Aspectos del Mantenimiento

The focus of this phase was to work with staff to refine the ideal by producing statements about positive caring practices and then design, implement and evaluate activities that would support staff to achieve these practices most of the time.

3.8.8.1 Developing positive caring statements

I worked with groups of staff to review data from the previous phases and used this to generate statements about care practices that worked well and that people were willing to defend. These were care practices staff had either been observed in the course of the

study, or had been highlighted as something staff aspired to. These were specific statements about practice that would help staff to design activities to enable the caring practices and to monitor whether they were carrying them out. In AI these statements are called provocative propositions (Cooperrider, Whitney & Stavros 2003).

The literature argues that a provocative proposition or statement should meet the following criteria:

 is it provocative? Does it stretch, challenge or innovate?;  is it developed from real-life examples?;

 do people feel passionate enough about it to defend it?; and

 is it stated in bold, positive terms and in the present tense? (Cooperrider, Whitney & Stavros 2003).

These criteria were useful in developing the statements. So, for example, in relation to the observed positive care practice, shaking a new relative‟s hand when you first meet them, we developed a statement:

We believe a deliberate welcome is important when we meet new patients and families. It costs nothing (provocative element). We go out of our way to welcome them (bold

positive terms), for example by shaking their hand when we first meet them and

introducing ourselves by our first name (developed from real life examples). When we do this it helps us to make a connection with them and develop relationships more quickly

(impact of the action).

I would add the criterion that it also states what the impact of the action could be.

Staff found it hard, however, to generate statements. To develop one statement from the wealth of data took around one hour of discussion. It was clear that developing a range of statements to prompt action would be time consuming and difficult. I was cautious about developing the statements alone, as this could have altered the caring practice that was

observed or talked about so that staff felt less ownership of it. Therefore I worked with all of the data and generated 72 positive caring statements that could then be debated on the ward and redrafted to arrive at care practices that people felt they could defend, and that generated specific actions in response to the statement‟s intent. So, although I took a lead on this work, staff owned the content of the positive care practices as they had already carried them out in practice. They actively debated and redrafted them. Examples of statements can be found on page 238 in Chapter 6.

Following development of statements the following process took place to enable all staff to engage with the messages, to debate them and decide on future actions if appropriate:

• developed statements from data and chose images to depict the essence of the message;

• displayed these using a digital photo-frame at nurses‟ station in centre of ward; and

• created daily opportunity to discuss and debate each statement using the framework of questions:

– How does it make you feel? – Does it happen most of the time? – What helps it to happen?

– How can it happen more of the time? – What action do we need to take?

This structure of questions was crucial to help staff focus, in what was often a very short period of time, on having meaningful dialogue that helped them to express respect and humility as well as open up conversations for discussing possibilities.

Examples of statements and images that were displayed using the digital photo-frame are shown in Table 7:

Table 7 -Positive Care Statements and Images

Image based on original image called Sunset in Acapulco by Esparta distributed under control of creative commons attribution license

http://www.flickr.com/photos/esparta/1443263202/sizes/l/in/phot ostream/

Image based on original image called A pair of African penguins by paul mannix distributed under control of creative commons attribution license

http://www.flickr.com/photos/paulmannix/552264573/sizes/o/in/p hotostream/

Image based on original image called Dandelion by Nerdegutt distributed under control of creative commons attribution license

http://www.flickr.com/photos/nerdegutt/3584415033/

Image based on original image called Bumble bee by Ahisgett distributed under control of creative commons attribution license

http://www.flickr.com/photos/hisgett/4849358448/

Image based on original called Toilet by dominiccampbell distributed under control of creative commons attribution license

http://www.flickr.com/photos/dominiccampbell/2398857758/sizes /z/in/photostream/

3.8.8.2 Designing and implementing the activity

Specific projects were identified by staff as care practices they wanted to take forward to try to reach their ideal. Decisions had to be made however about what would be left behind and what would be taken forward as there were potentially 72 actions available. Decision making was pragmatic and was guided by a range of factors, including the emotional impact the data extract had on the participants. Thus a level of consensus had to be negotiated.

3.8.8.3 Field notes to evaluate impact of activities

A number of action cycles were taken forward and I continued to work on the ward for two or three days per week carrying out informal observations and discussions to monitor the impact of the action cycles. These data were recorded as field notes. So, for example, in an effort to establish the impact for staff, patients and families of learning more about them as people, key stakeholders were asked a series of informal questions about how it felt to be asked questions that helped staff to find out more about them as people, and what impact this had on development of relationships and caring activity.

3.8.9 Phase 5 - Destiny Phase – implementing, evaluating and