Taking the time to work with processes to get the best experience for all

Working together with all those who were part of the caring process was an aspect of caring practice sometimes evident on the ward. Compromises had to be made which often required skilled communication. A key part of the process of taking time to get the best experience for all involved was ensuring that the patient and or family were seen as key collaborators, and included in decision-making:

The consultant approached one of the patients who had been in hospital for some time and would require quite an intensive package of care to enable her to manage at home. The consultant sat down beside her and asked her what she found difficult to manage at home and what she thought she needed to help her to manage at home. (Informal observation recorded as field work, May 2008).

Again the important skill of considering the perspective of another during dialogue is highlighted. Taking time to get the best experience for all through engaging in dialogue was not always seen as easy. One staff member articulated through her story the

resilience, perseverance and time that was often needed to find out what the best experiences for all would look like. She talked about caring for a lady who had volatile moods and often swore or shouted at staff and fellow patients:

She said she didn‟t eat porridge and that she wanted something else. She didn‟t want a roll she wanted toast, then she didn‟t want the toast, then she wanted a brown roll. I gave her a selection. She had everything- she had brown roll, toast, butter, flora, cornflakes, rice krispies, porridge, she had everything we had, but there was no pleasing... I found it difficult helping her to eat. My concern was she was not eating and she would be hungry. I was making her cups of tea and coffee just to make sure she was getting fluids.

She was calling us names and she said she hated me – and I said to her „but that‟s all right because I like you that‟s why I‟m trying to help you. ..‟ I felt like giving up but then I asked her if she wanted to go for a walk. ... I know I had lots to do but prioritised spending time with her because she was getting the other staff down.

Going for a walk with her helped me to find out a bit about her – she was talking about her family and how they felt she would be safer if she went into a home. ..She felt that she had to walk to prove that she didn‟t need to go there. .. Getting better at walking was the thing that was key for her, not eating. She started to say that I was her best friend. Not showing I was frustrated was important. I needed to find the key to get in. (Staff Story, SS5).

The tone of this account suggested that the staff member was frustrated by the reactions of the patient and her inability to provide „good care‟ as she saw it. The staff nurse recognised her own emotion in caring, and took time to work with the processes of „knowing who I am and what matters to me‟ and „understand how I feel‟ in order to move to a place where both the patient and the staff member were working together to shape the way things were done, and gaining a sense of satisfaction with caring.

Taking time to get the best experience for all can however involve taking risks. When does a staff member decide that „the professional knows best‟ and use this to influence care giving? The following quote illustrates a time when a member of staff made a professional judgment of what she felt was best for a patient:

The patient was in one of the bays and he smelt really bad. It was hard for the other patients. The smell lingered all day…I was quite firm with him. I did say to him that having a shower was going to make him feel really good. He felt great afterwards. I think it was good because I almost took it out of his hands in a way. Choices are really important for people, but I think for him he was just past making any. I kept on saying things like how bad we would feel that we hadn‟t

even given you a wash while you were in hospital. I said I was going to be really quick and that it would be lovely warm water and things like that. .. I didn‟t mention anything about the smell or anything. I think initially I thought- yes this is your choice, but then after a few days I made that decision that it would be good for him to have a shower, after speaking to the family and thinking about others around him and thinking about him. Maybe I was just taking control of the situation. (Staff Story, SS1).

It is evident that the staff member considered the perspectives of a range of different people, including other patients on the ward, in making her decision. Including the family in the decision making helped to minimise risk in this instance. Risk relates to potential negative consequences of communicating in an open and honest way, and to making decisions with people that may be in conflict with organisational policies, cultural practices or personal philosophies. Taking a risk asks that people act in courageous ways. Processes involved in AI, of asking unconditional curious questions to get at the heart of why something happened, enabled staff to share times when they took a risk. In addition, actions that resulted from risk taking legitimised as compassionate by the research process, gave staff confidence to share other experiences of risk taking and negotiation. To ensure an optimum experience for patients, families and staff, an

environment where it was safe to challenge the status quo was required. This is explored in the next section.