‘Rays of Humanity’ by Ewan Kelly

‘The glimpses, the rays of humanity that I received in the hardest of times ….kept me going.’

 Life working in the health service, whatever our role in clinics, wards, offices, corridors and health centres is far from easy in the twenty-first century – sometimes its downright challenging, even hellish.  So what keeps us going back for more each day? (apart from the need to pay the mortgage and feed our families!) A question I’ve often considered not just personally, but as a healthcare chaplain with colleagues I’ve supported over the years. More than that, I am now in a strategic role which involves promotion of wellbeing for staff as well as patients and carers across NHS Scotland.

There are lots of aspects of our lives and our work which may help keep us motivated and feeling fulfilled in our roles in the health service. What are they? What gets you up in the morning to go to work even when things are tough?

As a young greenhorn healthcare chaplain in my late twenties during my first month working in a large acute hospital in Glasgow, I was invited by an occupational therapist and a physio to come for a coffee to meet some of the folks they were working with who were adjusting to lower limb amputation. In the rehab gym I joined a bunch of ten or twelve folks who had paused from their physio for a coffee and a blether.  The idea behind the invitation was that I might provide some support during a period of loss, transition and adjustment in patients’ lives. Everyone who had gathered for coffee was invited to introduce themselves as the biscuit tin went round.  ‘Hello, I said, ‘I’m Ewan, I’m one of the chaplains who works in the hospital. I’m here to…’ Before I could say any more a wee fella in a wheel chair interjected, ‘Is that like a minister or a priest son…..do you do services on a Sunday. I’m not really intae that guff.’  ‘ Well yes, ‘ I replied, ‘ that’s part of what I do but most of my job is to be around and listen to people as they make adjustments and deal with changes in their lives.’  But my new acquaintance  was persistent. ‘Ach yon religious stuff causes more problems that its worth all that Proddie and Catholic stuff. Look at the trouble in Belfast.’  ‘Well’,  I retorted rather pompously ‘ the short services we have here on a Sunday morning are for everyone who wants to come….it doesn’t matter which fit ye kick with.’ ‘Oh aye,’ said my conversation partner with a twinkle in his eye looking down at where his two legs should have been, ’that’s no much guid to me is it now son!’

I wished the ground could have opened up there and then and swallowed me up. However, everyone else, including my double above knee amputee friend, was roaring and laughing. I was  bright red with embarrassment   but the ice was broken. I was no longer a rookie chaplain, a minster or a priest, I was human …..like everyone else. Numerous coffees and conversations, as well as fun,  followed in subsequent months in the  rehab gym

The courage, the humour, the banter, the human interaction even when life is tough  and a struggle ….observing  that, sharing in that, remembering that  and being inspired by that is one of the reasons I get up on a cold January morning to go to  work in the health service.

Michael  Wilson, a psychiatrist and healthcare chaplain,  in the early ‘70s wrote a book called  ‘Hospital  – a place of truth.’  His basic premise was that hospitals or healthcare is a place where we learn not just how to care but how to be human. Patients, carers and our colleagues can be our teachers and they are often a source of inspiration and motivation.

However, what is it that that patients and carers receive in return from us as members of staff who share our humanity as well as our professional expertise and technical proficiency in our daily work? 

Two weeks ago I had the privilege of participating in the Scottish Conference of Cancer Support Groups at the Beardmore Conference centre in Clydebank.  I was exploring with the volunteers from cancer support groups from all over Scotland  what  the motivating factors were which prompted them to help others living with cancer.  One woman spoke up in the gathering of over a hundred  people.

’ The medical and surgical care I received during my cancer journey could not have been better. It was fantastic but it was the glimpses, the rays of humanity that I received in the hardest of times that kept me going. That is why I have volunteered to help support others.’

Patient experience (human interaction) as well as clinical effectivess and safety together impact on the personal outcomes of patients.  (Doyle et al 2013) http://bmjopen.bmj.com/content/3/1/e001570.abstract

And …..meaningful human interaction as healthcare staff enhances our  wellbeing too.

Ewan Kelly is a former Medical Doctor and is now Programme Director for Healthcare Chaplaincy and Spiritual Care at NHS Education for Scotland

Enhanced Patient Experience by @kendonaldson & @peterbryden1

In the past three weeks I have had two very uncomfortable meetings with family members of patients who have died in Dumfries and Galloway Royal Infirmary. Both were daughters who had submitted complaints about the ‘lack of care’ delivered to their loved one in the last few weeks of their lives. These meetings were difficult for all involved as both daughters were clearly grieving and emotions ran high. In both cases what lacked were clear and timely communication, empathy and understanding. Regardless of what may have been going on “behind the scenes”, this was what was played out to the family and as a result their memories of the last few days and hours of their loved ones will be tarnished forever.

It was as a result of a similar experience that I was personally involved in some years ago that started me on the journey that would result in ‘Enhanced Patient Experience.’ I was very fortunate to be able to discuss these issues with some close friends and we came up with the idea of running one day work-shops where we raise these issues, discuss possible solutions, use improvement methodology to put them in place and, hopefully, make a difference.

In Dumfries Peter Bryden picked up the baton and organised our first day in November of last year. It was quite a small affair with 37 participants in 7 teams from primary and secondary care but feedback, both verbal and written, was overwhelmingly positive so we planned more events. A second, in March of this year, was cancelled due to heavy snow and the focus shifted to September 2013.

Around this time Jean Robson, Director of Education, saw Professor Jason Leitch deliver a talk on Person Centred Care and was inspired. Jean was keen to invite Jason to D&G to give the same talk and we wondered whether we could tie the two together. It would, however, be a waste to bring someone of Jason’s talents all the way to Dumfries to talk to 37 people so we had to think big. Peters advertising campaign kicked into gear and before we knew it we had 30 teams with over 200 participants and we had shifted to Easterbrook Hall.

On Friday September the 6^th we ran our second event which, in Twitter speak, would be known as #DGEPE2. Jason had been joined by Professor Craig White, Assistant Director at NHS Ayrshire and Arran, to deliver a morning of patient experience, person centred care and improvement methodology. The main outcome of the morning session was a driver diagram detailing an improvement plan for each team to take back to their workplace. Each team had a facilitator who would guide them through this process and also follow up their work.

The afternoon saw the return of Ewan Kelly, Programme Director for Healthcare Chaplaincy and Spiritual Care at NHS Education for Scotland, who had spoken at our inaugural event. Ewan was preceded by the powerful clip on youtube from the Cleveland Clinic. If you have yet to see this it can be viewed here. Ewan introduced us to the concept of Values Based Reflective Practice (VBRP). This is a process where a team will discuss a case in a structured and protected fashion. It is important that there is strong facilitation and team members feel ‘safe’. One person relates the story or case and then is asked questions, which are framed “I notice…….and I wonder” to ensure no direct blame is apportioned. VBRP is a very powerful tool and the objective here is to take the concept away and use it as groups in individual departments and also in day to day practice by asking “Whose needs are being met?”

We ended the day with a question and answer session involving all 3 keynote speakers and Jeff Ace, Chief Executive Officer and Andrew Johnston, Chairman of the board. This proved to be a lively and interesting session which, amongst other things, proved that our Board and CEO are very supportive of the Enhanced Patient Experience’ project.

So what did the attendee’s tell us about the event? We have been through the feedback and once again it is overwhelmingly positive and constructive. We are very grateful to all who took the time to complete the feedback which will we will use to plan our future events. The negative aspects mainly reflect that the Hall was too cold and audio-visual left a little to be desired which we have fed back to the venue… nothing has been decided but, in future, we intend to aim towards several smaller sessions 2 or 3 times a year with a large 200+ event every 2 years.

Are we making a difference? This is harder to answer and I suspect it is too early to say. What will tell us we are succeeding? Again hard to answer however, of all the great work undertaken by the Scottish Patient Safety Programme there is one small thing which never fails to impress me. 10 years ago I was not the best hand washer! I was not alone in this in the medical profession. Once or twice a ward round I would stop by a sink and quickly rinse….if you were lucky. Nowadays I am rubbing alcohol gel on constantly – as I enter ward, as I leave it, after every patient encounter and sometimes for no reason at all – I just haven’t done it for a while. Its second nature. And I know if I don’t do it a medical student or healthcare assistant will quite happily say “Dr Donaldson, you haven’t washed your hands.” One day I would like it if kindness, caring and compassion for our patients was equally as second nature. Even during a bad day we were able to reflect on their predicament and suffering and be kind. So if a healthcare assistant turns to me one day and says “Dr Donaldson, I didn’t like the way you spoke to that patient. I think you should go back and apologise” then I’ll know we are getting somewhere.

Enhanced Patient Experience will return……

Ken Donaldson is a Consultant Physician and Peter Bryden is Patient Experience & Safety Facilitator within the Acute Services Directorate, DGRI

 

The Listening Project by @fionacgreen

I was gutted when I read Professor Leitch’s blog – the idea of asking people “what matters to you?” was exactly what I planned for my Blog. I now had to convey my own pathway into this area in such a persuasive way

PRECONTEMPLATION

My journey (unlike Professor Leitch’s) did not begin in a formal Quality Improvement class with international experts in the USA but began in a more slow burning fashion right here in Dumfries and Galloway.

I arrived in Dumfries in the spring of 2004 –a newly trained consultant. My head was full of evidence-based treatments and guidelines combined with naivety and a genuine enthusiasm to improve diabetes care.

At that time empowerment, self-management and structured education were emerging as factors to improve outcomes in people with diabetes and other long-term conditions. Shortly after my appointment we were fortunate enough to be given funding from the Scottish Diabetes Group to pilot DAFNE. For those of you unfamiliar with the diabetes world DAFNE is not a person but stands for Dose Adjustment For Normal Eating and is an evidence based weeklong structured educated programme for people with type1 diabetes. Structured education means that there is a defined curriculum delivered using adult education theory and delivered by trained and peer-reviewed educators.

6-8 people with diabetes participate in each course and bring with them years of experience of diabetes – on a recent course within the room we had amassed 254 years of experience of diabetes

CONTEMPLATION

DAFNE didn’t just empower, educate and motivate those individuals with diabetes who attended but also provided our local diabetes team (myself in particular) a unique insight in what it was really like to live with diabetes. I listened with interest and a growing sense of shame as people with diabetes described their experiences of diabetes in hospital , the sense of foreboding they felt when they attended clinics – they felt chastised, felt failures and felt that they were not always listened to. They told us how seeing high blood sugars despite trying to balance food, exercise and insulin was frustrating and many said that they simply didn’t bother to test as the results made them anxious.

I listened and I learned and I reflected.

I learnt that our interactions with people were often more powerful than we realised but not always in the ways we hoped. I realised that we were often ineffective in promoting improvements in diabetes self-management.

I reflected on my own training -despite my knowledge of trials and guidelines I had little training in consultation technique and promoting behaviour change.

Somewhat shamefully over the years I had become very skilled at moving people away from topics that were important to them to focus on the topic of blood sugar which was what was important to me.

DECISION

I realised if we were to achieve continued engagement of our newly educated and empowered cohort of DAFNE graduates that this traditional medical model of diabetes clinics had to change

Alongside this realisation we became involved with our local psychology department who took on the task of teaching us the theory of behaviour change and demonstrating the use of motivational interviewing, Socratic questioning, functional analysis and other tools to help change unhelpful health behaviours. This training was further complimented and developed by the “Doing Diabetes Better” programme and PIDPAD (Psychology in Diabetes, Psychology and Diabetes) project funded by the Scottish Diabetes Group

The heart of the training was active listening and in particular listening to what was important to people.

Initially I struggled to use the tools- I worried about the time factor involved; I worried about opening up emotions that I was uncomfortable dealing with and it often seemed easier to stay in a traditional role but as I practiced more and began to see people with diabetes begin to successfully generate their own goals and solutions I knew that this was a way forward

LAPSE/RELAPSE

Behaviour change is difficult not just for people with diabetes but for all of us in all aspects of our lives and just like the people I see in clinic I have found that old habits die hard and I know that when I am tired, stressed or running late I don’t always listen as well as I should or apply the tools I have learnt as effectively as I should. In these circumstances I find myself slipping back into my comfort zone of focussing on blood sugars, targets and guidelines but through the increased self- awareness I recognise these factors and try to avoid dictating care plans

Finally I suppose it is important to know whether it has made a difference-I now have a better understanding of the reasons why people find it difficult to implement and sustain changes to improve health and wellbeing. I know that I now find clinics more tiring -exploring thoughts and feelings in relation to diabetes is emotionally exhausting but the things I hear and results I see encourage me to continue.

By changing from what from “what’s the matter?” to “what matters to you?” patient satisfaction scores have increased significantly as has HbA1c (a marker of blood sugar control)-both of these improvements matter to me.

Now when a consultation takes a diversion into areas unrelated to diabetes I stick with the diversion as I realise what I hear matters to us both

Dr Fiona Green is a Consultant Endocrinologist and Diabetologist at NHS Dumfries and Galloway

Next week we will have a joint blog from myself (@kendonaldson) and Peter Bryden (@peterbryden1) summarising the recent Enhanced Patient Experience Event.

An out-patient journey by Heather Currie

My father is 85, a “not-quite retired” farmer, with cardiovascular disease and arthritis. He lives alone and manages incredibly well, considering all, with family and neighbourly help.

A few years ago he complained of a small annoying lesion on the bridge of his nose. Not believing the opinion of his gynaecologist daughter (me!) or his then medical student grand-daughter that it was likely to be of no real clinical significance, he attended his GP and was referred to a dermatology clinic in a hospital 30 miles away. He can drive but struggles with negotiating hospital parking systems, corridors, finding clinics etc so was taken by a family member, to be told that yes, he did have a lesion and biopsy was to be arranged. It was deemed necessary to arrange the biopsy of said lesion (which was approximately 3mm in size), on another occasion. In due course, another family member was enlisted to accompany him, each of these visits took half a day from leaving home to return.

Biopsy completed without complication. That should be that, or should it?

Three months later, just before Christmas, father received an out-patient appointment, again at the dermatology clinic 30 miles away, for a review. He instantly thought that the biopsy result must be serious, that he had cancer, that he would require major facial surgery, or else why would he need to be seen? Despite my reassurances, he could not be convinced that it was unlikely to be serious and spent the next two months, over Christmas, worrying.

A family decision was made that because this was “so serious” it should be myself, the only medic in the family, who should take him to said appointment. I of course was happy to help, took a day of annual leave, cancelled clinics, did a 200 mile round trip in the snow to oblige.

We arrived early at father’s insistence, waited patiently and in he went. Out he came, 5 minutes later. “The biopsy was fine” said he with a smile. “That’s great” said I, but then “so why are we here?” I took the liberty of asking for the opportunity to pose this question to the consultant but no, how dare I ask to question the consultant. Instead I was allowed to have a discussion with the clinic sister. I politely explained the impact that this routine review appointment had had on my father, the family and indeed my own patients who’s appointments had to be cancelled, and enquired if the benign result could have been passed onto him by telephone, letter or through his GP. The response was disappointing, and yet not too surprising—“The consultant likes to bring all his patients back and has always done it this way. He would be concerned that results may be lost if patients were not brought back.”

My suggestion that a review of processing results rather than continuing to cause such worry and inconvenience to patients may be worthwhile was not welcomed!

 

Was this a good out-patient journey?

This did take place in the north of England, not in Dumfries and Galloway. We wouldn’t ever cause such unnecessary worry and inconvenience to a patient nor would we use NHS resources so wastefully—–would we??

Let’s always be aware of the impact, worry and inconvenience that we may cause by what may seem like a simple routine review appointment.

Dr Heather Currie is a Consultant Obstetrician and Gynaecologist at NHS D&G.