Caring about caring: Developing a model to implement compassionate relationship centred care in an older people care setting

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Abstract

Aim

This study actively involved older people, staff and relatives in agreeing a definition of compassionate relationship-centred care and identifying strategies to promote such care in acute hospital settings for older people. It was a major component of a three year programme (the Leadership in Compassionate Care Programme, LCCP) seeking to integrate compassionate care across practice and educational environments.

Background

Compassionate caring and promoting dignity are key priorities for policy, practice and research worldwide, being central to the quality of care for patients and families, and job satisfaction for staff. Therapeutic relationships are essential to achieving excellence in care but little is known about how to develop and sustain such relationships in a culture that increasingly focuses on throughput and rapid turnover.

Approach and methods

The study used appreciative inquiry and a range of methods including participant observation, interviews, story telling and group discussions to actively engage older people, relatives and staff. A process of immersion crystallization was used to analyze data with staff as co-analysts.

Findings

The study adds considerably to the conceptualization of compassionate, relationship-centred care and provides a model to aid staff deliver such care in practice, based on ‘appreciative caring conversations’ that enable all parties to gain two forms of ‘person and relational knowledge’ about ‘who people are and what matters to them’ and ‘how people feel about their experience’. Such knowledge enables staff, patients and carers to ‘work together to shape the way things are done’. The study generated a model called the 7 ‘C's that captures in detail the factors necessary to promote ‘appreciative caring conversations’.

Conclusions and implications

The study demonstrates that engaging in ‘appreciative caring conversations’ promotes compassionate, relationship-centred care but that these conversations involve practitioners taking risks. Such ‘relational practices’ must therefore be valued and accorded status. Staff require appropriate support, facilitation and strong leadership if these practices are to flourish.

Section snippets

Introduction: compassion, a concept looking for a definition

Concerns about standards of hospital care for older people have been apparent for decades (Norton et al., 1962, Townsend, 1966, Robb, 1967) and recent international literature suggests that rather than being ameliorated these concerns are being exacerbated as levels of frailty and acuity rise (Clarfield et al., 2001, Youngson, 2008, Edvardsson et al., 2010). Therefore as Clarfield et al. (2001) rightly assert, this is now an ‘international problem’. This paper describes the development of a

Compassion: we know what we say but what do we mean?

Prior to the empirical work, a comprehensive narrative synthesis of the extant literature on compassionate care using the key terms caring, compassionate care, dignity, relationship-centred and person centred care, was undertaken (see Dewar, 2011 for a full account). A pragmatic and inclusive approach was adopted with Medline, CINAHL, PsycLit and Index to Theses being the principal sources used to identify policy documents, theoretical and research literature, discussion and opinion pieces and

Participants

A range of staff including registered nurses, non-registered care staff, allied health care professionals and medical staff (n = 35 i.e. 85% of staff), patients (n = 10) and families (n = 12) took part in the study. Staff were asked to invite patients and families to take part and deciding who to include was pragmatic based on factors such as, how well patients were at the time and whether the lead author was present on the ward that day. The sampling is therefore best described therefore as

Ethical considerations

The research was approved by the University Ethics Committee. Due to its emergent design ongoing process consent was used whereby consent was continually renegotiated (Dewing, 2007, Winter and Munn-Giddings, 2001). Where participants were from potentially vulnerable groups (e.g. those with a serious or terminal illness) discussion took place with both the health care professionals involved in their care, and their family member, about the nature of the study and the extent to which they should

Data generation and analysis

A range of methods were used in data generation. These included: the collection of stories using emotional touchpoints, in which the storyteller identifies how they feel about different aspects of their experience (Bate and Robert, 2007, Dewar et al., 2010); structured observation; photo-elicitation where participants use images to sum up how particular experiences felt (Dewar, 2012, Dewar et al., 2011, Hansen-Ketchum and Myrick, 2008); exploration of beliefs and values through group

Findings

Detailed analysis of the extensive data identified two key forms of ‘person and relational knowledge’ (Liaschenko and Fisher, 1999) enabling staff, patients and families to ‘work together to shape the way things are done’: these were termed ‘knowing who I am and what matters to me’ and ‘understanding how I feel’. Developing such knowledge entailed a complex form of relational practice (Parker, 2008, Williams et al., 2009) that involved engaging in ‘appreciative caring conversations’.

Thus the

Being courageous

A willingness to take risks, feeling confident to ask questions, working with uncertainty and the ability to ‘stick up for’ changes to established practices required courage, as staff were aware:

The biggest thing for me about doing the work on the project is feeling much more aware about how I behave, being braver to ask patients and families more direct questions, being stronger in sticking up for the things I believe in and being much clearer about what it is we do well around here. (Staff

Being curious

This involved asking questions about the feelings and experiences of others as a means of challenging existing assumptions and finding alternative approaches. Such ‘curiosity’ became embedded into the working practices of staff:

Staff question practice more and check things out with patients. This feels like a normal thing to do now. In the past people might have been a bit on the defensive with questions like this. (Staff exit interview 9).

Staff now both supported and challenged each other to

Being collaborative

This meant talking together, involving people in decisions, bringing others on board, and developing a shared responsibility. The project had clearly enhanced opportunities for collaboration, not only between staff but also patients and families:

We have not always asked patients and families what they think – we tend to think that we have to have all the answers. We don’t and have found that patients come up with things we might not have thought about. (Staff exit interview 11).

Such

Considering others’ perspectives

This involved exploring another's point of view, acknowledging that they may not hold the same beliefs as you and feeling comfortable to discuss any differences in an open way.

Another key thing the project has brought out is highlighting that we make a lot of assumptions about things and we need to be much better at checking things out. This has been one of the biggest things for me. (Staff exit interview 3).

Acknowledging differences required the ability to compromise.

Compromising

This was about striving for consensus through discussion and reflection, and involved being prepared to ‘give and take’:

We are more open now about saying what we can and can’t do. The project has helped us to say what we feel, and our opinion has counted in decisions about care. It has not all been about what the patient thinks and wants because sometimes this can be unrealistic. (Staff exit interview 7).

Central to the success of the ‘appreciative caring conversations’ was that these

Being celebratory

Meant making a conscious effort to explore what works well and why, to let people know that their contribution is valued:

I try to commend people for good things more now. Before, I think when I thought people did things well, I didn’t say anything because I just thought it was part of their job. I do try to say these things more to people. (Staff exit interview 17).

The above comprise the 7 ‘C's of appreciative caring conversations, which have at their heart the courage to take risks. Without

Discussion

The long-standing international concerns about the quality of hospital care for older people (Brundtland, 2003, Mullan, 2009, Norton et al., 1962, HAS, 2000, Young et al., 2003) have, despite concerted efforts over the last decade, appeared resistant to change. Debates in a number of countries in the developed world reflect enduring tensions between the ‘metrics’ and ‘meaning’ of a system predicated on the goal of cure when the majority of users have long-term conditions (Tresolini et al., 1994

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