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Observation of patient experience

An observation of patient experience was undertaken by a nurse clinical observer (CO) and a lay-member ‘Ken’ (pseudonym) of the Clinical Commissioning Group (CCG) in the Minor Injuries waiting area of a community hospital.  The purpose of which was to enable the CO to reflect and challenge her perception of clinical environments to improve patient experience. 

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The structure of the session was agreed by both the service being observed and Ken. Patients were informed by reception staff that an observation was being undertaken (at the request of the Trust), this was a concern acknowledged by Gould et al (2017) who identified that when people know they are being watched, they change what they do to conform to the expected standard of behaviour; however, the waiting room and tea-bar environment was busy and it was easy to blend-in.

The observers undertook a 30 minute observation seated together, facing the same way with their backs to a wall. This enabled the whole area to be observed simultaneously whilst eliminating the risk of overlooking something occurring behind them.

Following the 30 minute observation Ken and the CO analysed the data together, identifying themes on which to base their reflection Braun and Clarke (2006);  from which initial recommendations were agreed, based on the actions identified, Gibbs (1998).  The CO was confident with the thematic data collection methodology and the use of Gibbs’ Reflective Cycle (1998); having considered and discounted Johns (1994) model due to a more formal structure and less fluency in its application.

The CO has further reflected on the observation process using a model of structured reflection as described by Johns, (1994) to identify and understand their own extended reflexive learning needs and explore a new model of reflection.

When reviewing themes, it became apparent that both observers had noted very similar environmental issues, but had different views about why they were significant.

Two people were observed walking in bare feet.  Ken was concerned that they may spread an infection to the floor, e.g. MRSA. Boyce et al (2009) reasoned that media coverage of MRSA was fixated on poor standards of cleaning within hospitals, a view shared by Washer et al, (2008) who highlighted ‘dirty hospital’ headlines.  

 In consideration of Ken’s concerns, the CO introduced the counter-observation that both people had ankle injuries.  The combination of an injury and bare feet on the smooth floor was a falls risk.  45% of people who fall in hospital had bare feet at the time of the incident López-Soto et al (2016).  Ken was surprised about the risk and sought assurance that his concerns were valid.  This was an opportunity to immediately reduce some of his concern and we agreed to follow this up with information sharing.

The dominance of temporary signage within the department was the main theme captured by both parties; Clapton, (2016) found waiting rooms littered with old posters.  This issue could be described as a ‘tame problem’, Churchman (1967), Rittel and Webber (1973) which could be addressed by the MIU team.  The content of the posters related to perceived health and safety risks and what appeared to be attempts to prevent complaints.  The effectiveness of the important signs was lost in the volume as outlined by the HSE (2007).

  Ken commented that the posters would be helpful if they were in a font size that he as a mature person could read and used words that he understood.   Ken felt the presentation of the information had excluded him from accessing relevant service information such as pharmacy opening times.  National Voices clarified in their 9 Big Shouts, Redding (2011) that information should be used to work for patients, further upheld by Entwistle and Watt, (2013) who recognised that ambiguous information is there to enable staff and not to help patients.  I had just seen the signs as being disorganised.

During this part of the reflection, I felt more exposed than I had anticipated.  Nursing is my purpose motive, I identify as an authentic leader, as Shamas-ur-Rehman and George (2008) described. I’m not alone, Rassin’s (2008) study identified that the top 3 professional values of nurses were maintaining dignity, equality and preventing the suffering of others.  I concluded that the discomfort was my acknowledgement of my assumptions and realignment of my focus, as defined by McGregor (1960) in that when presented with the information I can do something positive with it.

During feedback, Ken shared that he felt more frustrated the longer he sat in the waiting room.  Nyden et al (2003) highlighted that health organisations have improved meeting the basic needs of people in waiting rooms.  Roper (2010) identified that waiting rooms are an environment that increases feelings of apprehension, worry and irritation.  Ken and I were there to observe, yet the comfortable environment acted as a trigger for frustration.

Ken described the posters as an example of the NHS telling patients what they think the public want to know instead of asking what we want.  His point identified there isn’t a sign to show where the toilets are located. In the Hierarchy of Needs, Maslow (1943) highlighted that not meeting such basic needs would negatively impact on a person’s ability to function.  The impact on people with continence difficulties or limited mobility not finding the toilet in time could affect their esteem, belonging, safety and physiological wellbeing.  A simple sign could avoid this, Rousek and Hallbeck (2011) recommended a standardisation of pictorial signs to improve patient orientation; increased levels of anxiety can also reduce a person’s ability to navigate new environments, Lawton and Kallai (2002). This is a simple solution to something that could prevent embarrassment and complaints.

 This was a point of breakthrough for the reflection, the realisation of the value of our feedback to each other.    I advised Ken of new guidance for the ‘Fifteen Steps Challenge’, NHSE (2017) recommending that all Quality Assurance visits should have a patient representative present.  This also aligns with the 9 Big Shouts Redding (2011). 

The CO recorded interactions between staff and patients that Mr. K described as expected behaviour and not recorded.  Nurses were observed to introduce themselves using the prefix ‘Hello my name is…’ Granger (2013) who described why as a patient she felt the introduction so important,

‘I firmly believe it is not just about common courtesy, but it runs much deeper. Introductions are about making a human connection between one human being who is suffering and vulnerable, and another human being who wishes to help.’

                                                                  Granger, K (2013)

Analysis of the themes during reflection quickly identified that not all of the patients spoke English as their first language; other people were perceived to have limited cognitive function.  I felt that although professional, by introducing oneself wouldn’t equally enable the same feelings of trust and engagement to all patients.  This can be communicated (in my experience) through considered use of body language.  De Rezende et al (2015) agreed, they observed nurses using body language to form a connection with patients, by using head movements, touch and eye contact patients were seen to respond positively.  

As a leader, I need to be able to distinguish what differences people have and use tools such as this observation alongside patient colleagues to ensure equality and diversity across services, Schultz and Baker (2017).

Conclusion   

I had assumed that I would see the majority of what the patient saw.  Ken stated that he had confidence in the nursing staff.  They were smart and were working cohesively as a team as identified by Wocial et al, (2014) which caused him to focus on the environment. 

 As a nurse, I focused on patient and staff interactions. It is likely that I have been conditioned to normalise clinical environments over 24 years.  Unconscious bias and potential for confirmation bias, can lead to care or an environment that patients find difficult to understand and use, Bucknor-Ferron and Zagaja (2016).  This realisation was uncomfortable and required more structured time for reflection before concluding the recommendation.

Recommendations  

A)    MIU team member to undertake a co-observation with a member of the public

B)    Compare the observation themes shared by this study

C)   Develop action plan

By recommending the service undertakes the exercise, I anticipate that the exposure to the patients’ comments are more likely to engage the team, releasing them to consider their approach and over-time enhance their work through self-motivation, rather than being told what the problems are and how to solve them Herzberg (1968).  This participatory approach leads to greater job satisfaction McGregor (1960).

I recognise that this study was not about realising my assumptions alone or identifying my leadership styles and bias, but further, acknowledging that I must manage and address the bias by utilising patient observation and experience to enhance service delivery.  Importantly, it was also an opportunity to empower the service to identify the changes needed for them.  

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