Problem solving techniques

Chapter four established that formal problem solving skills were not taught as part of the LoTS care training. However two sessions were delivered that demonstrated problem solving techniques that could be applied when implementing the system of care. The aim was to shift the emphasis of the assessment to reflect a more collaborative approach, encouraging service users to take responsibility for their own problems where possible. Two Coordinators from service one, and one Coordinator from service two had attended the training. However, when asked most could not recall the problem solving sessions, for example one Coordinator (S1SN) commented:

S1SN: I can’t to be honest with you [remember the problem solving sessions]. It’s too far back in my memory. I remember being quite daunted by it [the system of care] initially and thinking oh my god how are we ever going to do this? How are we ever going to make the time for this as this is a lot more thorough and I think that was my main drive in the beginning, as I just looked at all that paper work and I remember that sense of doom in a way [laughs] how we gonna do this?

This Coordinator had worked in a hospital setting prior to joining the community stroke team. Their overriding concern was implementing the new system, which they initially found ‘daunting’ being a) new to the community, and b) new to the role of Coordinator. The Coordinator at service two recalled discussing how their practice differed from professionals in other localities, but not the specific problem solving sessions. Having no memory of these sessions suggests that the techniques advocated did not resonate with these Coordinators and therefore did not influence their practice. This finding is, perhaps, unsurprising considering the training sessions

were not intended to teach formal problem solving skills. One Coordinator (S1OT1), however, did remember the training sessions and commented:

S1OT1: The most useful part of the training session was the woman from

the benefits office. She put it all in such an easy way to understand and I’m really confident about benefits now. Yeah it was good [problem solving session] and I think if you were a Stroke Care Coordinator and you’d come from being a ward manager then it’s very much out your remit to do that, but when you’re involved with rehab and you’re a therapist sometimes you’ve written the problem list and the action plan before you’ve gone out the door of the patient’s house really cause it’s what you’re trained to see […] it was a good training session but it felt a bit like teaching your granny to suck eggs.

The benefits session, to which the Coordinator refers, was one of two lectures provided at the training days (the other was post-stroke pain). The Coordinator described that this lecture was ‘the most useful part of the training’, and provided them with confidence to discuss the assessment domain ‘finance and benefits’. In comparison to the lectures, the problem solving session was like ‘teaching your granny to suck eggs.’ Evidence of problem solving was observed during fieldwork e.g. during one assessment observed the Coordinator discussed causes of shortened concentration (a problem identified), and how the service user might address this themselves without further intervention. However, the Coordinators remarks suggested that their approach to the assessment was a continuation of their previous practice, as opposed to the implementation principles advocated by the system of care. Professionals who joined the team after the system of care was embedded in practice supported this view, for example, one Coordinator (S1OT2) described:

S1OT2: I kind of worked it out for myself [how to use the LoTS care assessment booklet]. It’s difficult because when the LoTS was

brought in, is when I started working for this team and I was only working one day a week with this team, so by the time I came full time the LoTS had been in process for quite some time and it was just a case of trial and error really for me. I wasn’t given a huge amount of training.

The Coordinator established how to implement the assessment booklet ‘through trial and error’ i.e. through practical experience. This remark highlights that the implementation principles did not form part of a formal induction process for new staff. Another Coordinator at service one (S1PT2) reiterated this: ‘Basically I sat in on a LoTS with S1SN and saw her deliver the assessment. I was also shown the LoTS handbook, but to be honest I didn’t read it all. I just read through the actual assessment itself and went from there.’ The Coordinator describes observing (shadowing) a more experienced member of staff as part of their induction. They were also provided with a copy of the LoTS care manual (the LoTS handbook); however they revealed that they had not read this. Therefore implementation of the system of care was dependent on their experience as a health care professional and their observations of more experienced colleagues. A similar induction process unfolded at service two; when asked how they were introduced to the system of care one Coordinator (S2SN) described:

S2SN: Here’s the LoTS document. That’s what we’re using for the trial. But

main, really, it’s quite self-explanatory really if I interpret it right on how I’ve been using it. I mean you don’t, I don’t think you need a lot of guidance to it […] after six months after I’d started working here I think a DVD, not DVD... CD Rom or something turned up, but if I’m quite truthful I’ve never had like looked at it ‘cos you just don’t have time, you’ve been using it for six months and you think...

The Coordinator reported that the use of the assessment structure was ‘self explanatory’. The assessment structure indicated what areas needed to be addressed as part of the intervention group, but it does not reveal the type of

interaction expected between the Coordinator and service user. The DVD, to which the Coordinator referred, was a recording of the training days and included the problem solving sessions. However, the Coordinator explained that when the DVD had arrived they felt confident in their ability to implement the assessment and had not watched it. Further to this, the Coordinator reported that they had not received a copy of the LoTS care manual and had not read its content. Therefore, their approach to the assessment process reflected their experiences as a health care professional. This discussion indicates that the implementation principles were not formally disseminated amongst the Coordinators. Implementation of the system of care was shaped by the Coordinators experience and the expectations of the service within which they worked i.e. the service was not enhanced by the problem solving techniques provided as part of the LoTS care training. The next point of inquiry was the formal review process i.e. repeated assessments performed by the Coordinators in the context of each service.