reflective commentary

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Introduction

This will be a reflective commentary on the implementation of change in service provision as

outlined in the Service Improvement Activity Notification Form (see appendix I). This is part of the

NHS Institute of Innovation and Improvement (NHSi) project (2010) which is used to look for ways

to improve the NHS. This reflective commentary will also consider the role of the nurse and

interprofessional working as part of the discussion. It will conclude with a summary of my learning. I

have chosen Gibbs reflective model because it helped to facilitate the discussion by the use of a full

structured debriefing presented in six stages (see appendix II). The Plan-Do-Study-Act (PDSA)

cycle lies at the heart of service improvement and is a method for application to the world of work

(Cleghorn and Headrick, 1996). For the purpose of this assignment I will not move beyond the

planning stage of this cycle as directed in the module guide (see appendix III). The Strengths-

Weaknesses-Opportunities-Threats (SWOT) analysis was used as one of the tools to evaluate the

initiative (see appendix IV).

Description

During my placement on the critical care unit, I noticed that the relatives’ room was segregated from

the patients by a locked door within the main corridor. The only form of communication was via an

intercom system situated at the locked door which was used to gain access.

Due to the close nature of care, relatives were asked to wait in the room while patients were being

admitted or while therapy sessions and care planning were carried out at the patients’ bedside by

members of the interprofessional team. In many circumstances, I noticed when relatives were

asked to leave the patient and wait in the relatives’ room it was explained by the nurse this is while

a procedure was carried out and an estimated time scale was predicted. However, due to different

members of the interprofessional team arriving to carry out therapy sessions concurrently, it

became apparent that an estimated short wait would become a rather long wait. The Department of

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Health (DoH) (2006) state in its document Modernising nursing careers: Setting the direction that

“…nurses will take responsibility for the care co-ordination, standards of care and leading the

nursing workforce as part of interprofessional teams…”. Therefore, it was not possible for nurses to

leave the bedside in order to advise the relatives of the extended waiting time, due to their role

within the team. This caused the relatives to become frustrated and increasingly distressed, as they

had no way of knowing the reason for the long delay.

I discussed this communication issue with my mentor, and she explained that this is an area that

needs to be improved, however despite all former efforts, a solution has not yet been found. I

discussed the issue with twelve relatives to fully understand their perspective, and they all agreed

that better communication was required to help alleviate anxieties. I analysed an existing

information book, which proved not to be effective and was not visible to the relatives.

I suggested the use of a poster in the relatives’ room to improve the relatives’ awareness of why

delays may happen, along with a brief description of all the interprofessional team involved in the

patient care. The poster would display the causes of delays, such as interactions between the

interprofessional team, or another patient being admitted. By displaying a description of the

individual roles within the interprofessional team would allow the relatives a better understanding of

those involved in patient care. This was welcomed by both the relatives and interprofessional team

members.

Feelings

I felt the relatives’ frustration as I watched them become increasingly anxious. Their anxieties often

escalated to anger, which was commonly aimed directly at the nurse or myself. This, at times, made

me feel fearful towards the relatives, despite trying to calm the situation. On many occasions I

witnessed nurses becoming defensive in such circumstances due to themselves feeling frustrated.

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Evaluation

The room allocated for the relatives was well provisioned with refreshment facilities; however this

inhibited communication resulted in a negative feeling from the relatives towards the

interprofessional team. The consequences of this negative feeling caused barriers in the

relationship between relatives and nurses. A change is necessary to improve this situation; however

change is not always readily embraced. It may be difficult for some team members to move forward

and adapt to a change, as discussed in Kurt Lewin’s Change Theory (Kritsonis 2004-2005).

Analysis

Interprofessional working involves professionals collaborating to effectively work together to

improve the quality of patient care. This forms a skilled, responsive workforce which is flexible and

coordinated (McNair et al 2001). Interprofessional working can be seen as a key element in

improving the delivery of health care where mutual understanding and collaboration develops

effective interprofessional teams (Finch et al 2000). The interprofessional team produce benefits

such as generating and sharing ideas, sharing information and research and supporting individual

staff (DoH 2001).

The importance of teamwork is emphasised in the NHS Plan (DoH 2000) and the National Service

Framework for Older People (DoH 2001), by placing the needs of the patient and those of their

families at the centre of practice. These documents advise, in order to achieve a good teamworking

environment, practitioners must have a clear understanding of interprofessional teamworking and

be aware of any potential barriers and the importance of effective communication. It is also

important they recognise their own role within the interprofessional team.

At each therapy session, the interprofessional team members were aware of the patients relatives

waiting in the relatives room, and the lengthy timescale that may be causing the relatives distress

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due to fear of the unknown. By the displaying of the poster reminding the relatives of the reasons for

the possible lengthy timescales, the pressure on the interprofessional team will be decreased, and

the therapy sessions can be less rushed.

The nurse is very often the conduit within the interprofessional communication, giving them the

knowledge of very aspect concerning the patients’ status and care plans. Often other

interprofessional team members carried out their therapy sessions separately, and to their own

individual agenda. As the nurse is required to be present at each therapy session, they were able to

convey any relevant information between the team members, and feedback any patient changes

and/or developments. In the knowledge of the relatives understanding of timescales from this

initiative would relieve the nurse of any anxieties of negative confrontation when the relatives were

called back in. The nurse then would be able to convey the collated information from the

interprofessional team back to the relatives at an appropriate level of understanding, while they

were in a better frame of mind. This would give the relatives a full understanding of the patients’

status and an opportunity to discuss any worries or concerns with the nurse, leaving them feeling

reasured.

Conclusion

Due to the close nature of patient care, it was necessary to ask the relatives to wait in the relatives’

room. This was segregated from the unit by a lock door for security reasons. An estimated short

wait often became a long wait due to the interprofessional team performing therapy sessions and

care planning at the bedside. The nurse was unable to leave the bedside due to their role within the

team, therefore a barrier of communication caused the relatives to become distressed, which had

an effect on the interprofessional team. The communication barrier identified has been recognised

by the interprofessional team, however a successful solution will be welcomed as one has not yet

been found.

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Action Plan

As the management team of the Critical Care Unit are welcoming this initiative, I will discuss further

with them, and by involving all members of the interprofessional team the production of the poster

can be initiated. Once the design and the information displayed on the poster has been finalised,

the in-house production team can then be involved to produce the poster. The use of the PDSA

cycle can be used to monitor how effective the poster is and amendments made accordingly until

the goals have been achieved. The introduction of this form of communication can be introduced to

similar areas, for example A&E cubicles, where similar communication barriers exist.

In conclusion, I have looked at the possible implementation of a new service initiative to decrease

communication barriers between the interprofessional team and patients’ relatives to relieve undue

distress for all parties involved. The sharing of experience, expertise and ideas from the

involvement of the interprofessional team will assist in the production of this service initiative, by

assuring the information displayed is accurate and effective. The interprofessional teams’

awareness of the initiative will relieve time pressures during therapy sessions, in the comfort of

knowing the relatives are consistently reminded of the reasons behind long timescales. The nurse is

the conduit in the interprofessional communications, and uniquely at the very centre of the team.

Knowing that the relatives are not unduly distressed while separated from the patient during therapy

sessions helps to alleviate any negative confrontation. It is important to continue to seek new and

improved ways of working, as evidence-based change and improvement will transform healthcare

for patients and their families.

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References

Audit Commission, 2000 The Way to Go Home. Rehabilitation and Remedial Services for Older People. London, Audit Commission Publications. Cleghorn, G.D., Headrick, L.A., 1996. The PDSA cycle at the core of learning in health professions education. South Carolina Area Health Education Consortium (AHEC), Medical University of South Carolina, Charleston, USA. Department of Health (DoH), 2000, The NHS Plan: The Government’s Response to the Royal Commission on Long-term Care. London, DoH. Department of Health (DoH), 2001, NHS Modernisation Agency: Changing Workforce Programmed – New Ways of Working in Health Care. London, DoH. Department of Health (DoH), 2006, Modernising nursing careers: Setting the direction. Finch J., May C., & Mair F., et al , 2000, Interprofessional education and teamworking: a view from the education providers. British Medical Journal 321: 1138-40. Kritsonis, A., Comparison of Change Theories. International Journal of Scholarly Academic Intellectual Diversity; 8:1, 2004-2005. McNair R., Brown R., & Stone N., et al, 2001, Rural interprofessional education: promoting teamwork in primary health care education and practice. Australian Journal of Rural Health 9: s19-s26. NHS Insitute of Innovation and Improvement (NHSi), 2010. [online]. Available at: <http://www.institute.nhs.uk>. Last accessed 9 September 2012. SWOT Analysis created by Albert Humphrey

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Appendix I

Service Improvement Activity – Notification Form

(Adapted from the form developed by County Durham and Darlington NHS Foundation Trust/North Tees + Hartlepool NHS Trust and University of Teesside, School of Health and Social Care)

Please complete the following details to register your service improvement activity Contact Details Student SID Number: 0924799 Details of service improvement project/activity: During my current placement on the critical care unit, I noticed that the relatives’ room was segregated from the patients by a locked door within the main corridor. The only form of communication was via an intercom system at the locked door which was used to gain access. Due to the close nature of care, relatives were asked to wait in the room while patients were being admitted or while any procedures were carried out on the patients by members of the inter-professional team. In many circumstances, I noticed when relatives were asked to leave the patient and wait in the relatives’ room it was explained by the nurse this is while a procedure was carried out and an estimated time scale was predicted. However, due to different members of the inter-professional team arriving to carry out procedures concurrently, it became apparent that an estimated short wait would become a rather long wait. It was not always possible for the nurse to leave the patient in order to advise the relatives of the extended waiting time, which in turn caused the relatives to become frustrated and increasingly distressed, as they had no way of knowing the reason for the long delay. I discussed this communication issue with my mentor, and she explained that this is an area that needs to be improved, however despite all former efforts, a solution has not yet been found. I suggested the use of a poster in the relatives’ room to improve the relatives’ awareness of why delays may happen along with a brief description of all the inter-professional team involved in the patient care. Reason for development: The consequences of the inhibited communication resulted in a negative feeling from the relatives towards the inter-professional team, which in turn caused difficulty in the relationship between relatives and nurses. Although verbal communication is best, it is not always possible in this situation, consequently the use of a poster as described in the above section will constantly remind the already distressed relatives the reasons for delays and the roles inter-professional team. This will give some reassurance during any delay and relieve the fear of asking or bothering staff. It will also save time by eliminating repeated questions which was found to be common place in the distressed relative.

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Time spent on the project/activity: The area for the need of improvement was immediately identified. Discussions into the details of the issue with my mentor took one hour. Discussions with twelve relatives took one hour in total. Defining a conclusive solution based on the information obtained took three days. Tool/s used: Initially I made notes of my own observations to identify the consequences of relatives being kept waiting apart from the patient. I carried out in-depth discussions with my mentor and other staff, highlighting the issue of heightened anxiety of the patients’ relatives due to inhibited communication. I also discussed the issue with twelve relatives/families to fully understand the relatives’ perspective, and I analysed an existing information book, which proved not to be effective and not seen by the relatives. The use of the SWOT analysis revealed: Strength

• Constant reminder of the causes of delays • The roles of the interprofessional team • Eliminating repeated questions and fear of asking or bothering staff • Cost effective • Give reassurance during any delay • Straight forward to change and adapt if necessary • Easily adapted for other areas

Weakness

• Existing friction may hinder the success of this improvement • Verbal communication is best • Managerial obstructions

Opportunity • Communication barrier already been recognised • A solution will be welcomed • In-house design and production department

Threat • Budget restrictions • Disagreement from managerial staff • Adaption to a change

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Who was involved: As a student nurse, I made the initial observation. I involved my mentor who is a registered nurse, and fellow members of the nursing team in discussing a possible solution. I also involved twelve relatives for their perspective on the issue. Outcome / Evaluation: The idea of a poster was well received by both staff and relatives. I anticipate the implementation of a poster would alleviate any undue frustration and distress for the patients’ relatives. Evaluation of the poster content can be monitored an updated if required, to achieve the goal of effective communication. Future plans: If successful in this area, a similar bespoke poster could be used in other acute settings where anxieties are raised due to long waiting times, such as A&E cubicles and waiting areas. Date discussed with clinical staff in placement area: 24th November 2011

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Appendix II

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Appendix III

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Appendix IV