Realising the way forward

Working together to review the records had helped the group see different perspectives and to see the chaos in which they were working.

The record review had helped the group realise that they all contributed to the problem and all had a part to play in the solution. Their response was to try putting it right by changing the record keeping system. This was a big task to achieve in the time that they had. By asking questions of each other and discussing alternative solutions they began to realise the way forward (Reflective diary)

The lack of continuity, the poor written communication and lack of evidence of teamwork in the records had been a shock but had also helped them realise that they needed to change. This change in thinking was demonstrated through a change in actions and questions were now being posed by others in the group

I was thinking it might be measuring up, I suppose, standards against what actually happens and is there anything we can do to make those two things meet somehow? (3.510 Theatre nurse)

The group could see that the challenge was not only to bridge the gap between acute and primary care but to bridge the gap between the expectation of the national standards and what was actually happening in practice.

So what do you think the goal might be at this point? (6.1305 Facilitator)

Just to provide a wish list to bridge the gap between Acute and Primary Care……… (6.1308 Physio2), to work towards bridging the gap (6.1287Community Nurse)

They were beginning to see the hip fracture journey following injury from the patients’ perspective rather than in terms of service delivery. They noticed that they had not really been working towards shared goals and that this might help reduce some of the difficulties.

If the team are all working towards the same goal where is the problem? (Ev8 Community nurse)

Choosing to create a wish-list or standards for person-centred records was structural way of agreeing a shared way forward. The group agreed that the records needed to be improved so they were ‘unified, user friendly, able to be

accessed by all and should include evidence of support for patients and those close to them’ (Fc9).

The process of agreeing criteria for a unitary record gave more time for thinking and reflection. It involved negotiation, working together and developing criteria that the managers would appreciate (Reflective diary).

This was the first indication that the group were beginning to work together as a team. The difficulty was that there was still something missing.

There was still a gap. The meeting time was running out and the group were not certain that they were closer to implementing anything new or finding evidence of person- centred practice (Reflective diary)

The standards provided an agreed structure to work with but the team needed evidence that would help support their case for change. An idea was proposed that might help find evidence from those being cared for. They still did not know the views of the patients and carers and wondered if they would be on their side. Listening to the patients’ and carers’ experience might provide evidence for why the newly developed criteria for record-keeping should be implemented.

It would be very interesting if you speak to people if they have been an inpatient and if they say at any point in your conversation when I got to the Rehabilitation Unit everything just started again. That would be amazing if they say that because then that would really reinforce………….and that would be something that we could take forward (7.1064 Physio 2)

Asking patients to tell their story might provide another useful source of evidence; the experience from the patient’s perspective. Other members of the group recognised that many older people with hip fracture, due to other medical conditions, age or the trauma of the accident, were not able to speak for themselves. It was agreed that carers would also be able to contribute a useful perspective.

………..the difficulty with that is that you’ll get a very narrow section of the population that we deal with because by definition they’re going to be probably more articulate, better educated, more cognitively alert people that we actually get in, and vast amount of the patients can’t speak for themselves and they may have different needs that these other people wouldn’t reflect, you know, how do you treat people with cognitive impairment, they can’t tell us that but carers might….(5.107 Geriatrician,…..get carers in, yeah…(5.114 Radiographer).

The group were realistic about the time involved in interviewing patients and carers; instead we shared out the tasks.

It did cross my mind that the group might be trying to avoid hearing the patient and carers stories. On further enquiry I found they were all very happy to hear these views. A couple of participants agreed to enlisted suitable patients and carers and I agreed to collect the stories. The next meeting involved reflecting on this evidence and planning the next step forward (Reflective diary)

The clinical world of hip fracture care was full of conflicts and complexities. A variety of mechanisms were used to cope with the anxiety that this chaotic fragmented environment created. Some denied the problems existed, some were defensive, many used laughter and others just listened wondering how and when they would be able to question the situation. Creating time and space to consider the issues gave the team an opportunity to express their feelings. It was not just a chance to talk but a chance to share difficult issues in a safe environment; an environment where they felt valued and listened to.

Creating a visual picture enabled the group to reflect on the situation. The group were uncertain about their knowledge but they knew more than they expected; sharing builds confidence. The values clarification exercise was rushed but the group were used to working within time restraints. Best thoughts always emerge when under pressure. I encourage the group to ‘think out of the box’. I created dissonance with the risk that it may increase the fear and blame. Instead it allowed the group to learn from each other. Staying calm, consistent and focussed was the key (Reflective diary).

Demonstrating understanding of the situation created trust and enabled the group to admit the difficulties that they were initially falling victim to. Along with this admission came a realisation that it could be different. Small examples of conflicts in the system and gentle questions to themselves began to challenge the status quo. Finally, the group acknowledged that they may not fully understand the experience of hip fracture care. With this was a tentative suggestion which becomes enthusiasm to find out more about the patients’ and carers’ perspective.