Background
Methods
The case
Setting
Framework for operationalisation of PCC core components
The core components – from principles to practices
Philosophical principles and values
Contextual factors
Structural elements that define the innovation
Core practices
Participants
Unit | n | Occupational role |
---|---|---|
1 | 2 | Frontline manager Assistant frontline manager |
2 | 2 | Frontline manager Quality developer |
3 | 6 | Frontline manager Assistant frontline manager HCPs represented by different care specialities at the unit: nephrology investigations and check-ups, haemo-, peritoneal and home dialysis. |
4 | 6 | Senior manager Quality developer Frontline managers representing three departments: Ordinary primary care, family centre and rehabilitation |
5 | 4 | Frontline manager Coordination nurse Registered nurse Assistant nurse |
6 | 4 | Frontline manager Coordination nurse Registered nurse Assistant nurse |
Data sources
Interviews
Activity logs
Documents
Data analysis
Results
Unit | Initiating the partnership | Working the partnership | Safeguarding the partnership |
---|---|---|---|
1 | New admission routine where assistant nurses ask patients questions in a standardised protocol about their life before admission to get a deeper understanding of each person’s needs and wishes for care. Conversation methodology in line with MI are encouraged (coordination nurses) to listen closely to patients’ narrative as well as enable discussions when they are working the partnership. The narrative is explored by a range of HCPs during patients stay at the ward | Patients are encouraged to be more in charge of their rehabilitation process by setting goals in line with their own wishes and needs and be part of taking decisions about their care. Goals are discussed and revised between the patient and HCPs on a weekly basis. Coordination nurses at the ward take extra responsibility of rehab plans as an ongoing process where plans for discharge is initiated on admission to the ward and changed at regular intervals. These plans are developed together with the patient and all HCPs involved in their care. Everyday care routines such as eating habits or showers on a weekly basis are encouraged to become more flexible according to patients wishes i.e., showers twice a week. Increased partnership is enabled through the introduction of videoconference equipment. Patients, their next of kin and other stakeholders e.g., at nursing homes can meet to discuss and plan for discharge, continued care and rehabilitation. | Patients’ narratives are documented in the health care record. Rehab plans are documented in the health care record. |
2 | Conversation methodology in line with MI are encouraged (for HCPs working in outpatient rehabilitation) to aid HCPs to listen closely to patients’ narrative as well as enable discussions when they are working the partnership. | Patients are invited to co-create their care in team meetings with HCPs where ongoing-, planned care and rehabilitation are discussed. Rehab plans are developed in partnership including short- and long-term goals based on each patient’s wishes and needs. Patients are given access to training facilities around the clock at the ward as they are viewed as resourceful and capable. Introduction of home rehabilitation enables an improved discharge process where rehab in the ward is followed through to the patients’ homes and guided by patient wishes and needs in relation to their home environment. New treatment alternatives are introduced to increase choices for rehabilitation for patients e.g., horse rehabilitation. | Rehab plans are documented in the health care record. |
3 | Patients’ narratives are elicited on admission. Warm handovers for patients transitioning between care specialities using patients’ narratives. Conversation methodology in line with MI are encouraged to aid HCPs to listen closely to patients’ narrative as well as enable discussions when they are working the partnership. | Increased work in partnership with all patients to explore their resources and wishes for increased responsibility in self-care. A self-care document is used where patients are asked if they wish to learn more and take more responsibility for self-care, participation and support in care activities which is documented into concrete activities. Examples of activities are patients doing their own calculations on how much fluid to pull in conjunction to dialysis. Starting up a teaching program for new patients to increase patients’ knowledge on kidney disease, diet, and dialysis modalities. Improve patients’ feelings of safety and freedom and using own resources by introducing videoconference equipment. | Patients’ narratives are documented in their own words under the heading narrative in the health care record. Patients’ wishes and agreements for care are documented. |
4 | Patients’ narratives are elicited on admission. HCPs are encouraged to listen to patient wishes. Conversation methodology in line with MI are encouraged to aid HCPs to listen closely to patients’ narrative as well as enable discussions when they are working the partnership. | Increased teamwork in partnership with several HCPs and the patient to meet patients’ needs and wishes, discuss goals and treatment plans and improve transitions between different HCPs within the unit. Patients are given information and support in line with their wishes such as being asked to describe how and what kind of information they would like, and how and when they would like to be contacted for follow up. Improve information to patients about treatment alternatives to ameliorate participation in decisions. Starting up a lifestyle unit catering for patients who are not ill but is running a risk of getting ill. The lifestyle unit is based on patients seen as resourceful and capable to use information, support and guidance to make lifestyle changes and make their own choices of how they want to live their lives. | Patients’ narratives are documented in the health care record using the search word narrative. |
5/6 | Patients’ narratives are sought on admission. Conversation methodology in line with open dialogue are encouraged. | Changing the daily round to make more time talking directly with the patient compared to talking about the patient. Defining the role of the contact person to fit closer with PCC, involving taking the time to listen closely to patients’ narratives, discuss goal setting, follow up on goals, weekly plans, wishes for care and if there are issues that needs to be raised in meetings with psychiatrists, social security or at home. Activity plans and goals that patients make in group sessions are followed up by each patients contact person and discussed and revised in relation to individual needs, resources and goals. The contact person participates and support the patient at meetings with psychiatrists and other stakeholders such as social security personnel. | A health plan based on the patient’s narrative, including a planned remittal date is written together with the patient on admission and revised regularly. |
Overall aspects of the operationalisations
However, there were also instances when change agents were vague in their descriptions of how a specific practice could be traced back to its ethical basis or vice versa. Change agents at one unit described introducing a high-calorie diet for all patients, but they could not relate this change to the ethical foundation of PCC. Other change agents discussed how they encouraged HCPs to listen to, collaborate with and co-create health care with patients by using a flexible attitude towards patients’ wishes and values. Thus, change agents sometimes advocated a PCC approach without specifying how this could be attained or exemplified in specific practices at the workplace. Descriptions of the number of times an activity was advocated, its duration and when it should be carried out differed considerably between the structural elements targeted and the health care units. For instance, PCC core practices specified for point in time and number of occasions at the units included developing health care plans with patients on admission and discharge to enable the improved transition to other care specialities, social security and care at the municipality. Other practices where the point in time was specified were listening to patients’ narratives on admission. Moreover, HCPs at units 5 and 6 underwent a changed routine of the daily round. This new routine entailed changing how work was scheduled at the unit in conjunction with work tasks and new staff roles. Assistant nurses were charged to take on more responsibility as contact persons towards patients and other stakeholders related to the patient’s wellbeing. Such additional responsibility included involvement with staff at the health unit (i.e., psychiatrists and registered nurses), next of kin and social security. The new round aimed to have HCPs spend more time (increased duration) talking to patients and less time spent in conference rooms talking about patients. When this new routine was implemented, HCPs were given guidance and recall notes about posing open-ended questions and suggestions for topics and queries to enhance communication with patients.We started to do rehab plans together with the patients. We have not had a well-functioning routine of making rehab plans with the patients, and we saw the potential of working mutually and creating it together with the patients. The patients will be more involved in their care, set goals and [describe] what they want. You would think it would already be a natural part for us to work with rehab plans where the patient participates. But it has not been evident for us. So that’s our goal, to make the patients more involved in their rehabilitation. (DI)
Operationalisations of initiating the partnership
Other change agents described how they operationalised narratives by using a set protocol to collect information about patients on admission to identify patient needs and other matters (e.g., if they were at risk of falling or had nutritional problems). However, the narrative was also expressed as something that needed to be explored daily or at each new visit to the health care unit as an ongoing routine. One change agent told how patients’ resources and needs could change daily and even during the same day. Thus, HCPs had to become attentive and listen to patients on all these occasions in health care:To talk with the patient and try to hear what she is thinking. Does she still have delusions? How is it with her suicidal thoughts? You can’t just see that when you go in and say good morning or if you take her blood pressure. You need to do something more. And I believe that patients need to trust you if they are willing to tell you something. (FG)
Some change agents described how patients’ narratives were built over time. These accumulated narratives were sometimes due to the patients’ health status and when they could express a description independently. In other instances, the narratives were accumulated with the whole team’s help working with the patient. HCPs with different occupational roles listened to patients’ narratives from their perspective and added ongoing information to build a holistic account of their lifeworld.Well, if I go in and see Margret and say hello, I need to ask what are you doing here and why do you think I am here for? What do you need help with today? Instead of getting a rapport from a nurse who says she needs help with her hygiene. And then you go in and do it, and perhaps it was correct yesterday, but it becomes a truth also today because we keep on doing it. So, I believe that it is vital that HCPs embrace the thought of asking patients, right here and today, what do you need help with right now. (DI)
Operationalisations of working the partnership
Change agents at all units used different communication skills to operationalise PCC. Motivational interviewing (MI) [44] was the most common communication methodology used by the units to aid HCPs to be attentive to patients’ narratives and work in partnership to co-create care. Some units decided that all HCPs should learn this methodology, whereas others felt that only the coordination nurses needed these communication skills. One change agent described the need to operationalise PCC in communication proficiencies.Well, we got this new patient law, and there we have obligations to relate to. We have laws that stipulate that we should inform the patients. They should be able to decide some … I mean, what kind of care suits me. Do I want surgery or not? You need to be able to participate in your care. (FG)
Another change agent described how she saw MI as a tool to aid operationalisation of most aspects of PCC and expressed an attitude of great relief of using this communication methodology concerning constructs embedded in a PCC approach.When you work according to MI, you are very explorative. I'll meet you where you are. What are your thoughts? Why do you think this is so? What do you want to do? And this is a person-centred approach. I [the patient] become more involved in my care and make my own decisions. (FG)
Working in partnership and seeing each patient as unique differed greatly depending on each unit’s contextual conditions and prerequisites. In unit 1 changes about daily and weekly work routines at the ward to align with patients’ wishes regarding how often they could have showers, rise in the morning and take their meals were advocated as examples and means to operationalise the partnership. In unit 4, representing primary care, co-operation was promoted in encounters with patients and regarded as sharing information and establishing goals based on patients’ needs and not on convenience. Increased co-operation was also encouraged in routines related to patients staying in touch with HCPs at the unit. Increased flexibility by moving away from routinised ways of organising care following set rules as to follow up, check-ups and which HCPs to contact was promoted to meet patients’ wishes and needs.One could say that I am entirely sold on MI. You can use it to explore resources and get patients more involved in their care. Instead of having this monologue, we can have a proper conversation where the patient is extremely engaged. (FG)
Changing how care was organised at the environmental level to meet the underlying ethical principles of PCC and the structural element partnership were also realised at the study units This change occurred in unit 2, where patients were regarded as resourceful and capable and encouraged to use training facilities around the clock and on weekends when rehab personnel were unavailable. Other changes in unit 2 to meet patient expectations were the introduction of horse therapy and the possibility for home rehabilitation.If I [the patient] feel confident and independent, I may want to book my own time using the net. I want to get my results on the net and log in and read them myself. Maybe I don’t want to have that much to do with us; instead, I manage most of it myself. But if I feel fragile, uncertain and insecure, I may need to have an established contact in primary care. I need to have someone that I can call when I crumble. We need to have many different ways to get in touch with us based on each person. (FG)
Other examples of operationalising PCC through increased partnership were changes in how care was organised, such as introducing video conference equipment to enable patients from their homes to contact HCPs and for next of kin or other stakeholders to participate in team meetings with patients in inpatient care.Those who are medically stable but still in need of rehabilitation can have their rehabilitation in their home instead of the ward. Patients will continue their rehabilitation where it will be most beneficial for them. It will be fruitful for patients and our unit-- well, for everybody. We will have yet another choice [for patients]. We have inpatient and outpatient rehabilitation, and now we will also have home rehabilitation to tailor more to your [the patients] specific needs. (DI)
Working towards patients’ goals and aspirations was a commonplace discussion at all health care units. Goals were often discussed with patients and documented in a health care plan. Some units were explicit about following up on goals and made ongoing revisions on daily or weekly visits. In contrast, other units were less precise about how often goals were revisited and revised. While change agents at one unit described that they had already worked with rehab plans before they were introduced to PCC, they now saw that the introduction of PCC and working in a partnership meant that its operationalisation in a health care plan provided a new perspective. This new outlook implied that patients had become more involved throughout their care and rehabilitation process.Well, what did the patient actually want? I cannot answer that question if I have not explored it. That’s where we have person-centredness. There is no idea for me to run my race because it will not get us anywhere. It’s not going to be efficient. In 2 months we will not see any change. So, in my opinion there’s where you have person-centredness. (FG)
Operationalisation of safeguarding the partnership
Another change agent described how PCC was operationalised in a health care plan and revised according to the patient’s status.It becomes more like the patient tells the story because when we write [in the health care record], we are supposed to use search words, and it [the narrative] becomes quite chopped up. It is really nice to write a patient narrative and get it, how the patients tell their stories. (FG)
Change agents at the primary care unit and the specialised outpatient care unit discussed documentation of PCC achieved in a health care plan less in terms of legal aspects and more related to documentation of the narrative and commonly agreed goals. Documentation was regarded as a means for follow-up and enabling other HCPs to be involved in the patient’s future care.The doctors write a health care plan directly when patients are admitted based on the patients’ narratives. So, the whole [plan] is person-centred. And then, based on the narrative, a joint decision is taken together with the patient of how long you [the patient] need to stay with us. From there, we plan a discharge date … then, you need to revisit it [the plan] and see if things have become more complex than they were initially, then the length of stay will be longer. We are overall more person-centred along the whole way now. (FG)