Effective Practitioner in NHS Scotland
Engage, Discuss & Shape the Initiative to 2016.
Everybody Matters – Developing Person Centred Care in Practice.
By Professor Belinda Dewer,
Professor of Practice Improvement, University of the West of Scotland
Well thank you very much for inviting me here today to share with you my thoughts about what I think is one of the most important opportunities we have ahead of us. Really looking at how we can shape health and social care in particular to make care and care giving truly person centred. I think for yourselves constantly striving to be effective practitioners you're having to develop capacity to achieve your aspirations and what is a really unpredictable and financially restrained care environment.
If this is one thing I would like you to get out of this presentation today it's hope. A little bit about language before I start. I've been involved in the past few years about developing compassionate care really focussing on the relationship centred care but the title today is up there "Person centred care". I would like to kind of excuse me for using the terms "Person centred", "Relationship centred" and "Compassionate" interchangeably. I think what I'm saying is it's all about excellence in care. Whichever term we use. One could argue that compassionate care is the way in which we achieve person centred care. So just that word about language as we go through.
In the presentation today I would like to share with you a bit about the evidence base, a bit about "Do we need compassion". I suppose arguably we would all say yes but there is evidence out there about why it's important. But also look at the current context of health and social care and to think about "what are we up against?". Before then share with you a model that I developed as part of the Leadership in compassionate care program which was part of my Phd. And to share that model with you - to look at strategies that can really help us move forward. And to also share the outcomes of using this model in practise.
So first looking at the evidence. The evidence suggests that health care has lost compassion and patients are suffering and I think perhaps it's very significant with the Francis enquiry that has come to highlight this. The idea that health professionals are burning out through stress and over burden. How much more have we got to give ? In contrast to that the idea that kindness, caring, compassion are the major source of health worker happiness and resilience I think that is something we need to remember. That is we get great satisfaction out of delivering care in this way.
Acting in a compassionate way improves relationships, reduces errors, increases patient compliance, has a positive impact on staff job satisfaction and improves patient experience. All of the things that we're striving for in the quality strategy here in Scotland. So there is evidence to suggest that we really need to and want to work in this way. I suppose if we look at who values what:
Patients value kind, capable and compassionate clinicians.
Employers value skilled, safe effective practitioners.
Governments value accountable, safe, person centred care.
What do professionals value? Any comments from the floor?
Being valued.
I am so pleased to see that the strap line under the Effective Practitioner initiative is about supporting and valuing professionals. That is what professionals say that is important to them. So in the current context of person centred care what is happening. Obviously the Francis enquiry (I don't know if any of you will have read the whole document but you will have read the summary and news / media around this). The key focus of that was about the failure and the poor care and pointing to things like culture, care and compassion were significant aspects that were reported in this and it's something we really need to focus on in moving ahead to the future.
Kind of along side this (of course the Francis enquiry is just out) the Department of Health has developed a new vision and this is for nursing and midwifery which is a bit sad because I wished it had been much broader than that. But they identified six values that are important in the way forward. Care, Compassion, Courage, Competence, Communication and Commitment.
Along side that the Scottish Government of course launched last year their "Person centred health care program". Very significant program which has at it's heart care experience, staff experience and co-production and read for co-production "working together to shape the way things are done around here".
So these are very significant policy imperatives that are driving forward health and social core currently. But what are we up against ? We're up against trying to make everything that is uncertain, certain rather than leaning into discomfort. I don't know if any of you will have seen Brene Browns? TED talk about the concept of vulnerability. She talks about this idea of supporting people to lean into discomfort because the world out there is not certain we cannot, we're dealing with the human factor so it is not certain. Pretending what we do doesn't have an effect on others. This need to be authentic and real and say we're sorry. How are we supported to do that ? This idea of living in a culture of never enough always onto the next thing. Always never actually achieving the 100% each time. Using the language of the market instead of embracing the language of caring and also this idea for perform and peril model rather than a relational and responsive model and we've seen the outcome of that in terms of this idea of people striving to meet targets sometimes at the expense of delivering truly person centred care.
This idea of the language of the market. This idea of compliance we talk about compliance all the time and the idea that you're non compliant sometimes if you don't reach what is the professional aspiration. What about should we be using the word 'Commitment' instead of compliance. What about all the words like throughput, patient flow, dashboards, scorecards - is that really reminding us of industry of car factories - where have these words come from - is this what we mean. I'm aware sometimes when I go onto wards and I look at some of the dashboards and the different run-charts and I ask staff. "Tell me why it's maybe had a little dip in August?" sometimes people aren't able to tell me there's something about getting the charts up on the wall but not necessarily understanding the meaning behind them.
And statements we see constantly this is from the Department of Health new strategy
"To ensure that excellent care giving is delivered on a consistent basis first time every time in the right setting in the right way"
And I suppose I ask you to think about "is this even possible?". It's good to have aspirations. But it's good to have aspirations that can actually be met otherwise are we constantly thinking we're going to fail if we can't actually do this. So I think a close look at language is something that is needed. I think there's also something about "hitting the target, missing the point". I was very conscious of, for those of you who are nurses and maybe some of the AHPs will perhaps be familiar with the process of care rounding intentional rounding whereby people are going round every couple of hours to speak with patients to check that they have things like their slippers on, the call bell, a drink etc.
I'm very struck sometimes looking at the questions on these forms they're all closed questions - so in fact we're encouraging practitioners to ask closed questions and yet we know that asking open questions is the way in which we develop meaningful relationships and really connect and find out what matters to that person. So that in itself I think what are we actually doing with this is this the right way forward ? I was struck in a ward recently they told me they had switched to 'taped hand-overs'. So you're not actually getting your handover from somebody you're listening to a tape recording. Probably around the idea of efficiency and time saving and this idea of difficulty and time to care. But really is that destroying the power of dialogue and reflection within the team to really share about how we reflect on care and make decisions about care giving. I've mentioned already about the dashboards and score cards and I'll also mention about 'bundles'. Bundles are something that's IN really now. We have these bundles with the five different points you have to follow. When I've looked at some of the bundles I've thought "yes, these are important" don't get me wrong they are incredibly important aspects of what you have to do to ensure that care is safe and effective but sometimes they are missing the relational and person centred elements.
I don't know some of you might be aware of the friends and family test. It's not here in Scotland yet. I worry that it's coming but it's in England every single ward and department in England in response to Francis have to do a friends and family test now. We are to ask "How likely are you to recommend our ward to friends and family if they needed similar care or treatment?". They haven't got a choice to go somewhere else [LAUGHTER] but anyway how likely are you to recommend this. You can imagine this came from America where there is a choice but who will feel free to say "yes" or "no". I'm really struck. My daughter is twenty four years old and newly qualified now for a year and she's moved to Leeds and she's asking this. She has to ask to ask that question and she has to hear the response. What support does she get as an effective practitioner to actually hear that response, work with it, understand what's happening. It's quite a tall order!
I would just say person centred care or compassionate care cannot be achieved by staff following recipe like guidelines for communications with patients and families. I noticed Liz shared with me a response to Francis by Alex Neil that came out yesterday and whilst there's really good messages in there about how well we're doing in Scotland and all the fantastic work that's happening - one of the things that they're proposing to keep moving forward with is a patient opinion site. And while that's a good thing - it talks about that as the importance of seeking feedback - it isn't enough to just have the patient opinion websites. We need to learn as practitioners to feel comfortable to talk to people about their experiences of care.
I'm reminded of the mottoes of the Olympics and the Paralympics in fact. The motto for the Olympics is
"Swiftly, higher stronger produces discipline"
For the paralympics it's
"Mind, body, spirit produces humanity"
And I guess I would suggest that we need to make sure that we profile both of these mottoes within health care not just the "Swiftly, higher stronger".
So, are we living in the shadow of Francis? I think we've got a choice here. It can either be desperation, concern and paralysis or an opportunity that really needs to be grasped and nurtured and I think that there is a real opportunity never before has person centred care and compassion been elevated to such a position that were all paying attention to it. In the million words of the evidence from the Francis enquiry there's 290 recommendations, a summary of over 100 pages and the most commonly used words if you do a wordle are culture, patients first, standards, caring and compassion and that's what we need to pay attention to.
So this idea of culture though there's no quick fix for culture. What is culture in fact ? It's the way we do things around here. I was at a conference recently where someone said it's "what you do when nobody is watching". I ask you to think about that. What do we do when nobody is watching. That is culture.
So that's culture gosh there is no quick fix and what is compassion. This is the definition that was derived out of my Ph.D.:
It's about the way in which we relate to other human beings. It can be nurtured and supported. It involves noticing another person's vulnerability, experiencing an emotional reaction to this and acting some way with the person to ease or alleviate the vulnerability in a way that is meaning for people. It is defined by the people who receive it. Therefore interpersonal processes that capture what it means to people are an important element of it's promotion.
I've highlighted in yellow the aspects that I think are particularly relevant here. The noticing. It's something we almost need to press the pause button and slow down and start noticing other people's vulnerability, it's not suffering, it's just vulnerability. Bringing in shower gel for a patient that doesn't have any is about a compassionate approach but you wouldn't necessarily say that person is suffering. I think it does require us to emotionally engage and often we think about emotion as something we shouldn't be sharing or we shouldn't be getting into because it can open a can of worms, but it may be unprofessional. I would suggest it's not and in fact that is often the thing - the sharing of emotion - give people fulfilment in their work. But these interpersonal processes the checking out. We don't know if we're given compassionate, person centred care the only way we can know is by checking it out with others.
And I just want to stress that compassion is for everyone thus the title of this presentation " Everybody Matters ". So it's not just about compassion and person centred-ness for patients and families it's for staff also. If employees are abandoned and abused probably clients will be too. If employees are supported and encouraged they'll take their sense of well-being into their day to day work. Perhaps a starting point for changing these cultures is about really valuing and supporting and being compassionate with staff. These are just a couple of quotes from my Phd that talk about what caring for or about each other meant to staff. It was things like going out of your way to remember the names of new members of staff rather than using the term student or bank staff. Giving positive feedback "I feel really safe and calm when you're in charge of the ward". How often would we give that feedback to somebody on a day to day basis? So these are just some of the things that really help people to feel valued it wasn't about the organisation having star prizes or awards for the most effective team. It was actually about this day to day stuff that actually made the difference about caring for and about each other.