Care to mind your language? by Lewis McGregor

If you’ve got past the opening title and aren’t offended by my language then someone has edited this blog already. As an occupational therapist working in a short term assessment and reablement service (STARS) my interest is how people manage their daily activities and what we can do to work together to regain activities following a period of illness / admission or injury.

One of the biggest challenges of working in this field is preconceptions and pre-existing beliefs. There are those held by our client’s, their families, relatives, next of kin and in some cases friends and neighbours. We are not helped by ‘careless’ use of language. Contrary to common belief the reablement STARS team is not a “6 to 12 weeks” service, nor is it “staffed by carers there to help you get home”. This may seem to be semantics however; we are dedicated in our belief in the therapeutic benefits of co-creating outcomes during a period of Reablement. As such the importance of positively influencing at the very starting point of a conversation about introducing the concept of STARS to avoid deterioration, admission or to support discharge from hospital of using strength based language is critical.

Reablement is an assessment lead process co-creating client-led goals initially with allied health professionals, nursing staff, social work and support workers.  It is delivered within the client’s home.  The ‘Carers’ present are much needed family, friends and spouses however none of us are ‘care at home’ staff.  That is a different service, different skill set and much needed resource that STARS on occasion work in partnership with to find safe longer term solutions when clients cannot regain skills to live safely and independently at home.  The reason this matters is to do with the right time, the right place, the right support and ensuring we are enablers of confidence, choice, control and independence.

So as potential colleague referring to STARS how does your language effect a client’s future?

In the 7 years that I’ve worked for STARS my colleagues and I have had many unnecessarily difficult chats with client’s and families ranging from why ‘6 weeks’ might not be provided (needed) to empathetically listening to disappointment that ‘care at home’ is not being provided (yet or perhaps ever).  Whilst courage to participate (sometimes in pain), motivation to identify ‘what matters to me’ and an assertion by the team that they believe, even when the client might not, in enabling each individual to reclaim their belief in their innate ability to achieve their goals again is the expectation.  Mentioning ‘6 weeks’ and ‘care’ leads to degrees of understandable expectation – normally about 6 weeks worth… which slows down the momentum of reactivating ability, success and accomplishment.

Please don’t take this the wrong way as it sounds contradictory.  STARS ‘cares’ (about you) and will deliver ‘hands on care’ where it is absolutely required, to assist in discharges from hospital, or when awaiting a registered provider of care to prevent hospital pressures/delays or indeed to assist our district nursing colleagues and Marie Curie in palliative care where staffing demands arise and to ensure the client gets home if that is the wish.  Of course we will… as anyone in health and social care would do that’s why we do these roles… because we care ‘about you and each other’.

However let’s start caring about our custom and practice use of ‘care’ language and its impact on client’s capabilities, families’ expectations/fears, colleague’s skills and our ability to create positive outcomes whilst reducing work pressure through sustained whole system flow.

This concept isn’t unique to reablement, occupational therapy or indeed health and social care.  It lays within all our psychology (Bandura, 1997) and the definition of self-efficacy (one’s belief in one’s ability to succeed in specific situations or accomplish tasks).  According to Bandura self-efficacy relies on 4 belief sources; mastering experience, vicarious experience (another person’s experience), verbal persuasion and emotional & psychological states. So language can strengthen or rob us of our belief in our capabilities to master problems when they arise – such as regain independent living skills – or not.

There is a suggestion of a 5^th belief source; that of imaginal experiences (Maddux, 2005) where clients are supported to begin the journey with the art of visualising success.  Lets use language that ‘cares’ about encouraging that imaginal success, that leads to client’s open minds and optimism despite a bad or painful health and well-being experience.  Let’s when looking to a period of reablement in STARS care to mind our language so it is always optimistic about performance and participation.  Let’s care to mind our language to strengthen client’s emotions to courageously face a challenging period of working together to reclaim independent living and well-being.

Lewis McGregor is a Specialist Therapist in Reablement for the STARS team at NHS Dumfries and Galloway

 

Innovation through Compassion by Ken Donaldson

Last week Jeff Ace introduced us to SAM, the Sustainability and Modernisation Programme, that NHS D&G are launching to address the complex and challenging landscape that faces the NHS today; increasing demand, reducing workforce and financial constraint. We started touring the region this week, meeting with teams to discuss these issues and ask them for their thoughts and ideas. It has been energising to hear from you all, there are lots of really good and simple ideas as to how we can change, but it is also apparent that there are many significant obstacles that it will take time to overcome. 

Lets be honest, working in healthcare today is really tough. We all know ‘winter is coming’  when in reality it never went away. Our recruitment challenges extend well beyond medics now with difficulty filling nursing, AHP and other professional posts. Beds are blocked, shifts cant be filled, and so on. What do we do? 

The following is a quote from a Kings Fund paper titled “Caring to Change’. 

“Only innovation can enable modern health care organisations and systems to meet the radically changing needs and expectations of the communities they serve. While adequate financial support is a necessary precondition, it is clear that more money on its own, without transformative change, will not be enough.”

Two words stick out to me, Innovation and Transformation. Both are necessary, both are hard, especially when we are busy, but both can be fun if we work together and support each other to deliver them. Done well they can make our lives less busy and our patients care safer and more person centred. But how can we achieve this? I know many people reading this will be thinking ‘Well, fill all our vacant posts and that will solve the problem’ and they may be right, but we know that is not easy and, whilst we cannot take our eye off the recruitment challenge, we need to do something else. 

There is a growing body of evidence showing that a different form of leadership can achieve cultural change and provide the environment that can lead to innovation and transformation. This leadership focuses on compassion. By compassion I don’t just mean Kindness and being nicer to each other (although I will come back to that at the end). So what do I mean?

Compassion can be understood as having four components: attending, understanding, empathising and helping.

Attending

If I am going to lead with compassion then first I must be present with you, pay attention, I have to Listen with Fascination. This may sound obvious but is not as easy or common as it may sound. Too often people listen with minimal interest. They clearly are waiting for the talker to stop so they can get their point across. Listening with fascination means giving your all to the person you are attending. Really hearing what they are saying so that you can fully understand their point of view. 

Understanding

If we truly listen to others then we can start to understand their point of view, what is causing this persons distress, angst or worry? It is only by fully understanding that you can apply the third aspect; empathy. 

Empathy

I have heard several people say that it is impossible to truly empathise, how can we feel what others feel when they are a complex mix of experiences and values that differ from our own. This may be true but if we listen and understand their problem then, at some emotional level, we can feel their distress and share their feelings. Then we will be driven to the fourth aspect, the motivation to help. 

Helping

Wishing to help doesn’t have to mean ‘give me your problem and I will sort it’ but thoughtful and intelligent action to address the individual or teams issues. More  ‘what can I do to support you, what do you need or who do you need to talk to to solve this problem?’ Providing reassurance that different ways of working, innovation & transformation, are welcome and will not be criticised and blocked or, if things don’t work, there will be no accusation or blame. 

To create a compassionate culture, one in which we can thrive and transform our services, then we all need to demonstrate these simple behaviours. I urge you to ‘Hold the Mirror up’ to yourself and consider your behaviours not others. What can you do to improve your service, not what others can do to improve theirs. 

Every interaction, every day, shapes our culture. The ‘leaders’, and by that I don’t just mean ‘management’ but all in senior positions, have a particularly powerful role in this. What they say, pay attention to, monitor and reward communicates what is valued by our organisation. As leaders if we pay attention to our teams, listen, understand,  empathise and seek to help then we are a step closer to the high performing, innovative and transformative teams that we need to get us through the difficult times. 

To quote Michael West, a founder of Compassionate Leadership….

“Virtually all NHS staff are committed to providing high quality and compassionate care. They represent probably the most motivated and skilled workforce in the whole of industry. However, we impose on them a dominant command and control style that has the effect of silencing their voices, suppressing their ideas for new and better ways of delivering patient care and suffocating their intrinsic motivation and fundamental altruism. Released, their motivation and creativity will ensure commitment to purpose and performance. 

Compassionate leadership means creating the conditions – through consistently listening, understanding, empathising and helping – to make it possible to have tough performance management and tough conversations when needed. Staff complain they only see their leaders when something goes wrong and that even if they do listen, nothing changes after the conversation. Compassionate leadership ensures a collective focus and a greater likelihood of collective responsibility for ensuring high-quality care.”

There is a lot more to Compassionate Leadership. Figures 1 and 2 demonstrate some of this which I will explore in a future blog. If you wish to find out more of this yourself you can listen to a presentation from Michael West here or read the Kings Fund paper ‘Caring to Change’ here. 

Just before I finish I would like to return to Kindness, which I mentioned earlier. Whilst Compassionate Leadership has many facets and some different ways of thinking, Kindness is at its core. If we are going to survive the next few years then we need to transform and adapt but we must not forget to be kind to each other. In the NHS we often discuss Kindness to patients but rarely do we discuss Kindness as a leadership behaviour. I am not saying that any of this is easy and I am certainly not saying that I have demonstrated Compassionate Leadership over the years, far from it. I am however willing to put my money where my mouth is and practice this way from now on. I would ask you all to do likewise.

Ken Donaldson is the Board Medical Director at NHS Dumfries and Galloway

Staying at Number 1 by Jeff Ace

Each of us will probably always remember where we were on Saturday 10^th August 2019 when Wales became the number one ranked rugby team in the world. Sadly, on Sunday 11^th, the technicalities of a loss (in a meaningless friendly that nobody at all cared about) meant that we lost this iconic status. We were heroes, but just for one day.

NHS Scotland does not use league tables as universally recognised as the IRB rugby rankings. Probably the closest thing we have is the analysis on the NHS Performs website NHS Performs | Home . Here you can see how NHS D&G performs against some of the major national targets and how this performance compares to the Scottish average. The tables make very good reading from our perspective and we should all take great pride in our performance. Behind all these statistics are real people and families who are receiving safer and faster treatment in D&G than in many other parts of the UK.

Given all of this, I should be sleeping better than I am and dreaming contented dreams of Welsh sporting triumphs. But the truth is, I’ve been pretty worried about our ability to keep on performing so successfully given the pressures we’re facing regarding workforce, rising demand and limited money. I could add Brexit to the list of course but that probably needs a blog of its own which, If Ken insisted on redacting all the swearing, would be a pretty quick read.

You’ll have heard it all before of course. Interviews for new Chief Executives largely consist of exercises proving that you have a sufficiently pessimistic outlook to take up post. We are renowned for prophesies of imminent doom and at our monthly meetings in Edinburgh can create such a singularity of gloom that no light escapes.

The Patron Saint of CEOs is a Doonhamer

 But, and I appreciate you need to trust me a bit here, this is different. Across the health and care system we’ve identified over 70 key posts to which we’re struggling to recruit. We started this year with a gap between our funding and our projected costs of over £21M and, even after a thorough and very difficult cost reduction exercise, still have a projected gap of around £8M after the first quarter of the year. Meanwhile our primary care workload, our A&E attendances and our hospital admissions continue to rise as our population ages. Add to that our requirement to make sweeping reductions in CO2 emissions (and to become carbon neutral in a couple of decades) which will necessitate radical change to our health and care model. These are not run of the mill problems and they are not going away. I think we now run a real risk of struggling to maintain the levels and quality of service that our population deserves.

This just isn’t an option for us. So the gloom has to stop and we have to change the future. 

I’ve been CEO here for over seven years now and have been absolutely astonished at what we’ve been able to achieve in terms of patient safety improvements and successful delivery of huge infrastructure projects. I simply refuse to accept that we can’t transform our current situation with equal success. If I’m wrong, well, we’ll still have much more fun trying to improve things than gloomily managing their decline.

So we’re creating a project structure to have a real go at putting things on an even keel again (it’s modelled on the project that delivered the new DGRI in 2017). NHS CEOs are required by law to use acronyms wherever possible so we’ve called it ‘SAM’, standing for Sustainability And Modernisation. You’re going to be hearing a lot about SAM. 

SAM!

(the graphics will improve, honestly. My suggestion for a Welsh fireman fell foul of copyright)

Whilst we’ve stolen some features from the financial recovery programmes already running in various parts of the UK, SAM has to be ours; it has to address what you see as the real problems and fix them in a way that’s right for NHS D&G. I don’t want us to shy away from the money problem (if SAM doesn’t reduce our costs it has failed), but I also want to raise the bar so that we make changes that improve our patient experience, make our working lives more enjoyable and make the delivery of health and care greener, with a lower carbon footprint. These aren’t optional extras of redesign, they are essentials if we’re to make change that will last, and that will give us reason for continued pride in our services.

We’re launching SAM next week and are going to try to talk face to face with as many of you as possible. We need you to tell us how to shape the programmes and work with us on the redesigns because nobody knows the services better than you. In the great lesson from Brexit, this time we’re going to listen to the experts. 

We need to make sure the changes work across health and social care so the tour will be a double act between me and the IJB Chief Officer, Julie White. 

I appreciate not everyone will be able to come to one of the sessions below so we’ll re-run the tour in the autumn. We’ll also film one of the events and post it on Beacon so that if first time round you miss SAM you can … play it again.

I look forward to seeing and talking to as many of you as possible over the next couple of weeks.

SAM Director Tour

19 – 27^th August 2019

Jeff Ace is the Chief Executive Officer for NHS Dumfries and Galloway

Think what not to say! #TWNTS by Jane Clark

Think about the last time you were talking to new colleagues or friend over lunch.  How did the conversation go? I bet the chances are a couple of questions were asked.  Do you have a partner? Are you married? Do you have children? How many? You have been married for how long, do you not want kids? These questions map out the socially expected journey of adulthood. Why do we feel we need to ask these questions? For some people these are very difficult questions often loaded with pressure, expected life goals that many won’t, don’t or can’t meet.  Questions that can cause anxiety, heartache, pain, sadness and tears.

Becoming pregnant and having a child seems so easy for so many people…we all know someone that has fallen pregnant after trying for a whole month or by accident!!! The reality for 1 in 6 couples trying to conceive is much more challenging.  It’s a journey that can take years.  Years of stress, heartache and grief.  The realisation that your dream to become a parent may never come true.

Causes

Fertility issues can be caused by a whole range of factors.  Gynecological issues such as PCOS & fibroids, low sperm count or sperm abnormalities, hormone imbalances, previous infections or STD’s, previous surgery or trauma to the reproductive organs as well as a consequence of medication.  Then there is “unexplained infertility”.  This is where no actual cause has been identified.  This can be frustrating for many couples because there isn’t actually anything to treat or a physical problem to direct treatment to.  It is just unlucky, but I like to think of it as the doctors just aren’t clever enough to figure me out!!!!

Then there are the social issues.  Some people don’t meet the right person to start a family with or when they do it’s later in life.  Some want to be financially secure before starting their family.  Some people do not want children, and some are childless by choice.

For those that are struggling to conceive luckily there are options to help.  None of these are guaranteed to work.  The most common one that you have heard about if likely to be IVF but there are less invasive options such as lifestyle changes, drug therapy and IUI.  In Scotland we are lucky that the NHS provides the gold standard fertility treatment, following the recommendations set out within the NICE guidelines.  After meeting the eligibility criteria, up to 3 funded IVF cycles can be provided to a couple. Elsewhere in the UK, this is much less or in some instances not provided at all.

The Emotional Toll                       

The emotional impact of fertility problems is frequently underestimated.  There is often a monthly cycle of hope, anticipation and dreaming followed by heartache and tears when your period arrives on time.  It’s not just the ladies in the relationship that feel this…It’s the men too.  After all they are 50% of this equation.  Plus, they are often on the receiving end and bear the brunt of our hormones too… sorry guys.  This monthly cycle can put a strain on even the strongest couples.  As the month’s and years pass this cycle becomes harder and where there was once excitement and optimism, doubt and worry creeps in.

Then there is the financial toll.  IVF is an expensive business if you have to fund it yourself.  A cycle costs upwards of £6000, with no guarantee of a successful outcome.

Work Life Balance

If you end up needing fertility treatment, this is done at a fertility clinic often outside your local hospital.  It involves numerous appointments, procedures (some involving sedation) and medications.  Some of these appointments are at very short notice, meaning that’s it’s often difficult to juggle both work and treatment.  Support from your workplace and flexibility in your working hours is often required.

Disclosing that you need fertility treatment is often difficult and many people go through treatment without telling anyone.  For this reason, it would be helpful if all employers had a fertility policy in place which both employees and their line managers could access easily. Currently, there is no mention of fertility treatment within the NHS Attendance Management Policy. My experience was that I when I tried to find out what help I could get; I was directed to my line manager from HR.  Not overly helpful if you’re not ready to disclose your fertility struggles!! The Fertility Network UK currently is campaigning for ALL workplaces to be have a fertility policy in place.

https://fertilitynetworkuk.org/trying-to-conceive/fertility-at-work/

By having a policy in place this would provide knowledge, reassurance and support to help both couples and their managers gain the information they require without having to initially disclose their treatment. It would also raise awareness of the physical, emotional and financial stress that fertility treatment can have on a person and would support workplaces and line managers to make accommodations to support their employees.  Considering the financial cost of IVF or other fertility treatments (which is often NHS funded) does it not make sense that the NHS supports its own employees through this journey?  My gut instinct is that this would save the NHS money in the long run.

#TWNTS

I am rambling so, going back to the start, when you are having those conversations and asking people if they are pregnant or have kids, please be mindful and consider the pain that those questions might cause.  That person may not ever be able to carry a child. They may have suffered a miscarriage or stillbirth.  They may be waiting for or undergoing investigations.  They may have just had a failed treatment cycle. They may disclose their story to you, but the chances are they won’t.

We are all human and it’s easy to make comments and not realise how they come across, we have all done it.   Here are a few examples of things not to say (especially to a hormonal lady on IVF meds).  These are examples of things people have said to me or my husband during our fertility struggles.

“Just relax and you will get pregnant”

“Are you doing it right?”

“Are you firing blanks?”

“Your better off without kids”

“IVF will get you pregnant 1^st time”

“So, you’re a career girl then”

@thisisalicerose has started a powerful, funny awareness campaign around this issue.  The following two short links from her Instagram show examples of things what not to say. One of these videos focuses on professionals.  Please have a watch, they only last a couple of minutes and certainly give food for thought.

https://www.instagram.com/p/BvQ0szWh0FM/?igshid=1gctzpfjjx9o1

https://www.instagram.com/p/BpEyWCWgcKy/?igshid=rhybzeeelrme

So what do I say?

If someone does disclose anything to you, please pause and think about what you say next.

Often all that is needed is to say, “I am here for you”, “I’m sorry your having a difficult time, can I do anything to make it easier for you?” “Would you like to talk”

And Finally

This is just my experience. I have written this out of some of the frustrations I have found along my journey to becoming a parent. This path is my life, it’s not how I would have choose it, but I am not ashamed of it.  It has given me opportunities, opened doors and allowed me to make new friends along the way, without which I would never have got. Its even allowed me to chat to royalty!!

Thinking about what not to say, is pertinent to EVERY ONE OF US, not just in this situation, but in our day to day lives, be it with our family, friends, colleagues or patients.  Just be mindful of who is in the room, you don’t know everyone’s story and to anyone in my shoes, GOOD LUCK.

Jane Clark is a Charge Nurse in Critical Care at NHS Dumfries and Galloway

Labours of Love by Ren Forteath

‘Labours of Love’ is a brand new musical celebrating the midwife-woman relationship and also the work of SANDS. Set in a fictional maternity unit, it follows the stories of five women with very different backgrounds as they become mothers, and also the staff who work in the unit.

The musical features songs from several genres including pop, gospel and ballad. There are comic songs and love songs, joyous celebrations of new life and moving laments as two of the characters have difficult experiences.

‘Chrissie’ lost her first baby two years ago and is pregnant again. She had grief counselling from SANDS but is anxious about bonding with this new baby after her previous experience. By the end of the show she has given birth to Megan and found her happy ending.

‘Judy’ is a teenager who did not plan to be pregnant, or for her boyfriend to leave her, but with the support of her parents she is facing the future with hope. Boyfriend Marco returns several months later and begs for another chance, so Judy thinks everything will be fine. However, in Act 2, tragedy strikes when she goes into labour prematurely and is rushed to hospital. The baby is born but there are further complications as Judy begins to haemorrhage and the doctors have to work quickly both to save her and to resuscitate the baby, described in the frenetic song “When the Buzzer Goes”. By the song’s end the bleeding has been stopped but tragically, the baby has not survived. There follows a heartbreaking scene as Judy and Marco begin to come to terms with their loss.

The other Mums to be are Annie and Frieda, both first timers who have very different experiences of labour, and Rachel, an old hand who has a serene water birth with partner Michael during the title song ‘Labour of Love’.

The other central storylines feature the staff of the maternity unit. Student midwife Ruth is in the final year of her studies.  She is deeply affected by Judy’s experience, but is supported by her mentor Alice to reflect and learn from it. Her dialogue in the final scene highlights the passion midwives feel for their work and the dedication they give to their patients. The final song is an uplifting celebration of midwifery and the with-woman relationship.

The show is to be part funded by an Iolanthe foundation grant of £1500; the Elizabeth Duff Award. ‘Labours of Love’ is to be shown at Dumfries Baptist Church Centre from Wednesday 9th to Saturday 12^th October 2019. The show will fundraise for the work of SANDS, who have allowed their name to be used in Judy and Chrissie’s stories to highlight the valuable work they do. SANDS will also have a stall in the foyer to provide information on their support services for any audience members affected by the show’s content.

Ren Forteath is a Midwife in the Women and Childrens Directorate of NHS Dumfries and Galloway