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Listening & Learning Hospitals Pilot Programme

Rapid Literature Review

Professor Brendan McCormack, Head of Nursing, Queen Margaret University, Edinburgh

Megan Dixon, Research Associate, Queen Margaret University, Edinburgh

Helen Riddell, Lecturer, Queen Margaret University, Edinburgh

Professor Jan Dewing, The Sue Pembrey Chair of Nursing, Queen Margaret University, Edinburgh

Project commissioned by the Dignity in Care Commission (Age UK, the Local Government Association (LGA) and the NHS Confederation) and funded by the

Burdett Trust for Nursing

Introduction and Background

The implementation group of the Dignity in Care Commission is focused on addressing prioritised recommendations arising from the Delivering Dignity report. One of these is the ‘Listening and Learning Hospitals Pilot Project’. The overarching objective of the project is to test out that listening; hearing, acting and learning on feedback from older people will lead to an improvement in the delivery of high quality person-centred care. The project aims to provide new insights into sector-led learning and understanding by improving skills in listening and learning from older people. The learning will give staff the skills and support to confidently translate the feedback into changes in practice and demonstrate measurable improvements within service delivery.

The project is being undertaken in two phases, with Phase 1 being a rapid literature review and model development. In this report we present the findings from the rapid literature review. Following consultation with the ‘Expert Advisory Group’, a model of listening and learning will be developed with older people and their care partners in the two pilot sites, that can be implemented in practice (Phase 2).

Methodology and Methods for Identifying and Evaluating the Literature

Therefore the purpose of the rapid review is to answer the following key question:

“What aspects of listening and learning work, in maintaining dignified care for older people and their care partners, for whom do they work, in what circumstances and why?”

Realist Synthesis Approach

The proposed review seeks to help nurses and other acute care staff to better listen; hear, act and learn on feedback from older people and subsequently improve in the delivery of high quality person-centred care. This review will examine ways of effectively listening and learning from older people and their care partners. The proposed review will pay particular attention to older people within the acute care setting. However, it is believed that what works in listening and learning from older people will also be effective in providing dignified care to all acutely ill adults.

Reflecting the emergence of more context-specific and naturalistic methods of evaluation research, the science of systematic review has evolved in recent years, and there is increasing recognition of alternative approaches to evidence synthesis in the academic literature (Mays et al. 2005). As outlined in the original proposal, the approach taken for the identification and evaluation drew upon ‘Realist Synthesis’ methodology. Given the time scale, a full realist synthesis was not possible. However, the review process was equally rigorous.

Realist synthesis (Pawson, 2006) was developed as a method of studying complex interventions in response to the perceived limitations of traditional systematic review methodology which, it is argued, follows a highly specified and intentionally inflexible methodology, with the aim of assuring high reliability. Realist synthesis views ‘context’ as critical to determining outcomes. In doing so, it

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steers away from failed ‘one-size-fits-all’ ways of responding to problems (Pawson 2006; Rycroft-Malone et al. 2012).

The realist synthesis approach to synthesising evidence focuses on providing explanations for why interventions may or may not work, in what contexts, how and in what circumstances. Rather than trying to answer the global question ‘are acute care services effective in listening and learning from patients in order to provide dignified care?’, a realist approach is concerned with understanding what it is about listening and learning approaches that work, for specific groups of people, when, why and how? The purpose of the current review is therefore to answer the following key question: “What aspects of listening and learning work, in maintaining dignified care for older people and their care partners, for whom do they work, in what circumstances and why?”

Overview of Specific Steps in the Review Process

The following steps indicate the specific process adopted by the research team in the completion of the current rapid review, highlighting how the process was guided by realist synthesis principles.

1. Identify the question: Based on the key question (above) the review team identified a series of ‘sub-questions’ that ultimately shaped the literature search strategies. These questions were identified through an exploratory scan of the literature to identify initial impressions and as a basis for brainstorming questions.

2. Clarify the purpose(s) of the review: Following the identification of the research questions to be addressed, the overall aim and purpose of the review was further clarified with the members of the Dignity in Care Commissioning Group.

3. Find and articulate the programme theories: As previously indicated, realist synthesis is informed by theory and the current review was ultimately driven by the key theoretical principles that underpin effective communication with older people and feedback from older people/care partners. The identified principles were used to shape the analysis of the literature and the findings from the review.

4. Search for the evidence: Initial search terms were framed from the principles and research questions developed in steps 1-3 and an extensive and systematic search was conducted to identify the relevant literature. All relevant databases were searched, such as - Applied Social Sciences Index and Abstracts (ASSIA); The Cochrane Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); ProQuest Central; Pubmed; Scopus. These databases were supplemented with searches of a number of relevant websites (Kings Fund, NHS). In addition, the research team already held comprehensive databases of literature that was relevant to this review. In order to manage the data, all the retrieved studies were entered into the bibliographic software package ‘RefWorks’ for ease of management.

5. Appraise the evidence: Data found in the searches were appraised using the review question and sub-questions as a guide. Two members of the project team screened each paper for relevance before inclusion and agreed key issues; themes etc. using derived principles and questions as a


framework for analysis. Following the initial screening, a second screen for relevance was conducted by a single reviewer who looked in more detail at the text.

6. Extract the results: A template was devised based on steps 1-3 from which the results of the evidence appraisal were inserted.

7. Synthesise findings: The data from all templates was reviewed and key findings extracted. Both confirmatory and contradictory findings were sought. Findings from different studies that address the key issues identified in the commissioning brief were compared and contrasted and present the evidence concerning the circumstances in which the various approaches to listening and learning can be considered effective.

8. Consultation on and refinement of findings: The findings will be presented for discussion with the commissioning group and with an ‘expert advisory group’ and refinements made as necessary before the final literature review is completed

Research Questions, Key Principles and Statement of the Ideal Model

As previously noted, the overall research questions to be addressed in this rapid review of literature is: “What aspects of listening and learning work, in maintaining dignified care for older people and their care partners, for whom do they work, in what circumstance and why?”

Research questions derived from standards and guidance

Following the extraction of relevant information from the numerous sources listed above, the research team collated, evaluated and summarised the key aspects with the aim of deriving a list of sub-questions to be addressed in the review. The following research questions were identified:

1. What is the nature and content of listening and learning?2. What circumstances help or hinder listening and learning from older people and their care

partners? 3. How effective are existing policy documents in promoting listening and learning?4. To what extent is listening and learning from older patients and their care partners evident

in practice?5. What effect do existing strategies have on service delivery?6. What evidence is there that nurses are adequately trained and supported to effectively

facilitate older people and their care partners to articulate their needs, opinions and experiences?

7. What is the nature and form of expected outcomes or impacts?

Key Principles

In accordance with the key principles that underpin the realist synthesis approach, this review is theory driven. Explicitly, the review evidence relating to listening and learning from patients and their care partners and developing effectiveness in this will be compared to current strategies and principles of good practice. Following the extraction of relevant data, the team summarised


information and the following principles which underpin effective communication and feedback from older people and their care providers were informed directly by these summaries.

Encouraging the establishment of relationships between patients, nurses and their care partners within the acute care setting results in person-centred care becoming an everyday cultural norm.

Active learning in clinical settings which focuses on raising awareness of the negative effects of ‘Institutional Ageism’ and encourages person-centred engagement can produce attitudinal and behavioural change towards nursing older people.

Continuous feedback from older people and their care partners, which is actively encouraged through a range of mechanisms, supports exploration of what important to them while in hospital and can inform individualised, person-centred care.

Flexible, creative nursing assessments, that are open to listening and constructing patient’s biographies, can ensure that individual’s stories are heard and absorbed into the clinical encounter.

Background and Methods

Background and context

The prioritisation of developing solutions to failures in the care of older people and to address poor practice has been emphasised within the Delivering Dignity (NHS Confederation, the Local Government Association and Age UK 2012) report. From this report 37 recommendations were produced that, if successfully implemented in practice, have the potential to significantly improve the quality of care and experience that older people receive. The Dignity in Care Commission has formed an implementation group named the ‘Listening and Learning Hospitals Pilot Project’ to test out that listening; hearing, acting and learning on feedback from older people will lead to an improvement in the delivery of high quality person-centred care.

Research Approach

The approach taken for the review of literature was a realist approach (Pawson 2006). While this review of the literature was rapid the process included the features of a full systematic review in the identification, critical appraisal, selection, and data extraction procedures implemented in order to ensure rigour.

Research parameters

The limited time scale of the project and the large body of research literature meant the scope of the review had to be limited in the following ways:

1. The research was specifically focused on the acute ward setting2. Studies which focused on patients with dementia were excluded3. A flexible search strategy using free text terms was developed which employed a limited

rather than exhaustive range of search terms 4. The search for grey literature included searches of key websites


Search Strategy

The focus of this research was to identify literature on best practice models in listening and learning from older people and their families and ways of developing effectiveness in this. Within this discussion of the literature on listening, the focus is primarily upon discussion of listening in relation to acute care generally and in relation to the care of older people in particular. It is also primarily based upon the UK context, although it does not exclude international literature, which may be of universal significance. Material that was published around topics that were of marginal interest to the current research questions was excluded.

An extensive and systematic search was conducted to identify the relevant literature. Searches were conducted using electronic databases.

Applied Social Sciences Index and Abstracts (ASSIA) ABI/INFORM Complete The Cochrane Library Communication and Mass Media Complete (CMMC) Cumulative Index to Nursing and Allied Health Literature (CINAHL) Educational Resources Information Center (ERIC) Kings Fund Database Linguistics and Language Behaviour Abstracts (LLBA) NHS e-library ProQuest Central Pubmed Scopus

Additionally, reference lists of identified studies were scanned and free text searches were carried out to identify evidence.

Reflecting the different databases search, a variety of search terms were used reflecting the different types of papers. A variety of permutations and combinations of the following search terms were used:

listening, active listening, compassionate listening, communication, interpersonal communication, engagement, dignity, person-centredness, person-centred care, person-centred practice, person-centred nursing, personhood, relational, interpersonal, nurse-patient interaction, nurse-patient communication, nurse-patient, nurse-patient relation, older people, gerontology, gerontological nursing, elderly, older adults, older person, aged care, acute care, carers, feedback.

Additional searches were conducted using the following keywords to identify sub-topics: narratives, biography, communication barriers, ageism, therapeutic relationship, patient experience, nurses attitudes.

In order to manage the data, all the retrieved studies were entered into the bibliographic software package ‘RefWorks’ for ease of management.


Inclusion criteria

Due to the nature of the nursing literature regarding listening to patients, the inclusion criteria was wide ranging. Inclusion criteria:

Focus on adults aged 65 years or older Acute care setting Published in the English language Conducted in a developed world country Investigate or discuss the effectiveness of different approaches to listening and learning

from older people and their care partners or factors which may affect this engagement

Due to time limitations a cut-off date for searching was established. Located papers were screened for relevance before inclusion.

Presentation of Findings

The findings of this literature review were broad-based, exploring numerous features of the nurse-patient relationship and contextual factors that can affect listening and learning from older patients and their care partners. The findings are presented within the four principles which were derived from the initial exploratory scan of literature.

Limitations of this review

As with any research, there are limitations to this review. The report aims to present an overview of the key messages emerging from national and international evidence on the effectiveness of listening and learning on feedback from older people within the acute care setting. Given the scope of this task and the rapid nature of the review, the most appropriate research approach to synthesise the literature was using a realist synthesis approach. The aim of realist synthesis is to provide an explanation to enable informed choices to be made in future practice, as opposed to providing a judgement. It is evidence informed rather than evidence based as decision making in practice is not always research-based, but rather takes in account a range of factors in addition to empirical evidence. Therefore, it is the intention of the research team to provide logic of enquiry. In summary, the data presented in this review are only a partial answer to the ‘what works’ question with respect to listening and learning on feedback to provide person-centred care.


Literature Review

Introduction

The vague, ambiguous and difficult-to-measure nature of dignity is identified as being key to debates of dignity in healthcare (Griffin-Heslin 2005), the relevance of staff behaviour to dignified care is underlined, as is the need for individual approaches if dignified care is to be achieved (Tadd et al. 2011). The need to strengthen the delivery of dignified care in UK health and social care services, in particular to older patients within acute care, is consistently identified as a high priority by policymakers (Department of Health 2014). Listening to patients is seen as essential to the provision of individualised, person-centred care that promotes patient dignity. However, from the research teams initial scan of literature it was evident that there is a gap in this area in caring and nursing literature. While there is literature that highlights the significance of listening, little is written about how to develop effectiveness in listening to patients or how these conversations can be used to inform practice. The diversity of situations that can arise in healthcare and the uniqueness of the people and circumstances involved make it impossible to develop a clear and applicable prescription for good listening. Effective listening is not dependent upon specific technique or method but the engagement, connectedness and shared understanding built within the context of relationship. Giving voice to older patients, their families and advocates is therefore dependent upon many interrelated factors which influence the development of such relationships. It is these factors which will be explored and discussed within this review. The review is divided into four sections which are made up of the guiding principles that were developed following the research teams initial scan of literature. It is vital to note that the organisational culture and context within which care is provided also has a profound effect on the engagement between nurse and the older person (McCormack and McCance 2010; Bridges and Fuller 2015; Kagan 2015). An appreciation of the complex social interactions that constitute the culture operating in acute settings has to take full account of the interdependent nature of attitudes, relationships and the everyday world of practice. Although each of the principles will be addressed in turn, one cannot be appreciated contextually without the others and so there will be notable overlap.


Encouraging the establishment of relationships between patients, nurses and their care partners within the acute care setting results in person-centred care becoming an everyday cultural norm.

In their commission on hospital care for frail older people, Moore et al. (2014) have highlighted that interpersonal relationships and approaches to care are of paramount importance to the older patient. Models of nursing, regardless of their philosophical underpinnings have emphasised the importance of relationships (McCormack 2003). The establishment of a ‘good’ relationship between nurse, patient and care partners can be seen as an indicator of ‘effective’ interaction within the care setting (Pursey and Luker 1995). However, relational work is most noticeable in its absence, when important connections are fragmented and relationships and care break down (Parker 2002). Highest on the list of complaints from patients about their care is how they are treated by people, with lack of respect and dignity cited as key issues. Embedded in a lack of respect of dignity is the lack of relatedness (Brown et al. 2009). Evidence shows that within the acute-care setting there is general lacking of relationships; not knowing the patient and not knowing the nurse. Furthermore, care is dominated by the routine and ritualised practices with minimal attention given to the older person’s beliefs, values and priorities for care (Nolan and Grant 1993; McCormack 2003; Mitchell and McCance 2012). Fischer and Ereaut (2012) call for recognition that many healthcare professionals are stuck in relationships with patients that do not meet current needs and which disadvantage the patient and professional alike. Patterson et al. (2011) state that initiatives aimed at enhancing the quality of acute hospital care for older people are unlikely to be effective without close attention being paid to a range of ‘relational practices’. Existing evidence is consistent in showing that person-centred care embraces the formation of a therapeutic relationship between nurses, older patients and their care partners (Binnie and Titchen 1999; McCormack 2001; Nolan et al. 2004; McCormack and McCance 2006).

Person-centred care is operationalised through range of activities including; working with patients’ beliefs and values, shared decision making, engagement, having sympathetic presence and providing holistic care (McCormack and McCance 2010). Engagement is described by McCormack (2001) as that which reflects the connectedness of a nurse with her/his patient. This connectedness mediates autonomy, informed by the person’s values and beliefs. ‘Knowing the person’, his/her ‘viewpoint’ and immersing in their ‘life world’ constitutes the starting point of person-centred care (Mitchell and McCance 2012). Kitwood’s (1997, p.5) definition of personhood as ‘A standing point that is bestowed on one human being by others in the context of relationship and social being’ signifies an understanding of personhood dependant on the quality of relationship. This definition of personhood is reflected through the core concepts which lie at the heart of person-centred practice: being in relation, being in a social world, being in place and being with self. Being in relation emphasises the importance of relationships and the interpersonal processes that enable the development of relationships that have therapeutic benefit (McCormack and McCance 2010). As Paterson and Zderad (1976, p.) emphasise, “nursing is an experience lived between two human beings” which requires the expression and enhancement of nurses’ relational capacity (Hartrick 1997) to form genuine therapeutic relationships. The development of such relationships between nurses and the older patient can be achieved through recognition of the human capacity for connection and relation and a focus on enhancing opportunities for effective interpersonal engagement (McCormack and McCance 2010).


McCormack and McCance (2006) emphasise the strong synergetic connection between caring and person-centredness, with both ultimately about the development of a therapeutic relationship. Morse et al. (1991) conducted one of the early concept analysis’ on caring which revealed five perspectives on caring: caring as a human trait; caring as a moral imperative; caring as an affect; caring as an interpersonal interaction; and caring as a therapeutic intervention. According to Gadow (1985) the interpersonal relationship in nursing constitutes of the human to human process of caring and communicating. Interpersonal nursing practice has in the past been equated with the acquisition and employment of behavioural communication skills (McCabe 2004). Relating and communicating have therefore been conceptualised as something a nurse does using a set of defined communication skills with emphasis being placed on goal-directed nursing actions. While relationship may be included in the discussion, it is assumed that forming and being in-relationship is done through these behavioural skills. This behavioural approach provides a profoundly limited view of human relating by failing to reflect the significance of relationship as a foundation for human caring (Hartrick 1997). As more current nursing literature has emphasised, the attributes of human relating extend far deeper into human experience than the refinement of behavioural communication skills. Alternatively it requires an appreciation of people’s connectedness, the development of relational awareness and an interest in the growth of relationship. Hartrick (1997) warns against mechanistic approaches to human relating that focus on behavioural communication skills rather than the enhancement of relational capacity.

In their systematic review and synthesis of qualitative studies which explored older people’s and their relatives views and experiences of acute health care, Bridges et al. (2010) concluded that older people want nursing staff to ‘see who I am’, ‘connect with me’ and ‘involve me’. These themes reflect older patient’s need for the nurse to use interactions to see the person behind the patient, to establish a warm and human connection and to establish understanding and involvement (Bridges and Fuller 2015). Similarly, in Patterson et al. (2011) exploration of the quality of acute hospital care for older patients and their care partners participants were able to identify often seemingly ‘little things’ that enhanced the development of therapeutic relationships with a selection of nurses. Nurses who paid sensitive attention to providing information and communicating with both the older person and their care partners were seen to ‘go the extra mile’; ‘keep their promises’; and ‘really get to know the patient’. Nursing staff were seen to value relational aspects of care if they engaged in real conversations or small encounters with patients. These encounters provided the older person with a sense of worth and value, promoting personhood and subsequently affected their overall experience of acute care. The therapeutic potential of the nurse-patient relationship is therefore built on an intimate knowledge of the patient and family, their illness and connections with previous experiences; and the desire of the nurse to enhance understanding (Bridges et al. 2013). Baillie (2009, p.24) identifies these emotional aspects of care as being intimately linked to dignity, and feeling ‘comfortable, in control and valued’. Van der Meide et al. (2014) emphasise that hospitalisation is characterised by experiences of uncertainty that give rise to feelings of vulnerability. Care ethics views vulnerability as a natural and inevitable part of life but also something that can be created and perpetuated in certain situations. Social interactions that allow patients to step out of their ‘sick role’ create feelings of dignified comfort that relate to being safe, cared for and possessing self-esteem (McCabe 2004). By counteracting significant feelings of fear, worthlessness and vulnerability, which acute care settings have been found to engender (Bridges et al. 2010; van der Meide et al. 2014), older patients and their care partners are more likely to feel


that their input is valued. This may result in a sense of shared responsibility and open sharing of information that could shape and define the older person’s priorities for care.

Within both Bridges et al. (2010) and Patterson et al. (2011) studies, features of the acute care environment that make development of relationships difficult were explored. Reflecting upon their experiences, all participants in Patterson et al. (2011) study voiced similar concerns regarding the perceived lack of visible nursing presence. This lack of physical availability caused anxiety to both patients and relatives as relationships with the nurse could not be developed. Subsequently, a lack of information and failure to communicate were major themes. Mitchell and McCance (2012) in investigating the nurse-patient encounters in the hospital ward, from the perspectives of older persons, highlighted similar findings. Within their study, a culture of ‘not wanting to bother the busy nurse’ had developed which hindered the opportunity for the building of relationships. According to Irvine (2008) fear of being seen as difficult, demanding or being labelled the ‘unpopular patient’ cause older patients to hold back from communicating their needs and anxieties. Within Mitchell and McCance’s (2012) study nurses who were highly valued and considered ‘special’ were those who took the time to sit with the patient, provided their name, were friendly and helpful, and set the older person at ease. These nurses were sought after by older patients as they conveyed a desire for care through working in transparent ways and demonstrating sympathetic presence.

When attempting to understand the world of relation, Marcel (1981) in his study of ‘interpersonal’ discusses the idea of availability, which expresses the willingness to put oneself at the disposal of others. According to Marcel, it is this kind of availability which enables a person to be present with the other, denoting presence as something rather different and more comprehensive than being physically present (McCormack and McCance 2010). While it is assumed that availability and kindness cost nothing, Benner and Wrubel (1989) stress that the emotional cost can be high. Rodgers (2000), McBee (2003) and Dewar et al. (2010) suggest that nurses lack of visibility, unless providing care to address physical need may be a distancing or avoidance strategy that reduces the risk of hearing something unsettling. As a result of withdrawal from patients for fear of ‘losing yourself’ or ‘being swallowed up by the other’s feelings’ care becomes depersonalised and the likelihood of an engaging interaction between patient and nurse is diminished (Maatta 2006; Morrison and Korol 2014). Within these situations the nurse’s impulse to ‘do something’ is often habitually irresistible and sadly, attentive listening does not feel like enough clinical action (Charon 2006). Mindfulness is an emerging concept in health care that can be thought of a shift from a “doing mode” to a “being mode” that teaches the practice of being present and listening without getting entangled in patients emotions (Hick and Bien 2008).

Mindfulness aims to facilitate therapeutic relationships, alleviate human suffering and enhance human well-being (McBee 2003; Hick and Bien 2008). Kabat-Zinn (2004, p.4) defines mindfulness as ‘paying attention in a particular way: on purpose in the present moment, and nonjudgmentally’. The attributes which cultivate and sustain the experience of being present are awareness, acceptance and attention. Awareness refers to the ability to become deeply aware of self, while acceptance and attention relate to a willingness to see things as they are and learn to respond rather than react in habitual ways of thinking, moving and doing (Kabat-Zinn 2004; White 2014). Rodgers (2000) argues that although mindful practices appear seemingly simple can be quite challenging as they require the capacity to endure uncomfortable experiences as they happen. Kleinman (2006) advocates that although nurses may be challenged in knowing how to react to painful stories it would be more


appropriate to acknowledge that troubling things happen to us and that this is part of what it means to lead a human life. The simple act of acknowledging and accepting an individual’s story can be highly therapeutic. For this reason, mindfulness practices are not goal orientated and need to be carried out without attachment to outcome (Rodger 2000). However, Charon (2006) argues that it is not enough to suggest that healthcare professionals have to bear witness to their patients suffering, on top of everything else they do. Mannion (2014) supports this emphasising that it is unrealistic to assume that nurses have an unlimited capacity for empathy, compassion and emotional support towards each of their patients. As Sawbridge and Hewison (2013) emphasise research shows that relational capacity can depend on ward level conditions. Sustained exposure to routine pressure can result in burnout manifested as emotional exhaustion, depersonalisation, avoidance of relationships and a reduced sense of personal accomplishment (Bridges and Fuller 2015), in spite of aspirations of a high standard of care. The well-being of staff and support of the organisation is therefore regarded as an important element in the development of practices that enhance therapeutic relationships (Bridges and Fuller 2010; McCormack and McCance 2010).

Dewar and Nolan (2013) carried out a study which aimed to actively engage older people, relatives and staff within an acute hospital setting in agreeing a definition of compassionate relationship-centred care. Dewar and Nolan (2013) sought to explore how such relationships can be established and enabled to flourish in practice. Through the use of Appreciative Inquiry (AI), caring conversations and emotional touch points both nurses and patients were able to develop personal and relational knowledge to better understand the experience of the ‘other’. These led to people making connections, engaging emotionally and reflecting on insights. These approaches to connecting and developing relationships with patients were seen as laying the foundations for ‘knowing who I am and what matters to me’ and ‘working together to shape the way things are done’. Dewar and Nolan (2013) claim that such relational approaches operationalise person-centred nursing by providing the means through which nurses could work with patients beliefs and values, share in decision making and meaningfully engage with both the older person and their care partners. Through the use of AI, two key forms of ‘person and relational knowledge’ emerged from the data: ‘knowing who I am and what matters to me’ and ‘understanding how I feel’. Such relational knowledge comprised three subthemes: ‘making a connection and clicking’, ‘knowing the little things that matter’ and ‘not assuming how people want to be cared for’. Strategies identified which allowed staff to ‘click’ with patients included: offering a warm welcome, sharing personal information, using humour and establishing a shared understanding.

The results of Dewar and Nolan’s (2013) study suggest that through skilled facilitation effective engagement in appreciative caring conversations can become the norm and the relational process of nurses and patient working together can shape how care is provided. This challenges the misconception that developing relationships and getting to know something about the person you are caring for is not always possible (Bridges et al. 2010; Dewar et al. 2014). Shattell (2004) and Charon (2006) support this view suggesting that the warmth and intimacy essential to the development of relationships tends not to be built over extensive periods of time, but can be shaped during relatively short, seemingly mundane interactions. This study suggests that engagement and the development of therapeutic relationships can encourage shared decision making. In the context of person-centred care shared decision making requires the nurse to facilitate patient participation in decision making integrating newly formed perspectives into established practice (McCormack and McCance 2010). This is closely linked to working with patients to develop a clear picture of their


beliefs and values. Within Dewar and Nolan’s study, establishing initial connections with the older person and developing a relationship through those connections was vital to delivering care through activities which operationalise person-centred nursing. Dewar’s project took place over the course of a year on a ward with strong leadership and a notable high standard of care. As a result of these limitations, Dewar and Nolan (2013) acknowledged the need for additional guidance for nurses regarding interaction with older people and their families in ways that best support relational practices.

Currently within acute care there is a general lacking of relationships which reduces the likelihood of older patients sharing information that nurses can act and learn from to provide person-centred care. The formation of relationships that have therapeutic benefit to both patient and nurse can be achieved through recognition of the social nature and interdependency of human life. By socially engaging and acknowledging older patients circumstances, relationships and past experiences individuals are more likely to feel that their contribution is valued and be encouraged to step out of their ‘sick role’. It is the quality of these interactions, not the length, that determine the relationship. Furthermore, the ability to enhance less tangible aspects of nursing, cultivating qualities such as presence, availability and awareness can create the sense of security and significance needed for older patients to engage and share what matters to them. Through an increasing openness to learning and growth, an increasing capacity to tolerate ambiguity and uncertainty, and a desire to connect to the older persons social world focus can be placed on caring for older people in a manner which acknowledges and supports the significance of their health and healing as they are meaningfully experienced. Person-centred care can emerge from routine enactment of behaviour, dialogue and decisions that reflect an interest in the growth of relationships.


Active learning in clinical settings which focuses on raising awareness of the negative effects of ‘Institutional Ageism’ and encourages person-centred engagement can produce attitudinal and behavioural change towards nursing older people.

Ageism

Since the 1950’s studies have identified negative attitudes of registered nurses towards caring for older people (Nelson 2004). Policy makers and society in general perceive older people as problems requiring considerable attention and resources (Ward 2000). These negative, age-based attitudes often manifest themselves through stigmatisation and exclusion processes known as ageism (Lagacé et al. 2012). The term ageism was first described by Butler (1969) as an attitude of the mind which may lead to prejudice and age discrimination (Palmore 2001). Age discrimination is recognised as the most common form of discrimination in the United Kingdom (Vize 2012). Within the NHS ‘institutional ageism’ is universal and has has its roots in the increasingly negative way that Western society views older adults (Lievesley 2009). Pursey and Luker (1995) have highlighted that the attitudes of nurses towards older people are no more negative than those of the general public. This has paved the way for societal tolerance towards it (Levy and Banaji 2002) and resulted in ageism within the NHS remaining ‘hidden’ and unchallenged despite antidiscriminatory policies and guidelines (Carruthers and Ormondroyd 2009; Equality Act 2010; Department of Health 2012) being in place. Oliver (2010) emphasises that not all ageism or age discrimination is hostile, conscious or intentional, but even when well-meaning it can still have a damaging effect.

Recent reports of nursing negativity in relation to working with older people are largely based on studies of student nurses’ attitudes and career preferences or nurse attitudes within long term care settings (Herdman 2002; Hanson 2014). Many of these studies have produced inconclusive results due to dated attitudinal measures being used to answer a broad range of questions (McLafferty and Morrison 2004). Little research has examined attitudes towards older patients receiving care within the acute care setting (Courtney et al. 2000). However, numerous studies (Armstrong-Esther et al. 1989; Lookinland and Anson 1995; Commission for Healthcare Audit and Inspection 2007) and anecdotal evidence suggest that older adults are generally perceived as unattractive to work with. Maben et al. (2012) have emphasised the challenges of recruiting staff to a service often regarded as ‘basic’, ‘dead end’ and ‘low esteem’ and derogatorily labelled as geriatric (Patterson et al. 2011). Research consistently reveals the relationship between attitudes and actions to be problematic and that behaviour cannot be predicted solely on the basis of attitudes alone ( Wicker, 1969; Herdman 2002; Liu et al. 2013). However, as attitudes may subsequently affect the behaviour of nurses (Courtney et al. 2012; Hanson 2014), impacting on the nurse-patient relationship, Powell et al. (2009) suggests that greater attention must be paid to staff attitudes and perceptions, thereby addressing the complex social interactions that shape care delivery.

Nursing has traditionally focused on a system based approach to care, in tandem with the medical model (Hickman et al. 2007) which adopts a curative stance to care. In an attempt to develop an evidence-based standardised approach to providing care and curative treatment Clinical Governance has attempted to regulate the healthcare professional-patient encounter through the use of protocols and care pathways (Tadd et al. 2011). This has resulted in standardised, routine care for specific illnesses which fails to take full account of the complex array of social, psychological and cultural factors that shape health and instead focuses primarily on curing a disease or restoring


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physical function (Polat et al. 2014). In reality the core business of the acute care setting are older people with complex co-morbidities and for who cure is often an unrealistic and inappropriate goal (Patterson et al. 2011). As a result of older peoples multiple needs cutting across disease categories these patients require creative, reflective approaches to care, for which a protocol is insufficient (Tadd et al. 2011). Person-centred nursing encourages the employment of creative activity whereby nurses are enabled themselves to carry out interventions unrestricted by routine (McCormack and McCance 2010). However, as hospital services have traditionally been designed to treat single acute illnesses, the system is often unable to provide older patients with the multidimensional care they need, deeming them inappropriate and labelling them as a problem (Rockwood 2005).

Tadd et al. (2011) carried out an ethnographic study of four acute hospital trusts within England and Wales with the aim of exploring the experiences of older service users and the key influences on the provision of dignified care for this patient group. In-depth interviews were undertaken with a range of frontline staff (N=79) and with purposive samples of middle and senior managers (N=32) to explore the occupational and cultural factors which foster or detract from dignified care. One of the four major themes which emerged from the data was ‘Right Place – Wrong Patient’. This theme explored the virtually unanimous view expressed by all participating staff that the acute hospital is ‘just not the right place’ for older people (Staff Nurse, p.116). This sentiment was echoed by many ward staff and trust managers. At times this reference was directed towards old people in general, but often it referred to older people who were confused or had a number of chronic conditions in addition to the condition for which they had been admitted. Staff characterised the atmosphere within acute care as that of chaotic activity with fast turnover of patients and little opportunity for engagement with older adults who have both medical and emotional needs. Many interviewees recognised these issues but concluded that it was the older person who is in the ‘wrong place’, together with the assumption that there must be a better place for ‘them’ to be. Tadd et al. (2011) suggest that these issues result from the widespread attitude that older people do not belong on acute hospital wards. A major strength of Tadd et als (2011) study is that four stakeholder workshops for NHS managers and staff, voluntary organisations and policy makers (≈150) were held throughout the UK to determine how the emerging themes resonated with their experiences, providing validation for the results.

In a similar qualitative study, Higgins et al. (2007) explored the attitudes of health care professionals towards older people in an acute setting within a large teaching hospital in Australia. Scenarios were used as a prompt for discussion with 9 nurses and thematic analysis used to uncover cultural themes. One of the main themes ‘Marginalisation and oppression of older people’ with a sub-theme, ‘if only we had time’, described the way in which older people are overtly and covertly marginalised as a group in the acute hospital setting. Marginalisation of older people within this study was evident in the ways in which individuals were regarded or disregarded, in the way action was taken, ignored or delayed, in the way staff behaved and in their communication with and about the older people in their care. Older people within the acute ward were often differentiated from the ‘mainstream’ patient who required highly valued, advanced acute care. This often resulted in older people’s needs being ignored or diminished to a lower priority in terms of care. The second main theme, in Higgins et al. (2007) study, was ‘Stereotyping the older person’ along with the sub-theme, ‘Chinese Whispers’ which captured the way negative stereotypes were exhibited through the time of older patients’ hospitalisation. Participants held the view that older hospitalised patients are not admitted


for ‘curing’ and that their quality of life cannot improve. Similarly to Tadd et als (2011) study, participants stressed that organisational constraints and inadequate resources often prevent them from being able to provide the time, support and level of care required to effectively nurse older people. Participants admitted that a focus on routine aspects of care within the acute setting resulted in standards of care being allowed to ‘slip’ and older patients only receiving essential care and attention. The subtheme ‘Chinese Whispers’ illustrated how word of mouth communication frequently perpetuates negative stereotypes and leads to ineffective communication.

According to Moore et al. (2014) older people should never be blamed for presenting inappropriately to hospitals where providers have designed a health system unfitting to their health and care needs. McMurdo (2013) further argues that statements which suggest that the NHS’s ‘core business’ is too problematic to manage and propose solving the issue by ceasing to attempt to deal with it is blatantly ageist. Additionally, the use of derogatory language, such as the ‘incurables’, ‘bed-blockers’ and ‘frequent flyers’ which has been evident in healthcare for many years ascribes negative attributes to the older person themselves, rather than shortcomings in the design and delivery of appropriate services and care (Tadd et al. 2011). This objectification of the older person leads to them being viewed, by the nurse, as entities to do things to rather than an individual with needs. Courtney et al. (2000) emphasise that technical, task based approaches to care have negative consequences, hindering the choices available to older people and forcing them into a dependent role. Additionally, Kagan (2015) emphasises that the influence of ageism and more specific professional socialisation processes diminish the state of being old. As a consequence there is a disregard for the valuable contribution and meaningful activities which many older people engage in such informal caring, volunteering and influencing local services. Built within these activities are meaningful relationships that are vital to the older person’s quality of life and well-being.

As mentioned previously there are four core concepts at the heart of person-centred nursing: being in relation, being in social world, being in place and being with self (McCormack 2004). Being in relation and being in social world highlight that the preservation of meaningful ties is essential to any human being. It is through and around these that an individual builds a sense of identity, integrity and most important dignity (Woolhead et al. 2006; Jacobson 2007; Lagacé et al. 2012). Merleau-ponty (1962) considers persons to be interconnected with their social world, creating and recreating meaning through their being in the world. Social-constructionist perspective argues that social phenomena such as identity and power result from social practices such as words and body language used within interactions. This gives rise to the construction of different sets of meaning within interpersonal relationships and can affect the personhood of older people. Through the ageist lens, the social construction of old age equates to a limited or absent future and loss of personal identity. Words, gestures and behaviours which reflect this ageist view may endorse exclusion and general insensitivity to the needs of the older person causing them to subscribe to stigmatising characteristics and believe that they are a reflection of reality. Subsequently, older individuals may come to believe that decline is an inevitable part of growing older and tend towards passivity or inactivity (Nussbaum et al. 2005). Whitbourne and Sneed (2002) emphasise that such a response confirms and strengthens these stereotypes. Draper et al. (2013) term this the ‘negative feedback loop’ in which the older person accommodates the caregiver, ironically reinforcing patterns of ageist behaviour. The sense of inferiority that older people feel, due to the judgements ageism makes about their actions, character and desires, results in older people being more reluctant to assert their views (Woolhead et al. 2004; Polat et al. 2014). This process devalues care and directly affects


quality of practice in a negative way, causing the older adult to receive substandard care which is not informed by their values and beliefs (Hickman 2004).

The majority of studies discussed above focus on negative aspects of care and do not capture the actions that exemplify good standards of care and practice. However, Higgins et al. (2007) emphasised that the less than adequate care evident within their study was clearly a source of stress for participants. Similarly, within Tadd et als. (2011) study the majority of staff participants expressed feeling motivated to represent patients’ interests but argued that their individual motivations are frequently compromised by systemic and organisational constraints including setting acute Trust priorities on the basis of measurable performance indicators; the organisation of service provision, particularly high bed occupancy rate and increased specialisation. Participants mentioned ideals and values such as individualised, person-centred care being emphasised in their education and recognised that these were central to treating people with dignity. Despite voicing the desire to provide person-centred care, these intentions were rarely reflected in practice. Maben et al. (2012), in their examination of the links between staff experiences of work and patient experiences of care, further highlight that despite reported deficiencies in standards of care the majority of NHS staff strive to offer dignified and high quality care.

How nurses communicate and engage with older people is significant as underlying attitudes are shaped by our language, as well as by our culture (Stone and McMinn 2012). Consequently, as Ryan et al. (1986) emphasise, ageism and stereotyping of older people can manifest themselves in careless terminology and inappropriate forms of communication. It is clearly necessary for health professionals to make allowances for sensory deficits or to simplify complex medical information; however such attempts can be experienced as patronising and unwelcome. Unfortunately, older people in hospitals often experience such discrepancies between their ability to communicate and others evaluation of this ability (Ryan et al. 1986).

Thakerar et al. (1982) were some of the first researchers to explain the link between communication and underlying attitudes. They suggested that when people meet for the first time they evaluate one another on the basis of what they see and hear, making provisional judgements about the other person’s competence and social status. Boujemadi & Gana (2009) describes these judgements as automatic associations between concepts of old age and negative stereotypes. Speech Accommodation Theory proposes that individuals modify aspects of their speech in response to their evaluation of another person. As these evaluations are often based on stereotypes, a person’s pattern of speech may reveal their attitude towards another person (Brown and Draper 2003). Well intentioned efforts to adapt communication style to the needs of older individuals, which are often stereotyped as feeble in mind and body (Lovell 2006), may result in over-accommodating forms of address (Edwards and Noller 1993). Common features of over-accommodation include the use of simplified vocabulary, high pitched tone of voice, relatively slow speech, assumed use of older adult’s first names, diminutive modifications of names or use of pet names (Ryan et al. 1991; Bowie 1996; Brown and Draper 2003; Maben et al. 2012). These communication adaptations inevitably convey a lack of respect which not only contradict the caring intentions of health care professionals but may also transform a well-intentioned message into a damaging one, with wide-ranging implications for the emotional and physical well-being of the older individual. Ryan et al. (1986, p.6) termed this mismatch between older people’s ability to communicate and other people’s evaluation of their ability as the ‘communication predicament of aging’.


Brown and Draper (2003) carried out a systematic review to examine the ways in which nurses and other health care professionals modify their speech when conversing with older people. Literature was selected from between 1990 and 2001 and twenty four publications were found which contributed to the issues of ageism. Speech accommodation, paternalistic behaviour, being abrupt and the blocking of communication regarding subject’s important to older patients were all evident within the literature. This review stressed that the majority of older people find over-accommodative speech to be condescending, disempowering and demoralising. Yet despite these feelings, many older people tolerate it (Ryan et al. 1986; Jacelon 1995; Brown and Draper 2003; Draper et al. 2013). Nelson (2005) highlights there is evidence from research that in some circumstances what can be described as ‘comfort talk’ can be calming and encouraging and that some older people have a positive attitude towards it. However, the majority of literature suggests that over-accommodative, patronising speech is to be avoided, not only because older people dislike being patronised, but also because it is associated with other dehumanising and harmful behaviours (Phelan 2011).

With the ageing process, the image of the body as an object becomes more of a reality (McCormack 2001). The alienation experienced as a result of deteriorating physical circumstances offers a daily tangible reminder of the body’s limitations to the outside. Such feelings of alienation can result in the individual seeing themselves as less of a person and more like an object, whereby the feelings of alienation within an ageing body limit the person’s connections with the outside world (Gadow 1991). It is the nurse’s job to facilitate transition through dependence in which the old person is engaged. The blocking of emotional ‘cues’ or topics important to the older person, attitudes that acute care is not the right place for such patients and paternalist language nourishes the objectification of their lives. Vize (2012) states that older people have described how their skills, self-confidence and ability to look after themselves independently can deteriorate as a direct result of patronising communication and the paternalistic behaviour of nurses. This has been theorised as a self-fulfilling prophecy in that older people come to accept and believe that they are no longer independent, contributing adults and must assume a passive and dependent role which subsequently erodes individuals of their self-worth (Vize 2012).

Despite the majority of over-accommodation, incidences of inappropriate address and patronising behaviour being harmless in origin, the unintended negative impact can have a profound damaging effect on the older person’s identity and general well-being. Guggenbuhl-Craig (1999) believes that all forms of ageist behaviour have the potential to result in abuse of power under the cover of good intentions and the desire to help. Draper’s (1996) qualitative research discussed nurses use of tactics which deny older people choice such as coming to a compromise, massive encouragement and forcing. Draper’s study suggests that despite the belief that older patients should be treated as individuals and empowered to make autonomous decisions nurses often provide justification for limiting older people’s choice. According to Pope (2012) the ethical dilemmas that nurses face as a result of limited human resources and time constraints in today’s health care environment provide an explanation for nurse’s abuse of power. Subsequently, older patients can become temporarily dependent on others while in hospital and may be expected to conform to what Parsons (1951) describes as the ‘sick role’. This suggests that use of over-accommodation in speech can therefore be explained not simply as the outcome of ageist attitudes, but also involves relations of power, inequality and controlling patterns of care (Hewison 1995; Armstrong and McKechnie 2003; Brown


and Draper 2003; Powell 2009; Phelan 2011). These power dimension inherent in the relationship between nurses and the older patients constitute a barrier to open and meaningful communication.

In essence we communicate with individuals based on what we know about them as people (McCormack and McCance 2010). Stereotypes and ageist opinions can distort the nurse’s view of the older patient. There is a general consensus that education and training is a key element in rooting out ageism in the NHS (Herdman 2002; Lievesley 2009; Polat et al 2014). Nelson (2005) advises professionals working with older people to develop awareness and continually assess their own attitudes towards older people, confront ageism where it arises, institute programs which focus on care of older patients in hospitals and integrate into their education interventions a thorough knowledge of ageism, as well as develop knowledge of the normal ageing process. Levy (2001) stresses that in order to eradicate ageism nurses need to become aware of not only the blatant forms of it, but also its more subtle forms that operate within us all. According to Devine (1989) the automatic activation of stereotypes can be overridden by individuals who do not believe the truth of negative attitudes and are motivated to challenge and change their perceptions of the older person. This can be achieved through exploration of the personal values, beliefs and attitudes of the nurse associated with older persons that often operate without conscious awareness and influence the actions taken within the care context (Greenwald and Banaji 1995; Nelson 2004).

Benner et al. (1996) note that nurse’s values regarding right and wrong are socially constructed and embedded within work culture, being shaped through dialogue and observation of peers. Subsequently, Wilkin and Hughes (1986) argue that it is necessary to consider the ways in which both old age and health are socially constructed if a full understanding of the complex factors that shape healthcare are to emerge. As a society we do not seem able to face the degeneration and changes that are often perceived to accompany old age (Patterson et al. 2011). Researchers have presented several different views that could account for the origin of ageism within society. Two related approaches which have received the most attention are Functional Perspective (Snyder and Meine 1994) and Terror Management (Greenberg et al. 1986). Function perspective holds the view that negative attitudes towards older adults serve an ‘ego-protective function’ for the stereotyping individual. While Terror management illustrates how younger people adopt ageist attitudes and behaviours to distance themselves from older people who they associate with death. Nelson (2005), a social psychologist, argues that ageism is a prejudice against our feared future self.

Clarifying values and beliefs and knowing self are at the heart of person-centred care and place a responsibility on the nurse not just to get to know his/her patient, but to also recognise what they bring of themselves into the caring interaction (McCormack and McCance 2010). ‘Knowing self’ is based on the assumption that in order to help others nurses need to have insight into how they function as a person (McCormack and McCance 2006). This includes the moral values and beliefs of the nurse and how he/she expresses these. According to McCormack and McCance (2010) these attributes shape how the nurse develops relationships and engages with the older person. It is especially important for the nurse’s values to be expressed for a mutual relationship to exist between the nurse and patient (McCormack and McCance 2010). Active Learning that places emphasis on the importance of learning in and from practice and being responsive to patients (Dewing 2010) can facilitate nurses in ‘Knowing-self’ by raising awareness of the negative effects of ageism, the impact that it has on patient care and exploring ways of providing person-centred care.


Active learning focuses on learning in and from the workplace (Manley et al. 2008) in a way that enables the learner to be emotionally connected or engaged with the topic of learning. Nurses tend to draw upon their clinical experience, professional training and life experience to inform practice (Higgs and Titchen 2001). Therefore being open to, engaging with personal experience and learning from experience are central activities in active learning (McCormack et al. 2009). Dewing (2009) emphasises that active learning can be used to explore language and discourse; values and beliefs and routines and rituals within the workplace and how these can be transformed to improve patient care. Traditionally nurses have had difficulty in articulating the knowledge, skills and expertise underpinning their practice and the impact that it has on patient care (McCormack 2001; Nolan et al. 2004; Dewar and Mackay 2010). It is through activities of self-discovery, self-reflection and education that negative attitudes towards older people can be challenged and changed (Fitzpatrick et al. 2004; Mezey et al. 2005; Pope 2012). Active learning also has a practical or action element that would encourage nurses to explore the origins of ageism and to use the learning to take personal responsibility for their practice and bring about changes (Dewing 2008; 2009). It can be argued all learning is intuitively active. However Dewing (2010) argues that to be active, must mean engaging in such higher-order thinking as analysis, synthesis, and evaluation. Being ‘active’ has therefore been described (Dewing 2009) as revolving around reflection, dialogue with self and others and engaging in learning activities in the workplace that make use of the senses, multiple intelligences and completing workplace learning activities together with colleagues and others. Through these processes nurses can explore factors, such as work stressors, which uncover ageist attitudes and behaviours (Hinchliff et al. 2008; Pope 2012).

Committing to developing person-centred engagement with older patients, teams must realise that learning is not something that takes place away from the workplace and is ‘taught’ mainly through study days and formal teaching methods (Dewing 2009) but that it must be integrated into everyday practice and workplace contexts. Recognising and challenging existing ageist attitudes, use of speech accommodation and relations of power through active learning could provide a means of transferring knowledge and skills into practice for the benefit of the older person in acute care. Active learning also places emphasis on nurses perceived needs in work and life, addressing concerns such as effective use of time and the influence of context of care (Dewing 2009). Facilitating staff to learn how to evaluate the processes and outcomes of practice and to demonstrate the impact of changes in practice for patients, families and staff is a core activity in active learning (McCormack et al. 2009).

As the Dignity Report (Vize 2012) highlights, undignified care of older people does not happen in a vacuum but is influenced by wider and deep-rooted negative social attitudes to ageing. Ageist prejudice exists and is multifaceted. Negative consequences of ageist behaviour such as loss of personal identity, fostered dependence, avoidance of speech situations and inhibition of effective communication subsequently hinders nurses from listening and learning from patients, working with patients beliefs and values and engaging in shared decision making. The outcome of ageist attitudes are also influenced by relations of power and controlling patterns of care that exist within the acute care setting. NHS nursing staff hold knowledge of ideals and values such as dignified, person-centred care and strive to provide such care. However, there is a severe mismatch between the patients who the acute sector is currently set up to care for and the needs of the majority of actual patients who are admitted to the acute care system, namely the old. This is having a damaging effect on the lives of acute older patient as nursing staff believe there is little opportunity for engagement with older


people in the busy routine of everyday working. Active learning can be used to explore the many factors which may influence effective listening and learning from older patients and their care partners such as language and discourse; values and beliefs and routines and rituals within the workplace. Becoming mindful and aware of the effect of unconscious beliefs and attitudes on health care processes and outcomes may be a starting point for improving engagement with the older adult in acute care. Active learning can enable this process of ‘knowing self’ and exploring how values and beliefs impact actions taken in the care context and when communicating with older persons. Additionally, measures of unconscious beliefs and values which affect health care interactions may allow individuals to confront their own vulnerabilities and fears about aging.


Continuous feedback from older people and their care partners, which is actively encouraged through a range of mechanisms, supports exploration of what important to them while in hospital and can inform individualised, person-centred care.

Introduction

The Delivering Dignity (Vize 2012) report states that ‘care organisations must ensure that staff caring for older people have the confidence, support and skills to do the right thing for the people in their care’. As care is not only shaped by illness and frailty but also by the broader context of the older persons life and relationships, it is essential that staff do not assume how people want to be care for (Dewar and Nolan 2013) but listen to and respond to their needs. Feedback on the delivery of care, from older patients and their care partners, is vital to ensuring their needs are understood and met. For that reason there is a need for older people to be provided with an authentic space to voice their opinions and offer their own particular perspective and area of expertise on what dignified care means to them (Garbett et al. 2007). Numerous policy and legislation (National Institute for Clinical Excellence 2012; NHS Patient Feedback Challenge 2013; The NHS Constitution 2013) developments have made an important contribution to stressing the significance of patient feedback yet there has been little acknowledgement of the body of literature in this area, and in particular the conceptual and methodological difficulties in eliciting patient perceptions of the quality of their care (Staniszewska and Henderson 2005).

Reluctance to provide feedback

Among older people within the acute setting there is a reluctance to assert views and provide feedback in regards to their care (Lanceley 1985; McCabe 2004; Woolhead et al. 2004). Additionally, it has been noted that when older patient’s experiences of care are sought individuals often provide markedly positive accounts. This observation is backed up by Tadd et al. (2011) previously mentioned study in which participants (patients and families members) expectations of care were not very high yet in general complimentary comments were made about nursing staff who were thought to be very hard working. Generally, older people within this study presented a positive picture of care, but probing specific aspects revealed many examples of undignified practices. Similarly, Koch et al. (1994) used an existential phenomenological approach to gain access to the experiences of older people in acute care. Using an open interview approach patients were asked to describe their day in hospital followed by probing questions such as ‘what matters most’ and ‘what is important’ to you while in hospital. Initial responses from participants included, what Koch perceived as, superficial statements that described the nursing staff as ‘wonderful’ and having ‘very hard jobs’. These comments were subsequently followed by stories concerning inadequacies of care and perceived negligence. Koch (2006) noted that although strongly negatively experiences of care were identified within this study, they were cautiously conveyed by participants.

Williams et al. (1998) theorised that such positive summary evaluations are possible when, following a negatively perceived aspect of care; older people are able to consider issues of duty and culpability, and to identify justifications for less than adequate care. This allows patients to redirect blame for poor care onto ‘the system’ resulting in a positive rating of standards. However, Woolhead et al. (2004) argue that older people’s reluctance to provide feedback regarding care and assert their views is a result of having experienced healthcare before the introduction of the NHS. Consequently, older people are more appreciative and forgiving as, even with significant shortfalls, the NHS is a vast


improvement on what existed before (Cornwell and Gearing 1989). Shattell (2004) suggests that patient’s paradoxical and contradictory accounts of their relationships with nurses and the coexistence of two opposing views of care can be considered through Goffman’s (1967) Face Theory. Goffman (1967, p.6) used the concept of ‘face’ which he defined as ‘positive social value a person effectively claims for himself’. The social unacceptability of negative evaluation provides a strong motivation for patients to form positive evaluations even when care has been substandard (Staniszewska and Henderson 2005). This social desirability response bias often results in overly positive comments which patients and their care partners are happy to voice publicly due to awareness of the need to maintain constructive social relationships with those caring for them (Edwards et al. 2004) and may actually have a therapeutic effect similar to that harnessed by the placebo effect (Lick and Bootzin 1975).

Individualised, person-centred care must be informed by the older person’s voice. However there are a number of influencing factors which have been discussed that prevent older people from asserting their views and providing feedback on the provision of care. In the Care and Compassion report the Ombudsman (Abraham 2011) concludes that older people simply don’t like to make a fuss and as a result suffer unnecessarily within the acute care setting. These barriers to active and purposeful dialogue suggest that older people must be encouraged and guided by the nurse to provide feedback, clarify their values and take part in decisions regarding their care.

Patient satisfaction and Complaints

In 2010 the Department of Health published the Equity and Excellence strategy in which a commitment to gathering information generated by patients themselves was made. The strategy stated that The Department will seek views on how best to ensure that providers are more responsive to patient experience data and real-time feedback. It was emphasised within this report that all sources of feedback, of which complaints are an important part, should be a central mechanism for providers to access the quality of their services in order to avoid the experience of Mid-Staffordshire, where patient voiced concerns were continually overlooked. Within this strategy and many other NHS policy documents emphasis has been placed on patient satisfaction surveys and complaints as means of collecting patient feedback. Within the NHS senior managers consider complaints, comments and compliments, patient surveys, and information from the Patient Advice and Liaison Services (PALS) to be the most useful sources of patient experience information (YouGov 2005). Additionally, there has been an increased emphasis on the use of patient satisfaction surveys to assess elements of quality of care as a result of the growing concern that current models of acute hospital care may not adequately meet older people’s needs (Vize 2014).

NHS patient surveys systematically gather the views of patients about the care they have received and results are used to improve performance and to understand patients’ experiences (Care Quality Commission 2013). A characteristic feature of both local and national patient satisfaction surveys is their tendency to record consistently and remarkably high levels of satisfaction, compared with the more wide ranging opinion that has been detected anecdotally (Edwards et al. 2004). Koch (1995) argues that an overall measure of satisfaction skims the surface of hospital life, providing an incomplete picture of care which frequently masks dissatisfaction with particular elements of care (Draper et al. 2008). Research in the field of patient satisfaction has been dominated by the assumption that the service provider knows what is important to ask about and how to ask it


(Edwards et al. 2004; Dawood and Gallini 2010). Consequently, one of the difficulties in interpreting survey results is that most surveys do not attempt to determine what aspects of their health care experience patients most value, and what their priorities for change are (Draper et al. 2001; Janssen et al. 2013). As a relatively blunt instrument which only captures a moment in time, from a small number of patients’ experience the most common barrier to using national patient survey results is that feedback is not specific enough to be salient to those who need to act on it (Reeves and Seccombe 2008). Subsequently, there is evidence that patient satisfaction survey data is underutilised by staff, contributing to the ambivalent nature of evidence which suggests that patient surveys can stimulate local quality improvement.

Organisational commitment to act on the results of satisfaction surveys has not been established and there is little published research on improvements resulting from information obtained (Draper et al. 2001; Reeves et al. 2013) despite NHS leaders claiming that positive changes have been made. Over the last 10 years aspects of care that have improved, as detected in the national results, are those that can be linked to national targets (such as waiting times for inpatient admissions and ward cleanliness) (NHS Confederation 2010). However, there is little evidence that the survey programme itself has driven any improvements in patients experiences (Reeves et al. 2013). This adds to the increasing concern about the concept of satisfaction as accurately representing the process of evaluation (Staniszewska and Henderson 2005). If patient feedback via the National Survey is to have any value it must be clearly linked to action that produces meaningful changes in service quality and be part of a broader range of approaches (Draper et al. 2008) rather than an annual ‘snapshot’. Relying solely on annual and/or ad-hoc local patient satisfaction surveys may result in a large number of the hospital population not being reached and therefore it is felt that organisations need to provide a more responsive and individualised reaction to patient feedback.

Despite surveys being viewed as a more robust way of eliciting patients experiences, complaints and Patient Advice and Liaison Service (PALS) information are valued more highly (Reeves and Seccombe 2008). According to Cowan and Anthony (2008) patient complaint data has been utilised in the

quality improvement process and has resulted in changes to policy and procedure. However, detrimental effects of patient complaints on health professionals and the relationship with their patients (Henderson et al. 2005) and frontline staff perceptions that complaint data have no effect on quality improvement (Blakemore 2013) suggest that the role of complaints in the improvement of delivery of care is complicated (Debono and Travaglia 2009). The imbalance of power between healthcare provider and the older patient combined with the social unacceptability of negative evaluation may provide strong motivations for patients to form positive evaluations of care (Staniszewska and Henderson 2005). Fear of judgement and retribution may act to inhibit the voicing of many queries and criticisms which could negatively affect the social relationships with those providing care (Koch 2006; McCabe 2004). Additionally, the NHS has a culture of denial and defensiveness regarding the handling of complaints from patients that has shaped nurses reluctance to listen (Clwyd and Hart 2013; Reeves et al. 2013). This reluctance to listen was evident within Tadd et al. (2011) study in which a relative was handed a formal complaints form after approaching staff about a particular problem that they were willing to resolve with the staff involved. Power (2004) suggests that this lack of engagement regarding patient and their loved ones queries exposes the tendency to self-protect amongst NHS staff.


Regardless of the spot light on patients voices and feedback demonstrated in recent reports, these reports do not go far enough in helping us to name, value and defend behaviours that support exploration of what is important to older patients and their care partners. Furthermore, no existing policies provide advice on how nursing staff can effectively collect real-time feedback. Fischer and Ereaut (2011) argue that for feedback to have a powerful impact, prompting real-time changes in practice, it must be specific and obtained in the present. Additionally, improving patients’ experiences depends on the engagement and understanding of those who deliver care (Dawood and Gallini 2010). As indirect, retrospective forms of feedback, patient satisfaction and formal complaints procedures fail to recognise the humanity and individuality of each person and therefore cannot directly inform individualised, person-centred care (Janssen et al. 2013). There is an inherent inability within ‘quality’ measures to adequately account for wider aspects of patient experience such as relational aspects of care and feeling of wellbeing (McCance et al. 2009; Tadd et al. 2011). Such aspects of care which are immeasurable, but are nonetheless exceedingly important to patient experience, are subsequently neglected (Brown and Calnan 2009). This raises questions as to whether qualitative data is being valued and used to inform practice or disused due to traditional evidence hierarchies. Ziebland et al. (2013) suggest that given the short comings of existing methods of collecting patient feedback, alternative approaches should be sought that might hold the key to understanding and improving relational aspects of care.

According to Hodge (2005), the nurse controls the interpretation of participation and the ways in which the older person and their care partners are involved in their care. Poulton (1999) states that true participation and empowerment can only progress when there is a recognised shift away from paternalistic approach to health-care to a humanistic and person-centred one. Humanistic nursing provides patients with as many opportunities as possible to exercise freedom of choice, to express opinions, to make decisions, to talk while the nurse actively listens and to have the opportunity to express their authentic self (Ford and McCormack 2000). According to Van Heijst (2011) this requires the nurse to recognise when the situation demands them to resist urges to carry out actions and listen to the older person. However, within the nursing literature the concept of listening is almost never clearly defined or delineated from communication which is often considered to be a behavioural action (Hartrick 1997). Although listening styles have been address there is not a single theory of interpersonal communication that directly addresses listening or places it as the central aspect of a study. The importance of listening is assumed (Bodie 2011). What is evident in the nursing literature is that the outcome of listening is creating a relationship or connection with the patient which encompasses entering the patient’s world.

Van Manen (1990) stresses that the best way to enter a person’s world is to participate in it, integrating the authentic patient voice early and often with communication across the care continuum (Hickman et al. 2007). By participating in the older person’s life world it is possible to collect patient feedback and experiences as they happen (Larsen 2011) and be responsive to human concerns (Todres et al. 2007). Van Heijst (2011) further highlights that in order to attach value and concern for the experiential dimensions of care as it is actually felt by those who receive it nurses must create a sense of presence in practice. This can be achieved by full immersion in the social context of the older person (McCormack and McCance 2010). Subsequently, feedback should be integrated into everyday care activities as opposed to being viewed as a formal activity which takes place at a specific point in the older person’s hospital experience. This is backed up by Binnie and Titchen (1999, p.18) who state that “in skilled hands, the opportunities presented by everyday


bedside caring become the medium through which the patient’s experience of illness can be transformed”. Foot et al. (2014) advocate the use of narrative-based approaches and learning theory which encourages healthcare professionals to reflect in and on practice by drawing back, pausing and gathering information, people and insight that can inform care delivery.

Appreciative Inquiry

One of the most recent approaches to capturing and exploring patient and carer experiences with a view to inform care delivery is through the use of AI (Dewar and Sharp 2013). Initially AI was developed as an innovative participatory approach to promoting significant and sustainable change through facilitative workforce engagement, and the promotion of organisational learning in the health care context (Trajkovski et al. 2013). First coined by Cooperrider (1986) AI adopts a social constructionist view based on affirmation, appreciation and positive dialogue. Cooperrider (1986), in his exploration of organisational change, found that change could be fostered by a supportive approach to the people involved in the change (Gubrium and Holstein 1999; Reed 2007). Furthermore, he realised that this support could be effective if it was appreciative, i.e. it would discover, value and acknowledge the skills and abilities that people have, and the work that they do. AI is reported to have significant transformational potential that shifts the focus from problems to be solved to discovering and building on what words well within an organisation and using that as a beginning point for change (Reed 2007; Koster and Lemelin 2009). The process of AI involves participants in uncovering and co-constructing narratives about positive experiences that they have valued (discovery phase), discussion then moves on to exploring the dimensions of their experience that were valued and appreciated, and the process of enabling and support that facilitated them to have these experiences (dream phase) (Reed 2010). From these discussions participants can develop activities designed to achieve the dream phase and work to sustaining these developments over time (destiny phase) (Cooperrider and Whitney 1999; Dewar and Nolan 2013).

Although AI was originally designed as a research method, Reed (2007) argues the case for taking an appreciative stance towards practice, mainly on logical grounds. The link between nursing and AI is most evident at an individual level, where person-centred care is predominant. The basic idea of inquiring appreciatively is that in every situation something works well and that if we take time to appreciate what works well and understand why, this can inspire change and development (Cooperrider and Srivastva 1987; Dewar and Sharp 2013). AI is a relational process that focuses on careful questioning and creative conversations between people, to uncover what people value in the care they receive and aims to translate these accounts into statements of aims and practices that can be applied to promote person-centred care (Reed 2007). Through simple questioning and probing the nurse creates a space open to feedback that challenges assumptions about care (Dewar and Sharp 2013).

The use of AI in settings for the care of older people has had limited impact to date. Dewar and Nolan (2013) adopted a participatory action research approach, utilizing AI and a range of other methods (participant observation, interviews, storytelling and group discussion) to actively engage older people, relatives and staff in identifying strategies to promote compassionate relationship-centred care. A collaborative approach, which focused on real-time feedback, reflection and evaluation on positive attributes to develop practice, were central to the methodology (Dewar and Nolan 2013). Feeding back and measuring compassionate, caring practice emphasised the value of


knowledge, the views of patients, families and staff, and the flexibility of the AI, which is concerned with celebration and growth rather than external monitoring and identification of poor practice.

Da Silva (2012) suggests that how appreciative conversations open is extremely important as the older person must feel emotionally safe when being exposed and honest about their care. Fischer and Ereaut (2011) support this view stating that older patients require guidance and facilitation to support engagement in conversations regarding their care. Dewar and Sharp (2013) highlight the seven C’s of caring conversations as an approach to facilitating appreciative dialogue and maintaining real-time feedback (Dewar and Nolan 2013). This framework asks that nurses consider seven key attributes in their interactions aimed at supporting learning and action from feedback; being courageous, connecting emotionally, being curious, being collaborative, considering other perspectives, comprising and celebrating what has worked well. Appreciative dialogue can be facilitated by such careful curious questioning aimed at asking people to consider possibilities, to try to understand why specific actions works well and to engage emotionally with each other using affirmative language. Van der Meide et al. (2014) suggests the following questions can be useful in encouraging such learning:

Can you say a little more about how you see things? How can I support you in a good way? What impact have my actions had on you? Can you say a little more about why this is important to you? Can we work on this together?

The purpose of courageous conversations is to build an effective relationship in which both parties feel emotionally safe; nurses can reflect back what they hear and validate what the older person and their care partners are saying. Both nurse and patient must be prepared to learn and have a genuine curiosity about the other person’s perspective. This involves willingness to taking risks (Dewar and Nolan 2013) and address patients and relatives concerns directly instead of avoiding what may be seen as unpleasant confrontation (Wilson et al. 2009). Such conversations can challenge the personal philosophy of ‘do unto others’ and long held implicit beliefs about how people want to be cared for (Dewar and Nolan 2013). Dewar and Sharp (2013) emphasise that these courageous conversations must happen in day to day conversation. Therefore nurses must appreciate the impact of individual encounters and realise that each encounter is an opportunity to listen and learn from the older person.

The flexible nature and lack of rigor in the AI process may be viewed as a limitation. Carel and Kidd (2014) emphasise that by gathering real-time feedback through practices such as AI nurses are given the power to decide which testimonies and interpretations to act upon. Comments and feedback made by older people may be judged as irrelevant or insufficiently articulated and may cause the hearer to give a deflated level of credibility to patient’s experiences. Despite this argument, Carter (2006) claims that AI encourages less hierarchical structures and more equalised power and input into decision making processes, empowering patients to contribute to positive changes in practice. AI could additionally be criticised for failing to explore the negative aspects of care. However, Reed (2007) argues that while AI has a focus on the positive, it elicits accounts of a range of experiences, including negatives ones while its appreciative stance facilitates the development of a supportive environment for discussion. Wilson et al. (2009) further argue that this form of open communication


provides a means of identifying gaps in service provision rather than direct criticism of individual nurses abilities.

Narratives

As Woolhead et al. (2006) have emphasised, one way in which the dignity of older people can be maintained is by ensuring that they feel valued as a human being, promoting a sense of both self-respect and self-esteem. One of the ways in which nurses can ensure the older person feels valued in this way is by encouraging feedback against the narrative background (Van Heijst 2011). The gathering of narratives ‘are based upon a philosophy that puts patients and carers at the centre, and values listening to their experiences as a way of gaining insight which is unavailable elsewhere’ (Matrix Consultancy 2005). It is the gaining of insight into these experiences that gives meaning to the values of the older person and provides the explanations which are needed when care decisions are being made (McCormack and McCance 2010). In a wider context, biographical approaches have been used in order to draw out the views, experiences and preferences of older people concerning service provision and delivery.

Hsu and McCormack (2011) examined the usefulness of narratives of older people’s experiences for informing practice and service delivery. Narrative interviews were applied in practice, within a rehabilitation unit, as a means of enabling the older patient to tell their story (McCance et al. 2001). This was achieved by nurse’s actively listening and facilitating the telling of their story, avoiding a question-response structure when interviewing and avoiding restructuring of events by questioning the narrator’s response. Supportive and encouraging questions were used to facilitate the older person in narrating their story. Through the use of such questions, nurses were able to gather individual needs and preferences and enter into the older person’s social world through the surfacing of emotional connections to past experiences. This encouraged the revealing of the relationship between the older persons past with the here and now and in the context of their usual level of well-being. Such information is vital for exploration of what is important to the older person while they are in hospital and within this study informed the development of individualised programs of care that took account of individual life experiences. In concluding Hsu and McCormack (2011) state that nursing staff could use stories as a means of exploring issues, defining problems and determining solutions within the nurse-patient relationship. To be used effectively narratives need to be built into the clinical setting in the form of continual assessment and exploration of how the older persons past and world view shapes their priorities for care.

One of the criticism of the use of narratives as a means of exploring what is important to the older person and their care partners is that the interview style may result in gaining answers to professionally led questions (Bridges and Nicholson 2008). Wengraf (2004) suggests that this can be avoided by ‘inviting a narrative’ rather structuring it around specific routine questions. Additionally Manley and McCormack (1997) emphasise that the ability to recognise the needs of the patient may rely on picking up on cues that can be missed or dismissed by others. This can be linked to Rogers (1975) seminal work in which he claimed that intent of reflective listening and responding to patient cues is to test the accuracy of the listeners understanding. The natural tendency to evaluate from the listener’s own frame of reference is a major barrier to successful listening. Bridges and Nicholson (2008) highlighted this issue in their exploration of the use of narratives to inform service improvement. Within their project the nurses were trained to undertake Discovery Interviews only


partially picked up on cues/probes from patients, or not at all. Furthermore, on occasions questions were asked which were unrelated to what the older person was saying. McCormack and McCance (2010) suggest nurses must perceive the idea of ‘being present’ as more than sitting and talking to the patient to overcome barriers that inhibit active listening and the exploration of cues. The idea of presence should be interpreted in terms of being present, attentive and available to the older person in each moment that he/she is approached by the nurse. Fredrinksson (1999) emphasises that the art of being present and listening are intentional acts.

For feedback to be significant to frontline staff it needs to be tangible, transparent and actionable, leading to learning and appropriate outcomes. Both AI and narrative inquiry have been utilised within qualitative research as ways of gathering patient experiences. However, the underlying principles of each can be applied in practice and become embedded into the everyday working practice of nursing staff. Subsequently, the nurse can facilitate ongoing conversation with the older person which depends on curiosity, questions that explore older people’s experience of health and illness, their shared and individual journeys, and their interactions with others. Dewar and Nolan (2011) highlight that processes, such as AI and narrative inquiry, can be applied to relatively simply conversations and give voice to the things that need to be said and heard. Such conversations can open up an empathetic understanding of what the older person in going through and exploration of how the nurse can provide care that eases suffering within the experience. Picking up on cues, probing lines of inquiry and asking curious questions in the context of the patient’s narrative is vital to gaining feedback which can inform individualised, person-centred care. These practices can also challenge the current uncritical acceptance of care. As stated previously feedback which can make meaningful changes in practice for individual patients, must take place in the context of relationships.


Flexible, creative nursing assessments, that are open to listening and constructing patient’s biographies, can ensure that individual’s stories are heard and absorbed into the clinical encounter.

The aim of assessment is to unearth the stories or themes that have shaped a person’s life. People carry these stories with them to say who they are and what is important to them and to make meaning of their experiences (Osis and Stout 2001). Critical to the development of a plan of action, assessment is the process by which the nurse and patient together identify actual, potential and perceived needs (Dougherty and Lister 2011). Patient participation that values the views of the older person as a legitimate basis for decision making is vital to effective assessment (McCormack and McCance 2010). Therefore, assessment can be seen as providing the foundations of care in which therapeutic working and care needs are identified, clarified and agreed by nurses, older patients and their care partners. As a continuous process, nursing assessment should not be viewed in isolation but as part of a picture that is emerging which reveals the older persons current situation, past experiences, perspectives and desires for the future (Heath 2000; Webster 2004).

Assessment strategies in nursing have been influenced by the problem-solving framework of nursing models and the nursing process. According to Ford et al. (2004) these influences have resulted in the systematic and comprehensive assessment of an older person’s health status. There remains, however, much debate about the effectiveness of such strategies for assessment in practice (Dougherty and Lister 2011). Some argue that person-centred care can be compromised by fitting patients into such rigid, inflexible assessment frameworks which can stifle creativity and devalue relationship building. The tools for assessment are not in themselves problematic, the problems arise when these aids to assessment become the assessment itself (Tadd et al. 2011). Johns (1991) argues that such structured assessment criteria leads to the risk of assessment becoming a mechanical activity or a task that the nurse must complete in which the opportunity to ‘see’ the older person is lost or not valued (Webster 2004). Additionally, older persons may become disengaged as a result of being asked the same structured assessment questions repeatedly and come to the conclusion that no one is listening. The outcome of such assessment may be result in nursing priorities competing with or disregarding the older persons contrasting priorities (Fischer and Ereaut 2012). This presents an apparent contradiction in identifying needs or problems with the risk of jeopardising the concept of personhood. Binnie and Titchen (1999) further this argument, stating that structured assessments encourage the compartmentalisation of the person and reinforces the traditional bias towards physical aspects of care when in reality, the older person may be more interested in their social situation than their symptoms (Fiscner and Ereaut 2011). As Thomas and Pollio (2004) emphasise what we know about the physical body from a nursing or medical point of view will be incomplete until we also take the first-person view into account. For these reason there should be a clear understanding of assessment frameworks, their benefits and limitations and their appropriateness to the context of care (Webster 2004).

As previously emphasised it is vital for nurses to connect to the whole life experience of the older person under their care by immersing themselves in the social context of the individual (Van Heijst 2011). Only then can the nurse begin to understanding something of the context, the ‘life world’ in which both the values and beliefs of the older person arise. Todres et al. (2007) emphasise that the perspective of the ‘life world’ is the foundation for humanising the practice of care. McCormack and McCance (2010) suggest that one way of enabling full emersion in the ‘life world’ of the older person


is through the concept of ‘authenticity’. ‘By authentic is meant a way of reaching decisions which are truly one’s own – decisions that express all that one believes to be important about oneself and the world, the entire complexity of one’s values’ (Gadow 1980, p.85). Being authentic requires nurses to consider such factors as the meaning of individual relationships, emotional engagement, knowledge and decision-making capacity of the older person in determining their ‘being in the world’ (McCormack and McCance 2010). Many older people may be unable to represent their authentic self autonomously and so need help from others in situations when their authenticity may be under threat. Having some understanding of the older person’s ‘life plan’ enables the nurse to potentially provide such help. For the majority of people, a life plan consists of our closest friendships and relationships in which we share our deepest sense of ‘self’ with others. Knowledge and appreciation of these facets can enable the nurse to know who the older person is as a person, what values are important them, the dreams, hopes and desires they hold in their life and the kind of life they strive to live. Taking such a dynamic into a professional relationship and as a nurse facilitating the care of another person, that life plan translates into a formal comprehensive assessment that takes account of the older person’s biography. McCance and McCormack (2010) argue that ‘knowing the person’ in this way, through historical narrative and identity, is essential to person-centred nursing.

Biographical approaches to assessment are not just about collecting patient stories (McCormack and McCance 2010). Instead, respect for the older persons narrative reflects the Kantian ideal of respect for the intrinsic worth of a person (Ford and McCormack 2000; Wright and McCormack 2001; McCormack and McCance 2010). Scholars establish narrative as the way that humans exist within, and make sense of, the world (Manning and Kunkel 2014). At the broadest level of abstraction narrative is viewed ontologically. In life in general, we are recognised by our narrative identities (Gadamer 1993), that is ‘who’ we are as individuals and in communities and relationships with others (McCormack 2002). ‘People have a past, a present and a future and to detach oneself from the past serves to deform the present and plans for the future’ (McCormack and McCance 2010, p.15). Therefore, exploring older people’s past and present lives with them, particularly the circumstances which have shaped their experiences, potentially provides greater insights into their needs and aspirations (Clarke et al. 2003).

Narrative identity is grounded in language and manifested through dialogue (Hsu and McCormack 2011). Patients and their families must be empowered and encouraged to tell their stories, share their ‘life plan’ and reflect on their meaning and implications for themselves (Clark 2001). Therefore, the role of the nurse is to enable the clarification of values in order to maximise opportunities for growth and the making of authentic decisions which are representative of the person’s life as a whole. Relying on narrative activity to gather information, keep records, build relationships with patients and make therapeutic decisions depends on a break from the structured assessment discussed above (Charon 2009). McCormack (2003) argues that it is not enough to just take note of another’s beliefs, values, views and experiences but they must be integrated into the biography of that individual. Nurses need to be open to listening and hearing patient’s stories and valuing this activity as an important part of continual assessment (Goldsmith 1996; McCormack 2002). According to Finfgeld-Connett (2007), going beyond routine assessment in this way involves creativity and risk.

Many studies, which have taken place in long term care facilities, have concluded that the biographical approach enables nurses to gain a better understanding of the older person by providing knowledge which may directly influence care. Additionally, it has been emphasised by


Nolan et al. (2001) that there is therapeutic value in using the biographical approach with older people and their care partners. Listening to and acknowledging an older person’s life story is a powerful way to show that they are valued as an individual (Clarke et al. 2003) and has the potential to prevent the reduction of the person to a ‘thing’ and to maintain personhood (McCormack 2001). Although there have been many advocates of biographical approaches within nursing literature (Clarke et al. 2003; Wilcock et al. 2003; Bridges and Nicholson 2008; Bradshaw 2014) and biography is used informally in some settings, few studies have evaluated the impact of biographical approaches on care delivery in the acute care setting. However, McCormack and McCance (2010) argue that applying the principle of ‘life-plans’ should be no different for patients being cared for an acute hospital setting than it is for people in residential and continuing care.

Findings from Clarke et al. (2003) investigation of the use of ‘story-telling’ biographical approach, on a transitional care unit at a NHS hospital, suggested that nursing staff within the study were encouraged to see the person behind the patient and build and strengthen relationships with patients and their relatives. However, it was noted that nurses were often too busy to engage in the process and build trusting relationships which may result in a ‘hit and run approach’. Time is a valuable commodity and is frequently cited as a reason for not getting to know the patient and develop a therapeutic relationship (Dewing and Pritchard 2000). Webster and Whitlock (2003) suggest that nurses should consider whether their available time can be used in a different way to find out what is important to the patient. Clarke et al. (2003) advocate integration of the biographical approach into everyday care activities as opposed to a more formal activity stating that the biographical approach can be developed and sustained over time. Indeed, it is argued that physical care provisions by nurses is essential, as it provides a ‘way in’ to operationalising person-centred processes and achieving person-centred outcomes. McCormack and McCance (2010) support this idea maintaining that every time an older person is approached by a nurse for whatever the reason be it to administer medication, perform a procedure or ask a question, is an opportunity for the nurse to be attentive, available and provide person-centred care in that moment.

As previously mentioned, Hsu and McCormack (2011) carried out a study which explored the use of narrative inquiry interviews with older people within a rehabilitation unit, to inform practice and service development. In discussing the results of the study Hsu and McCormack (2012) suggest that nursing assessment is similar to a research interview (Rose 1994) in which skills such as listening and probing need to be applied. Facilitation of narratives and the expression of a desire to understand the origins of patients’ thoughts and feelings, to ‘hear’ their questions and concerns were highlighted as key to successful assessment. According to Hsu and McCormack (2011) the narrative inquiry process is appropriately applied through the use of questions which address how older people feel about their surroundings and everyday events rather than questions that are interrogative, explanatory or based on specific examples (Jovchelovitch and Bauer 2000). Clandinin (2013) supports this view, stating that narrative inquiry begins and ends with a respect for the ordinary lived experience. Bradshaw (2014) believes that it is this bearing witness to patients shared story over time over time that is vital to narrative approaches.

According to Fredriksson and Eriksson (2003) in order to access the older person’s ordinary lived experience or ‘life world’ focus must be shifted from communication with older patients to conversation. Genuine conversation requires nurses to ‘drop roles’ so that listening becomes less of a performance and more an availability (Lee and Prior 2013) which Gadamer (1993) describes as a


fundamental way of being with another. This places an emphasis on the relational meeting of persons in a conversation rather than emphasis on the exchange of information in communication. Lee and Prior (2013) label this therapeutic listening which is linked to phenomenological practice and requires the listener to avoid common responses when listening. Robertson (2005) emphasises that the continuous process of self-awareness is vital to breaking habits of common responses which merely gain answers to professionally led questions (Weiss 1994; Chase 2006). By guiding the older person to experience and express their feelings through interpreting stories, evaluating previous comments and formulating the next question nurses can become attentive to how the older person’s health problems impact on their everyday life and relationships.

In the previously discussed study, Tadd et al. (2011) suggest that for the nurse to engage in such conversations and see the patient as ‘person’ nurses must ask the question ‘What do I need to know about you as a person to give you the best care possible?’. Similarly, in Dewar and Nolan’s (2013) previously mentioned programme which sought to integrate compassionate care across practice and educational environments, nurses were encouraged to engage in the process of ‘appreciative caring conversations’ in order to understand a) who people are and what matters to them; and b) how people feel about their experience. Dewar (2012) suggests that by integrating this process into practice nurses are able to work together with older patients to shape the way care is delivered. Underpinning these conversations Dewar and Nolan (2013) emphasise seven essential attributes; being courageous; connecting emotionally; being curious; collaborating; considering other perspectives; compromising; and celebrating. This study suggests that these seven attributes are crucial to the delivery of relational care and can enable nurses to step out of their comfort zones and take risks by asking questions which facilitate engagement with older people and their care partners. Examples of such questions:

What matters to you most whilst you are in hospital? Tell me something that will help us to care for you here? How do you feel about your experience? What helps you to feel up beat and well? How would you like us to respond if you are feeling low? Who/what are the most important people/things for you? What worries/concerns do you have? What things have worked well for you here?

Chochinov (2007) promotes the routine use of such questions stating that they acknowledge personhood beyond illness itself. Dewar et al. (2014) specify that there can often be a misapprehension that there is no time for nurses to engage in such conversations. However, within their study nurses were able to incorporate engaging in these conversations into daily practice suggesting that it does not need to take extensive time.

Narrative approaches to assessment humanise the healthcare experience by recognising and emphasising the social nature and interdependency of human life rather than independence and autonomy (van der Meide et al. 2014). However, the essence of biography is not its contents but the process that are triggered and sustained by it. Hart (2011) emphasises that the way in which patient stories are heard and absorbed in the clinical encounter, during initial and continual assessment, has the potential to promote either person-centred or fractured care. A potential danger is that the


information shared is seen as of interest of fascinating but has no impact on the way in which the nurse works with the older person. As emphasised by Dewing and Pritchard (2000) ‘ the ideal of person-centred and holistic assessment as an ongoing activity that forms the foundations for care planning and evaluation still seems to be far from the usual or norm for many older people’. To be successful, nurses need to act as facilitators of narratives and to express a desire to understand the origin of patients’ thoughts and feelings to ‘hear’ their questions and concerns (Hsu and McCormack 2011). Recognition and validation of what is considered salient or meaningful to the older person and their care partners must be followed by curious questioning as to what hospitalisation and their physical condition means in relation to their social world and how they can be meaningfully supported.

Being listened to is an acknowledging engagement and the role of the nurse is to enable the clarification of values in order to maximise opportunities for growth and the making of authentic decisions which are representative of the older person’s life as a whole. Within acute care, it is essential that there is a shift from the problem-orientated form of assessment, in which goals and priorities of care are determined by the professional, to a goal-based paradigm in which wishes and needs of the patient become central value in the response to complex co-morbidities. For this to be achieved the nurse must be creative and flexible in their assessments, integrating questions that invite patients narratives. Genuine curiosity as to what is significant to each patient in each moment is vital to discovering, understanding and accepting individual’s stories. Construction of patient’s biographies throughout the continual assessment process should allow older patients and health care professionals to build shared expectations and priorities for care that reflect what is meaningful to the individual.


Key Findings and Recommendations for Model Development

As outlined in the report, the research team evaluated literature which indicated guidelines and standards of best practice for effective listening and learning, in maintaining dignified care for older people, in the acute setting. This process informed the development of key principles of best practice models in listening and learning and research sub-questions. The key findings and recommendations are presented below as well as the model in Figure 1 (below).

Attributes of a Model in Learning and Learning

The model of listening and learning compromises of 8 recommended attributes. Desire and motivation are indicative of commitment to providing person-centred care. Self-awareness reflects the awareness of professional and personal attitudes, beliefs and values and how these can influence practice. These attributes shape how relationships are developed and how patients are engaged with at an emotional level. Emotional engagement involves the acknowledgement of patient’s stories and experiences, openness to the reality of the situation, the courage to ‘drop roles’ and deliver human responses. Presence and availability highlight the importance of communicating accessibility, warmth and a readiness to listen. Curiosity and risk taking necessitates questioning, discussing and clarifying of how man experiences his existence and openness to the unknown. Ultimately, the purpose of curious questioning is to gain contextual knowledge of both the patient and family and to strive for understanding as to how these shape their priorities for care. Continuous feedback focuses on the validation of what is salient or meaningful to the patient, through the


exploration of patient’s narratives in everyday conversations. This is closely linked to flexible, creative assessments that integrate shared decision making through negotiation. The outcomes expected as a result of effective listening and learning from older patients and their care partners include the establishment of relationships in which a sense of security is developed and dignity is maintained.

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Figures

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· web viewreport. one of these is the ‘listening and learning hospitals pilot project’. the...

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