5. RESULTADOS
5.1 Análisis de Resultados primer diagnóstico
Commentary
The results above appear to clearly indicate staff believe the Trust has a long way to go in developing a culture whereby SMS/SDM is everybody’s usual practice, or to use O’Donnell’s phrase “the way we do things round here” (O’Donnell, 2008, P.70), although almost half say they have seen changes in the organisation to develop this agenda. Whilst changes are clearly being made across the four elements of culture described previously Chapter 2 by Hogan and Coote (2014), namely values, norms, artifacts and behaviours, it would appear that barriers remain. Very few staff report these changes are easy to put into practice. One nurse said “this is a massive culture change. You can’t do it with a little bit of a fix here and a little bit of a fix there; I don’t this there’s enough to make this really happen for us – people lapse back into their old ways”. An AHP said “I think we focus on crisis management and the co-production stuff is secondary and often falls off the bottom of the list”. Another AHP expressed their view “we still have an anxiety that letting go of control will come back to bite us”.
Respondents felt their peers also placed high importance on the SMS/SDM agenda, reporting that their own teams have good systems for SMS/SDM embedded in their teams. However this appears to be a fairly locally held belief, as only approximately one third of respondents felt this was the case across other teams in the Trust. Evidence of sub-cultures will be explored more fully later in this chapter.
In relation to ease of access to training opportunities to gain awareness, skills and competence, only one quarter of respondents said they had easy access to these opportunities. This is not typical of access to training and development for PCFT staff: secondary data from the NHS Staff Survey (NHS, 2016) report a higher than average rating for the quality of non- mandatory training on offer through the organisation. The Self-Management Toolkit (Dixon and Poole 2014) signposts staff to training opportunities that are readily available within the Trust, however it appears awareness of these opportunities (and perhaps the Toolkit itself) and how they relate to supporting SMS/SDM is limited. This may be related to staff having a poor understanding of the skills required to practice effective self-management support and shared decision-making and therefore are unaware what kind training they need to access. One nurse said “the self-management training is brilliant when you get there – the problem is that people don’t seem to recognise their own need to change”.
Secondary data (Munn et al) showed that when teams were asked to self- assess their current competence in SMS/SDM, the results were unreliable. Some teams believed they had low levels of competence but had the ability to evidence significant good practice; conversely other teams believed they delivered excellent self-management support with very little evidence to substantiate that belief. The secondary data therefore suggest there is poor understanding of SMS/SDM, and ‘what good looks like’.
To address this, all team leads in Bury were mandated to attend awareness- raising training as part of a project, with 95% saying they learnt a great deal from the session, and their practice would change as a result. One key finding from the project was that “clinicians who previously did not think this was an issue for development in their service reviewed their opinions following awareness-raising training” (Munn et al 2015 p.7). Furthermore, undertaking a self-assessment of service competence in supporting SMS/SDM was reported to be the most useful part of the project, suggesting that teams appreciated the opportunity to better understand their development needs. One nurse said; “we thought we did this well already, however through the self-assessment and the training we now think differently, and realise that sometimes, inadvertently, we take control away from the patient, creating a dependency on the service through the language we use, and the systems and processes we have in place” (Munn et al, 2015, p.6).
The Individual Performance and Development Review (IPDR) process is partly a mechanism to support delivery of Trust objectives, with all relevant staff having a clear contribution to make to the achievement of overall Trust objectives. The SCQ demonstrates that only one fifth of respondents have any objectives identified to support SMS/SDM. Secondary data from the 2015 Staff Survey (NHS, 2016) report low levels of PCFT staff satisfaction regarding the quality of their appraisal, additionally 1 in 10 had not been appraised during the previous year. One quarter reported the values of the organisation were discussed during the process, with just one fifth saying that the appraisal had helped them to improve how they did their job. It would
appear this mechanism for supporting the delivery of strategic goals could be strengthened with respect to delivering the SMS/SDM strategy. One AHP interviewee said; “none of my team have anything in their IPDR to support this agenda. I wonder if everyone doing IPDRs makes the connection between strategy and setting objectives for people through IPDR?”
Less than 10% of SCQ respondents felt there were good systems of reward and recognition for implementing SMS/SDM. Recognition and value of its staff is one aspect that PCFT is striving to improve, with the 2015 Staff Survey (NHS, 2016) demonstrating that the Trust scores lower than the national average in this respect. In the survey, only 40% of staff said they were satisfied the organisation values their work; in contrast to local recognition, with 75% of staff reporting satisfaction that their immediate manager values their work. During the SSI a number of interviewees expressed their views about recognition and reward, one nurse saying “there’s nothing that champions this being a good thing to do”. An AHP said “I don’t think there is any particular reward for people who work well this way. I think people listen, but can’t see how this has ever been rewarded in the Trust”. One of the strategic leads alluded to a lack of certainty about the behaviours the Trust wanted to recognise and reward, saying “What do we want to recognise – is it good service, innovation, change for the better? What is it?” with another strategic lead saying “The formal reward mechanism is the Principles of Care Award; these hint at self-management but aren’t explicit”. It appears that, in general, staff do not feel adequately recognised and rewarded for the work they do by the Trust as a whole, whether or not this relates to SMS/SDM.
Recognising the correlation between organisational culture and organisational outcomes as described in Chapter 2, the organisation would benefit from considering and implementing ways to support cultural change towards embedding SMS/SDM.
Staff were asked in the SCQ to suggest ways they could act to support a cultural shift towards more robust SMS/SDM. Four strong themes emerged; these are presented in Table 6 below, in order of frequency of suggestion.
Theme Description Specific ideas for development Theme 1 Engage in co-
production as a fundamental way of practicing
Offer patients choice of treatments Deliver person-centred care planning Collaborative agenda setting i.e. ask the patient what is important to them Develop more robust mechanisms to
co-produce service models Theme 2 Access training Self-management support
Shared decision making Motivational interviewing Positive risk taking Theme 3 Better use of
available resources Provide accessible to support patients’ knowledge and
understanding of their condition/care plans
Better understanding and use of the services that are available within the borough to support patients to self- manage
Better understanding and use of opportunities available in the borough to support development of patient confidence and empowerment Theme 4 Set clear
expectations
Develop tools to support conversations that ensure patients and clinicians have clear expectations of each other’s input to the care process
Table 6: Staff suggestions of ways they can improve their SMS/SDM practice
The SCQ then asked staff their views about what the organisation could do differently to better support SMS/SDM. Four key themes emerged which are presented in Table 7, in order of frequency of suggestion.
Theme Description Specific areas for development Theme 1 Trust to champion
SMS/SDM more actively
an internal campaign to staff to ensure wide knowledge of this as a priority area
support for more active positive risk taking
ensuring incidents/complaints management support positive risk taking and patient empowerment an external campaign to support
system-wide change, engaging with citizen and health and social care partners
Theme 2 Access to training Ensure sufficient training is available to staff to support the development of self- awareness of the agenda, as well as specific skills acquisition
Theme 3 Influence a shift to outcomes-based commissioning
Work with commissioners to identify patient-focused outcomes as
measurement for contract delivery, with associated key performance indicators supporting person-centred care
Support the shift away from activity- based performance management where this doesn’t reflect patient outcomes
Theme 4 Support staff to develop new ways of working
Ensure caseloads are manageable and allow for personal and service development activity to deliver SMS/SDM
Identify early adopters of SMS/SDM and support them to spread good practice to other teams
A number of comments were offered during the interviews which support the above themes, and give further insights to how these actions might happen in reality, for example; “we need someone to model it, perhaps a trouble-shooter or peer-to-peer frontrunner – helping staff to see how they could work differently, pushing this forwards and taking people with them”. Another spoke about the time pressures faced by staff, saying “there is no dedicated time for innovation and developing new ways of working”. Identifying champions was further supported by the comment “if the people in the team who have skills in both SMS/SDM and making change happen are identified, and given some time, that would lead to culture change within the team”.
Setting a clear strategic direction, measuring relevant performance indicators and underpinning both with recognition and reward were additional ideas from the strategic leads interviewed, who said; “we’re doing some work around our values and how these are expressed, this will be launched at the AGM and will give us clear direction about what we want to encourage and recognise”, another saying “we could think about making self-management an internal key performance indicator, make it like managing a budget or something, to prioritise this for all staff and management alike. We’d need to be careful what we measure, make sure it’s relevant to demonstrate that this is really happening, and make sure it isn’t a tick box exercise rather than holistic change”.
One interviewee also alluded to this being a culture change and as such is a multi-faceted agenda to implement, saying “we should take it in chunks; we
might be getting ourselves immobilised with the enormity of the challenge. However when we do the small things it doesn’t give us huge impact we are looking for and we get disappointed. We need to be aware that’s what we do!”
Leadership
Staff were asked three questions (Q11, Q12 and Q13) relating to their perceptions of leaders with respect to SMS/SDM, recognising that leaders have a significant part to play in influencing the culture, setting the vision and supporting the implementation of the changes required to deliver the strategy.
No priority Low priority High priority Top priority Don't know 0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
In your view, what priority is given by Trust senior leads to better supporting self-management/shared decision mak-
ing?
Not at all Partially Mostly Fully Don't know 0% 10% 20% 30% 40% 50% 60% 70%