Being responsible and getting involved

Being responsible was an important part of the process. This was expressed in a number of ways by the patients, carers and the team. In the first instance the patients needed to influence their return to independence by being responsible and getting involved in their progress. Alfred, a patient, speaks of the elements he used to make decisions and to return to driving his car. He took into account the instructions he had been given by the professionals but also asked his relatives to help check things out.

………… Well, as you can see, our flat has got every convenience. So, it was no problem at all. The physiotherapist came to see how I went with my stick, and all that sort of stuff. As you've probably noticed I can walk about without it now……but as a precaution, I'm not quite stupid enough not to use it outside. I always use it when I go outside now because, as I say, with this neuropathy ...and plus this, so I think well better be safe than sorry. But I went back driving again, no problems at all with that……….Mind you, one of the guidelines that I got from the hospital, they say that between six and eight weeks that you can possibly start driving. I suppose it depends on the type of hip that you've got. But I ... well, having been in the Police, safety is the most important thing. It was twelve weeks before I started driving again and on that occasion I went out with my daughter, and she, you know, sort of gave me an MOT, not an MOT, but a test……So, I'm independent again now, we can go and do our shopping……(Alfred 257) (Patient)

Not only patients took responsibility for their care but the team also needed to be responsible for getting involved and carrying out good care. Below the radiographer reported how being able to hoist a patient in the department had a positive impact on the experience for the team, the patient and his carer.

From our point of view, in terms of communication, kind of on what you're doing it, how you're doing it, and why you have to do something like hoisting. We actually had a marvellous one the other day because your heart sinks when someone in the fracture clinic needs a hoist. [laughter] but because of the fact that we hoist so many patients at the service I have now become an expert hoister. And there was one of the ones that worked really smoothly. It was a Polish carer, he was fabulous, the patient was fabulous, she was grateful, it moved so smoothly. She didn't complain, she was happy with everything that was happening to her. She'd had a stroke, but she was very happy with

to come back again next week?" Because so often we do not get any help from the carer. And it's not my prime function is to hoist patients, but we end up doing it, because there isn't any …obviously, nursing support. That was a good outcome on her, she was quite happy and…she understood what had to happen……totally and she was quite comfortable and she was terrible grateful and actually we hoisted her……But the fact that we actually had a carer, and the fact that we also made her comfortable because if you'd ask me to hoist about two years ago it would have been like taking your life in my hands. [laughter] But now we are slick. And I felt that……because we are now very competent at hoisting. Because before it was always like the nurses did it. So I think from that point of view, and she was comfortable and she was happy. And he was a good carer; I think that was the important thing. He knew his patient, he was supportive, he knew how to hoist, he knew what we were trying to do and he’d helped us. Anything he could do to possibly help us, if we moved on the table, he came to help us……….and it was a good interaction (4.1291Radiographer)

Accepting that there are times when family and carers are also willing to get involved and to take responsibility. An example of one story is provided below.

This lady has reached her maximum level of function but she still requires assistance twenty four hours a day for mobility transfer, self- care, bathing, domestic, everything. Her family are willing to provide round the clock assistance if they have additional care morning and evening to help with self-care. This lady really needs nursing care but the family are willing to do it, so they're going against what we might advise because you think they can't really sustain that, getting up during the night and going to work during the day. We explained the risks and they were willing to accept those risks (4.1136 OT3).

Providing a seamless service in which communication was evident and accurate throughout the journey not only involved having the opportunity to influence that communication but also to learn new skills. Seeing that this

applies to patients as well as the team was important in learning and development. In this session, reflected back to the group the value of the process, was a means of checking understanding, and of learning of a new skill which led to feeling confident and competent in caring, meeting the patients’ needs and understanding between everyone involved.

But you've highlighted some really important things there. That they were happy, the outcome was they were happy and you felt satisfied with the process and the outcome……..you got cooperation between the patient, the carer and yourselves and you got understanding …… so the communication was good (4.1326 Facilitator)

This concept although initially applied to patients and staff was also evident in the team dynamics. The team had moved through the process of learning, recognising the accepting responsibility and were then able to move forward in a way that they hadn’t before. They were beginning to express excitement about the findings and could identify quick fixes for themselves and others. They demonstrated better understanding of themselves, their professional roles and the people they were caring for and consequently could see the value of being involved. However, I was aware there was still reticence about how the team could influence the organisation. Reflecting this back to them reinforced the strength of their voice and their potential for influencing others.

……….I still sense of your uncertainty in the authority you have to take this forward. You have worked together for seven meetings now and you are coming out with the same things and that is incredibly powerful. You don’t sound as though you feel it in yourselves but you have a big voice here (7.1691 Facilitator).

There was a general consensus from the group that this was an accurate interpretation of their position. Below, however, one physiotherapist did express a concern that, in reality, away from these meetings it was difficult to maintain momentum required to influence the organisation as their clinical work becomes the priority again.

I think at the end of these meetings it is like you are empowered and enthusiastic and I think we all go away and back into our normal [ways]…..and that is when I asked the first question of how we are going to change...…I can’t remember what we said at the end of our last meeting…I think we forget so we don’t drive anything (7.1697 Physio 3)

Another physiotherapist explained how within the group she felt more focussed and this reflected her confidence and willingness to develop. Interestingly, she also became more aware of how her colleagues reacted to her actions and reflected on how maybe she needed to change her stance to promote good group dynamics.

…… in the beginning we had oodles of different stickies but now we only have three…maybe I’m more focussed (7.1707 Physio 2)…..I feel I make an effort to contribute to discussion but aware that sometimes I talk too much and maybe this doesn’t allow quieter members of the team to contribute; maybe I need to influence the group or seek approval (Ev8 OT 3)

The team recognised that despite their being able to take responsibility it was necessary for the managers to increase their awareness as well and to take responsibility for their part in the care.

The team knew they needed to get their managers to see what they had learned and found out about the service. I continued to involve the group in the decision-making process. Despite all this they showed an understanding of the process they had been through and of the managers’ roles and expectations. They discussed how they could impart their own experiences in a way that would be useful to the service. Two in the group made suggestions.

………… I would ask them to do a SWOT analysis, what would be the strengths, weaknesses, opportunities and threats, sum it up how, a little bit like that, what would be the benefits, what would be the disadvantages, what would help this and make it easier and what things would make it difficult, what people might make it difficult………and also the action plan would have to be very clearly focussed so that they didn’t feel like they had to do it, they would have to ok it and have people assigned to things within the action plan to say well that person is responsible for that and so on (7.1451 OT3).……If we had the time with the managers…say and hour and a half…managers like things like snazzy PowerPoint presentations and various bits and pieces…We don’t want any work for them, no work…They would want you to turn up with the paperwork, this is what we are doing, this is how much it is going to cost… actually being there to say yes this is what you want to see happen (7.1470 Physio 2).

The team had developed insight though the process and were keen to impart their knowledge to others. However, they were still a sense that the managers would want to be told what was happening and how much it would cost. The point was that ‘being responsible and getting involved’ need to happen at every level of the organisation in order for the experience to improve. The challenge was to feedback to the managers in a way that they could share their expertise while listening to the experience and feedback from the team.

Sharing these new insights with the managers using a participatory approach rather than ‘reporting back’ was going to be a challenge (Reflections)

Taking a collaborative, participatory approach respected the group’s new understandings, accepted the workplace relationships between the management team and those delivering the care and produced positive evaluations. As indicated in the box below, there was raised awareness of the

team diversity; the value of time to listen, the development of new understandings; realising that the team really cared and that they needed support and praise for their work.

The opportunity to look at group issues with varied different contexts and to meet different disciplines was valued.

The open group discussion with an interactive creative element gave time to listen and become more informed.

Like mindedness reassured and brought better understanding of others perceptions.

There are lots of people who do care about what they do and how they do it and will continue to do it.

It is important to praise and value staff.

Support staff in working towards the right ends with patient outcomes paramount (Workshop evaluations).

The overall messages were

‘Remember to treat the patient not the condition’ (Workshop evaluations.

If the team feel valued, listened to and understood they will be able to value, listen to and understand those they are caring for (Workshop evaluations)

The participatory support of working together reduced the threat, diffused any anxiety, involved the participants and the managers, generated action and transformed thinking.