Step 3: Acting

Once knowledge is gained and given meaning by understanding it, the professional moves to action if needed. The third step of acting in the assessment process is therefore an optional one. In the data five different ways of acting could be found: fixing, making a treatment plan, verbally communicating, documenting, and coordinating. The last three of these aspects are also key aspects of the theme ‘Networking’, which is presented in section 4.4.

1. Fixing

Action can be undertaken immediately by fixing or sorting out the issue. For instance, by providing pain medication to a patient or arranging resources as needed:

‘They say: “Oh I am sorry to bother you”. ... It might be a blanket, you know “that is not a problem, I will go and get you one”.’ (Senior nurse 10)

‘I take Clamazapine ... I can’t bear it without those. And they haven’t got any, and then later on, the night nurse came “I have got those tablets for you ... I went down and ordered them myself”.’ (Patient 15)

121 2. Making a treatment plan

Making a treatment plan is another element of acting on knowledge about the patient, that has been gained and understood. For most patients a formal treatment plan, or a number of treatment plans, were made during admission:

‘Every patient needs a plan. We can’t just be wandering through their treatment and not knowing where we are going.’ (Junior nurse 30)

‘We make sure that we have got a clear plan for the next few days.’ (Physician 39)

Treatment plans were made by a variety of HCPs, as the quotations below represent a physician and a therapist.

‘I still like to make a plan, based on the problems that we have picked up so far.’ (Physician 15)

‘I will come up with a plan of what we need to do with this person.’ (Allied HCP 53) When looking at making treatment plans, it was found in the data that standardised nursing care plans do not really lead to an individualised written treatment plan:

‘Care plans are not personalised, they are standard care plans and just require a signature from the nurse who puts it in the folder.’ (DR Patient 2)

‘We have to print them out ourselves. So when we go on the internet … and it will have all the care plans. … Most of them are like generic for everybody ... like the handling and moving, skin, falls, they are all just the same, you can’t change them.’ (Junior nurse 22) Although nurses may not write individualised treatment plans for patients, their role was important within provision of patient care by the multi-disciplinary team. This is addressed in more detail as part of the theme ‘Networking’. The role of the patient within decision-making regarding their treatment and care is also further discussed in that section.

3. Coordinating

Coordinating care requires a logistical plan, which differs from a treatment plan as it focuses on coordinating the process of care, whereas a treatment plan focuses on deciding the content of individual treatment. This process of logistical planning could be invisible when HCPs made these decisions in their mind without communicating them to

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others. Logistical plans were closely linked to job lists or to-do lists, in which professionals planned their own care delivery for each individual patient:

‘I tend to get a piece of paper and write my list of jobs down ... The nurses have their own jobs list and they then write it on their jobs list.’ (Physician 13)

‘Sometimes not all of the jobs on the jobs list are done ... but then it depends how busy it has been. If you have got ‘poorlies’, they have obviously been focused on that more.’

(Junior nurse 24)

Logistical planning was highly influenced by a separated approach where care processes were divided in isolated jobs carried out by a number of care professionals:

‘She mentioned a few times that the doctor in the morning seemed like a general doctor, with no particular interest in her knee or her blood. About the knee he said: "I am not orthopaedic", and P5 said she was to see a specialist about the blood in a few days.’

(Patient 5)

‘The young doctor, because she is medical, she didn’t know the surgical side of it. So I don’t know what is going to happen with the surgical side.’ (Patient 8)

These examples showed how the planning of care was dependent on the fact that different people have to be involved for different aspects of care. The separated approach to care is further addressed in section 4.3.2.3.

Logistical planning by professionals could be created based on their own treatment plan, provided they make one, or through treatment plans or logistical plans made by others:

‘I will come up with a plan of what we need to do with this person.’ (Allied HCP 53)

‘I just try and make sure that everyone who needs to do something knows that they are doing it .... If it is stuff I am going to do, I just jot it down to do it at some point later on that day.’ (Physician 15)

This section focused on coordinating the provision of care by each individual professional. However, coordinating the team process is also crucial part of planning care. As this was found to be a key part of ‘Networking’ as well, coordination of the multi-disciplinary team process will be presented in depth in section 4.4.

123 4. Verbally communicating

Another way of acting on knowledge was by verbally communicating it. This included communication between professionals, as well as communication between patients and professionals. This was not merely a way to act on knowledge that had been gained and understood, but it was a key aspect of the process of ‘Networking’ within the navigation the assessment process (see section 4.4).

5. Documenting

Documenting the care process also was a way to act on knowledge that had been gained and understood. Professionals used a variety of documents to address this throughout the day. These documents were part of the networking system between professionals and due to this, documenting is addressed as part of the theme ‘Networking’ in section 4.4.

4.3.2 Ways of working

In this section the different ways of working that were found in the data are presented. These ways of working contain different levels of formality and visibility, and care was found to be given in a separated and prioritised way, resulting in comprehensive process being divided into isolated tasks (Table 6).

4.3.2.1 Levels of formality