Theme 3 – Enablement for Integrated Working

The resulting thematic network for the third theme is enablement for integrated working (figure 6.10, p.115). The basic and organising themes appear reflective of barriers and facilitators to integrated working identified in the evidence base (table 2.4, p.31).

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Enablement for integrated working

Acting differently

Enabling patient empowerment

Enabling role clarity

Not feeling respected

Empowering patients Changing traditional

practices and beliefs

Autonomy

Clarifying team roles and responsibilities

A patient-centred approach

Involving other professionals

Key

Basic theme TCI Organising theme

Global theme

Team members are convinced of the value of

the team s objecties for themselves/organisation/ wider society and consider

them worthwhile

The team consider itself to be one of the

better in its field The team professes

support for innovation. Top management in the organisation favours creativity and assistance in developing new ideas

is readily available

Figure 6.10 Case study 1: Theme 3 – Enablement for integrated working.

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“Better integration can help drive positive change. But in the end this is not about systems, it’s about people. It’s about inspiring local leaders, dedicated and

energetic staff and individuals who deserve the most integrated, personalised and empowering care and support we can offer” (National Collaboration for Integrated Care and Support, 2013).

Care Aims appeared to be seen as an enabler for how the team wanted to work, particularly with other professionals and patients but the team recognises that cultural change is required and this needs to be supported by the organization.

The team describe themselves as a specialist service but expressed they did not feel valued or respected by those who refer into their service. At the same time they saw the value and wanted to work with other professionals. Nurse 1 said:

“You are doing the patient a disservice if you don’t allow other people to become involved” (Nurse 1, p.6, line 5) (basic theme 18, table 6.6, p.105).

As described earlier in theme 2, team members viewed the team type, their roles and approach to care differently. The team felt that one of the biggest impacts of the Care Aims training was in helping to clarify their role and responsibilities. Nurse 1 said:

“For me the biggest impact was understanding where my role ends so it’s not keeping patients on for endless reviews” (Nurse 1, p.3, line 25) (basic theme 20, table 6.6, p.105).

Nurse 2 felt that using Care Aims:

“helps with clarity and reduces the risk of unnecessary follow up” (team questionnaire 2, question 11) (basic theme 20, table 6.6, p.105).

Team members identified that to embed Care Aims they needed to change how they worked. Team members described how they felt liberated and had been given permission to act differently, implying that the organisation had given permission to act differently by commissioning Care Aims. Nurse 1 said:

“Suddenly I think it becomes quite liberating for a lot of staff because it can be really tough working with patients where there is no improvement but you feel you’ve reached an impasse you don't have the confidence, the clinical confidence to let go” (Nurse 1, p.2, line 23) (basic theme 14, table 6.6, p.105).

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Nurse 2 describing a patient who had been referred to learn to do a specific intervention for them said:

“following assessment it became apparent he could not do this. Care Aims helped as that was the end of the episode of care and he was discharged” (Team

questionnaire 2, question 6) (basic theme 14, table 6.6, p.105).

Confidence regarding decision making was frequently cited. This may have also come from discussion with other services. AHP 1 said:

“Other services that are much further down the line than we are, most of them have said it’s been beneficial and it does change your practice” (AHP 1, p.5, line 17) (basic theme 15, table 6.6, p.105).

Similar to the findings of Goodwin et al (2014), the team described how Care Aims had helped them clarify eligibility criteria for receiving care, a single point of referral, a single and holistic care assessment, a care plan and support from a multi-disciplinary team of professionals. Whilst not explicit it was implied by the team that one member of the team co-ordinated the care provided by the team for a patient.

Nurse 2 and Nurse 3 described Care Aims as supporting them to work collaboratively with patients:

“what impact can we help service users manage” (Team questionnaire 2, question 12) (basic theme 16, table 6.6, p.105)

“looking at the impact of the problem and setting achievable goals and outcomes” (Team questionnaire 7, question 4) (basic theme 17, table 6.6, p.105).

Nurse 1 also felt Care Aims helped them to respect when patients chose to not follow their recommendations:

“this was the patient’s choice and I had more professional confidence in accepting this” (Team questionnaire 1, question 6) (basic theme 16, table 6.6, p.105).

Care Aims may facilitate integrated working as it encouraged the team to work more collaboratively with patients. This is supported by Shaw et al (2011) giving the example of clinical integration as facilitating the role of patient’s in shared decision making with the underlying principle that:

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“the patient’s perspective is at the heart of any discussion about integrated care” (p.7)

The potential of Care Aims to support self-care was recognised and summarised by Nurse 1 as:

“It’s about ensuring that you know and define your role and responsibilities with that patient and that patient is clear about what you can offer them and also where their own personal patient responsibility lies as well in improving their own health condition” (Nurse 1, p. 2, line 2) (basic theme 17, table 6.6, p.105).

However in order to support self-management clinicians also have to overcome their anxieties about Care Aims as described in theme 1 earlier.

The team describe how they wanted to work in the future and described a different relationship with patients, namely with patients as equal partners in their care. The shift from problem solving to impact focused thinking which is integral to the care aims approach appeared to lead to different discussions with patients and referrers about possible solutions with potentially longer term benefits for the patient. Unlike a medical model of care, Care Aims is designed to focus on outcome and requires the clinician to understand the meaning of a problem/diagnosis and its impact on the patient to identify interventions (Malcomess, 2005b) i.e. the focus is on the reason for intervening as opposed to what is being done.

One of the difficulties several members of the team described was the challenge referrers found, changing from focusing on the problems the patient had to impact of those

problems for the patient so that the team could assess the clinical risk for the patient.