visiting’ professionals did not do likewise. Observers here were mainly care staff; posing the question as to whether their social location made it more difficult to raise issues of practice; in other sites observations were undertaken by a more hierarchically diverse group. Yet, feedback with the researcher revealed that observers had ‘seen’ and noted little interaction between staff and patients for long periods in the evening, but since it was interpreted as requiring additional staff to resolve, did not feature as a goal for change. ‘Knowledge’ of the problem was uncontested; their judgement that they were powerless to act on it impacted its utility as a focus of action planning.
Informal conversations between virtual PIE members occurred to discuss observations but no formal meeting to pursue action planning took place. The practice development co-ordinator who was to provide a steer for PIE implementation had taken up the post of matron shortly after the PIE workshop. Although she had negotiated time for PIE, her working life was absorbed by organisational demands: staffing shortages and a wide-ranging re-organisation of ward models and bed closures, following a poor CQC inspection (inadequate staffing being a particular focus of concern). The ward manager was also on sickness leave in the month following observations. Similar to Netherton, the PIE implementation record had stuck on observation.