Transcript The University of Sheffield: PowerPoint template

Integration
Creating an enriched environment
Presentation to ‘Health and Social Care
Integration: Delivering the outcomes’
Edinburgh November 2013
Professor Mike Nolan, University of Sheffield
[email protected]
Achieving Integration: a ‘wicked problem’?
Australian Public Services Commission (2007)
• Difficult to clearly define
• Complex interdependencies
• Proposed solutions have uncertain effects
• Problem is unstable and evolving
• No clear or correct solution
• Socially complex, involves several stakeholders
• Crosses organisational boundaries
• Solution requires behavioural change
The challenge of integration
• Rise in long-term conditions the greatest challenge to
health and social care systems (Kane 2005)
• Health care systems still mainly focussed on acute care
• Social policy is underpinned by an individualistic view of
society
• Need for a change in values and a new model of service
delivery
• Relationship-centred care/Senses Framework
Agreeing where to focus
• Position paper from ADSW, Four Nations United, RCN
literature review on integration
• Clearly articulated and widely agreed vision,
underpinned by shared values
• Attention to matters of culture and leadership
• The focus must be on outcomes
• The ‘humpty dumpty’ conundrum
• ‘When I use a word it means exactly what I choose it
to mean’
Time to question the values
• Independence, well-being and choice
• ‘Cultural glue’
• Consistent with other recent concepts in academic
and policy literatures
• Successful ageing
• Person-centred care
• Autonomy and independence
• Rosy concepts
The roots of ‘person-centred’ care
• Pioneering work of Tom Kitwood, Bradford Dementia
Group – Dawn Brooker
• Person-centred care
• See the person not the disease
• Creating a positive environment of care
• Original vision not consistent with current usage
• Little more than a political slogan
(Burstow 2006)
Person-centred care – mantra of
the Century
• Care that is based around an individual and their needs
(DoH 2001)
• Key values underpinning the ‘single assessment process’
are person-centred care and independence
(Norman 2005)
• Assessment is a person-centred activity with an emphasis
on establishing areas of need to maintain or increase
independence and quality of life
(McCormack and Ford 2000)
What of autonomy and independence?
• Beware the ‘new gerontology’ with its focus on ‘individually
successful ageing’ that results in an impoverished view of
what a good old age can be’
(Holstein and Minkler 2003)
• Autonomy and individuality are ‘incapable of underpinning
any shared societal responsibility for the health of all its
members, including the least advantaged’ (Evans 1999)
• Need a relational view of autonomy that recognises that
people are never fully independent
(MacDonald 2002)
Integration: Some inherent contradictions?
• Need to shape ‘more inclusive environments and
communities’
• ‘Reform starts from the individual citizen’
• Better outcomes for individuals ‘become a central
ethos’
• Evans (1999) are such values capable of
underpinning any shared societal responsibility?
What is the solution?
• Culture change
• Buzzwords of the 21st century (Stone 2003)
• Social Movement (Meyer and Owen 2008)
• New core values – compassion (Darzi Report)
• Highly complex
• Attend to ‘complex social interactions’ (Powell et al
2009)
• Fundamentally ‘relational concepts’
The future of Health and Social care for
older people: W(h)ither now?
Developing The Senses Framework
• Evolved over a 25 year period
• Intellectual itch
- What provides a sense of therapeutic direction for staff
in LTC environments?
• Cure
• Rehabilitation
• ‘Good geriatric care’ (Reed and Bond 1991) or ‘Endless
residual care’ (Evers 1981)
Creating an ‘enriched environment’
• Security – to feel safe physically, psychologically, existentially
• Belonging - to feel part of a valued group, to maintain or form
important relationships
• Continuity - to be able to make links between the past,
present and future
• Purpose - to enjoy meaningful activity, to have valued goals
• Achievement - to reach valued goals to satisfaction of self
and/or others
• Significance - to feel that you ‘matter’ and are accorded value
and status
An enriched environment for all
Older
people
Security
Belonging
Continuity
Purpose
Achievement
Significance
Family
carers
Staff
Students
Models of culture
•Perform or Perish
•Relational and Responsive
-Pace: quick fix, short term, process
driven
-Complexity – longer term, evolving focus
on people and perceptions
-External, top down agenda
-Locally contextual
-Select few determine goals
Highly inclusive of all groups
-Punitive mandatory way of working and
transactional change
Empowering, inspiring, transformational
way of working
-Metrics matter: superficial quantiative
targets for success
Meaning matters, relational, dynamic
qualitative ‘indicators’ of success
-Scored
-Profiled
-Impoverished environment ‘senses
reduced’
Enriched environment ‘senses enhanced’
Culture change: Looking to the literature
• Highly complex ‘slippery’ concept
• Multifaceted (Stone 2003)
• Service culture-goals of care
• Caring culture – quality of relationships
• Work culture – staff nurtured and supported
• Local culture – culture of the office (Twigg and Atkin 1994)
• Relational practice has to matter (Parker 2008)
Creating an enriched environment for staff
• Key leadership behaviours
• Do you:
•
Instil a sense of pride by focusing on what is done well?
•
Inspire confidence by saying positive things?
•
Consider everyone’s opinion when making decisions?
•
Consult colleagues about daily issues?
•
Act in a caring and supportive manner towards colleagues?
•
Set clear and explicit expectations?
•
Establish strong standards of excellence in care?
•
Have a “presence” – make yourself readily available?
• Actively coach colleagues to help them improve their care delivery?
• Lead by example?
Sharing a Philosophy of Care
Where you work do you:
• Share an explicit philosophy of care?
• Value the holistic aspects of care?
• Communicate your philosophy and values to new members of
staff?
• See involving users and carers as essential?
• Have a culture that is about caring for people and supporting
them rather than ‘achieving targets ’?
Supporting Each Other
Where you work:
• Do colleagues show concern and support each other to deal
with stresses at work?
• Do colleagues provide each other with emotional support?
• Are the emotional demands of care-giving acknowledged and
addressed?
• Do colleagues feel confident about the competence and
abilities of other team members?
• Is there a great deal of trust among members of the team?
• Can team members really count on each others’ help with any
difficulties?
Improving Practice
Where you work:
• Do the team discuss performance objectives?
• Do the team discuss ways of making your vision a reality?
• Do the team make the time to share relevant information?
• Do the team discuss how to improve things when mistakes or
errors happen?
• Do team members take time to reflect on their performance?
• Do the team regularly take time to figure out ways to improve
care delivery?
Having a Say
Where you work:
• Can team members influence what goes on in the ward?
• Can team members have a say in how work is managed?
• Can team members participate in all decisions that affect
them?
• Do team members have the freedom to make important
work decisions?
• Can team members determine how work is done?
• Can team members carry out their work in the way they think
is best?
Developing our Skills
Where you work:
• Are staff given time and opportunity to develop new work
skills?
• Is training and professional development readily available for
everyone?
• Is staff development supported by mentoring and clinical
supervision?
Team Working
Where you work:
• Do staff work well with other members of the Team?
• Is there good communication among members of the Team?
Having Resources
Where you work:
•
Is there sufficient basic equipment and supplies to deliver good level of
care?
• Is there adequate support services to allow staff time with clients?
• Are there enough skilled staff to provide high quality care?
Too Much To Do
Where you work:
•
Is there too much work to do in too little time?
• Are staff asked to do work without adequate resources to complete it?
•
Can staff follow best practice in the time available?
•
Do staff have to make trade-offs between the quality of work and cost
savings?
How are things done around here’?
Where you work what processes are in place for:
• Facilitating good communication (belonging/continuity)
• Allocating work (continuity)
• Agreeing goals and values (significance/purpose)
• Celebrating success (achievement/significance)
• Addressing difficult issues (security)
• Providing staff with emotional support (security)
• Indentifying individual goals and aspirations
(significance/purpose/achievement)
• Inducting new staff (all the senses)
• Ensuring everyone has a say (all the senses)
• Involving users and carers (all the senses)
‘It is certainly possible to coerce people into
compliance, but is impossible to coerce them
into excellence’ (Guba and Lincoln 1989 p 226)
‘Relational work in caregiving organisations thus
depends, not only on the skills of individual
practitioners and care workers but, also on the extent
to which the workgroup and the organisation are
structured and operated in ways that are supportive
of relational work behaviours (Parker 2008, p206)