Frontline healthcare professionals:

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• Front-line healthcare professionals
• Can you remember the first patient you cared
  for who died?
• Other professionals
• Can you remember your first love?

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Where does healthcare take place?

• old model
• done by doctors to people in hospitals and
  surgeries
• new model
• exists in peoples (families) lives in
  effectiveness of health-related behaviours
• intimately linked to quality of life
• co-created (facilitated) in interactions between
  patients and professionals (clinical microsystems)

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Quality in clinical microsystems

• Interactions all in-patient, out-patient,
  phone, information leaflets, e-mail, web sites
  etc. etc.
• Experiential quality
• seeing through others eyes
• valuing diversity
• valuing patient autonomy
• creating experiences and being aware of the
  experiences we create

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Listening the forgotten communication skill

• Ignoring
• Pretending
• Selective
• Attentive
• Empathic

Quality
10 words 30 sounds 60 non-verbal
mirroring
Relationship
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If it doesnt work stop doing it
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Decision on breast masses
GV choice

• 1000 women asked how to make decision
• 1/3 said Give me information Ill decide
• 1/3 said Ill discuss information with Dr.
  well decide together
• 1/3 said Tell me what to do
• Need to organise services to accommodate all of
  above and change between them

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Two paradigms for organisational change

• Organising is a problem to be solved
• Problem identified
• Analysis of causes
• Analysis of possible solutions
• Action planning

• 2. Organising is a mystery to be embraced
• Appreciating- valuing best of what is
• Envisioning what might be
• Dialogue what should be
• Innovating what will be

process
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Appreciative Inquiry interview process
What was going on for you? How did you feel?
What do you think was going on for them?
How did that make you feel?
Keep talking Im getting a picture of this
What do you think s/he meant by that?
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Ai the first question

• Tell me a story about
• When did you see healthcare at its best?
• When did a family experience healthcare at its
  best?
• When did you make the difference?
• What inspired you to become a
• (healthcare professional)?

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Results - data

• Little things/decisions make a big difference
  for parents(3 respondents)
• spending quality time not just dishing out
  medicines Time is a resource
• What would it feel like to be that patient?
  Feelings about peoples feelings are right -
  parents tell you that
• You can change people by listening

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Results - data

• Its about making partnerships properly with
  patients
• Maintaining empathy is rewarding but draining
• Every family has their own story human to
  human Its nice when they can be honest with
  you
• happy for the family - I enjoyed their progress
  good to see him happy
• After all that, she came back and she looked
  great

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Results - data

• My judgment about what was right proved right
• I was a good nurse that day
• Having a bit of fun - thats what its all
  about
• They were terrible experiences but they made me
  a better, caring and sensitive person
• I used my fundamental beliefs to know what to
  do

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Results - feedback

• has been useful good excellent
• I feel very reflective reflecting is always
  positive
• I needed it so much I felt I needed to....
• makes you think why you are doing what you are
  doing made me think how I feel about families
  makes you appreciate what you do nice to think
  about it job is worth doing feel better about
  my job
• It gave me a lot more confidence
• didnt think I would open up didnt realise
  how much I get involved with parents
• makes me realise Im not different from parents
  helps you take a reality check brought
  together a lot of things for me
• looking back on how you coped gives you a
  clearer insight into how you and parents would
  like things done

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Managed clinical network by Ai

• Linked groups of health professionals and
  stakeholders working together in a co-ordinated
  manner unconstrained by existing professional
  boundaries to ensure equitable provision of high
  quality care

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Services designed by a parent from an Ai
interaction
What would ideal services be like?
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Terry an expert

• Rugby spinal injury aged 19 15 yr ago
• Discharge from Stoke Mandeville
• Education on care of bladder
• bowel
• skin
• We are all ultimately responsible for what
  happens to ourselves
• Lives alone with Possum
• Proud to organise my life to live independently
  set up company to employ carers

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Terry 2

• ..people realise I do know what Im talking about
• I have lived with it for 15 years that gives me
  the right to explain what I think is happening
• I rely on people to tell me but I assess things
  and decide for myself
• Over the years I have tested things and have
  found what gets better and what gets worse
  through trial and error you find out what your
  body can stand and what it cant
• Some very good staff, some OK but a few very poor
  I make sure agencies dont send them back
• If I could choose between getting back control of
  my legs or my bowels Id choose my bowels

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Tell your own healing story-
Breathing, relaxation, be somewhere else
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anger
pain
applications
anxiety
grief
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Rules of thumb

• Be accountable Ethos integrity, pathos
  understanding, logos - explanation
• Look at yourself get feedback, audit, record,
  reflect etc. - Only you can change yourself
• If in doubt ask!

• Listen first - skills
• Everyone has a story -so
• everyone is an expert
• People surprise themselves with their reflections
• Wants and needs change
• Empathy is therapeutic

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Finally

• Homework for all professionals
• Tell yourself a story called
• the best care I ever provided

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You dont know what you do
H Loonen 2001
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Organisation of care a complexity view

• Society
• Managed clinical network
• Clinical microsystem
• ? Fractals?

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All staff will require CC training
Dont let anyone fall behind
More care out of hospitals
Take time to reflect on roles and how they
need to change
Hospitals will be mainly for critically ill
patients
Respect, support value (yourself others)
Need better links with 1y care community
with effective commmunication
Increase patient involvement in developing and
shaping services
Train GPs and community nurses
Ownership responsibility
Less traditional style roles
Empowered staff
Support from organisation
Patient centred Critical care 2007
Develop role of Nurse intensivist systems
practitioner
Flexible working practices
More CC Specialists Outreach intensivists
ICUs supported by Electronic monitoring And
records
Recognise patient need provide for that need
Health checks on teams
Expanded roles
Bigger ICUs
Involve pts carers as the norm
ICUs supported By PACUs to Use resources More
effectively
See things from their perspective
Sharing knowledge capabilities and experiences
More disciplines involved in CC
Partnership
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memory
imagination
From Frogs into Princes by Bandler Grinder