Fundamentación teórica
4. Contexto de enseñanza de la lengua en el país: políticas lingüísticas
The following is a narrative summary of the cross-case analysis of the interview data focusing on care planning and co-ordination, support systems, safety and risk, organisational context, recovery
and personalisation.
Care planning and co-ordination
Many members of staff across sites talked of the importance of collaborative care planning. Many also spoke of the value of plans being kept up to date with service users actively involved, and of plans being used as a way of pulling together multidisciplinary contributions and of helping manage transitions between hospital and community. However, staff, service user and carer interviews all revealed gaps between shared aspirations and realities, even when service users drew attention to receiving good-quality care. Staff accounts of routine collaboration with service users in care planning contrasted with service user accounts that pointed to lack of involvement. In all sites service users were interviewed who said that they were not involved in the planning of their care, or were unaware of the content of their care plans or had not received copies, or did not feel a sense of care plan ownership. Staff sometimes spoke of service users’ unwillingness or inability to collaborate in care planning, or of the barriers to collaborating brought about by the introduction of electronic records. Lack of a shared language was cited as a barrier in one inner-city site (Dauphine). Staff in
Burgundy said how the all-Wales CTP template was not well suited to the short-term nature of acute hospital care, with some domains (e.g. housing) emerging as higher priority than others. As a solution, staff here described having created add-on‘intervention’ or ‘management’ plans for exclusive use in the inpatient environment. Coherence and continuity in care across hospital and community interfaces were identified as important by many of those taking part, and examples of detailed and collaborative discharge planning involving staff and service users were given. Innovations were also described, such as‘interim discharge summaries’. However, rapidly arranged discharges were also talked of along with protracted admissions. Across sites carers, too, reported generally low levels of formal involvement in care planning processes, although carers also spoke of high-quality care being provided.
Across sites two types of care plan review were described: formal, typically weekly, multidisciplinary meetings chaired invariably by consultant psychiatrists and daily handovers in which care on a more immediate basis was reviewed by staff. Formal ward rounds were described as key events by staff and as places where progress and plans could be reviewed in a multidisciplinary context also involving service users and carers wherever possible. Service user views and experiences of these differed, within and across sites. For some they were helpful, serving as opportunities for catching up with psychiatrists and the whole MDT. Some service users also described having been supported ahead of time to plan and prepare for formal ward round participation. Others spoke of limited time to fully consider service user needs and issues, of excessive jargon being used and of inflexibility over ward round scheduling.
Support systems
Training and support for staff in care planning varied, from reports of structured sessions to reports of no training whatsoever. In Provence, for example, staff spoke of classroom teaching, e-learning and updates. Irrespective of reported levels of ongoing training, staff across sites talked of their commitments to involving service users and carers and to offering support even if participants were unable to identify specific organisational policies on (for example) carer involvement. Expectations of staff spending dedicated, therapeutic, time with service users were described (e.g. in Languedoc). The majority of service users talked of their positive relations with ward (and community) staff, and of being treated with respect and dignity. One-to-one time was described, and of staff able and willing to listen. For some service users, though, differences in staff approach were described even on the same ward so that some workers were more likely to model particular attentiveness and care than others. Many service users also spoke of having had valuable support from workers not directly attached to the ward (e.g. from social workers). Not all service users had named nurses, however, with shifts creating discontinuities of care also being described. The use of bank staff and staff without qualifications was cited as problems for some. Carers’ experiences were also positive in many instances.
Safety and risk
Assessing and managing risk were invariably seen by staff as central parts of the work of planning and providing care, with formal ward round-based review meetings also being named as a place for risks to be discussed although not necessarily in the presence of service users. Particularly challenging discussions with service users were described in the context of talking through medication. Some staff also talked of the particular issues surrounding risk and decision-making in the care of service users who were detained. Risks mentioned by staff included those to self and others, with some also noting the dangers of overestimating risks and the importance of attending to strengths and of positive risk-taking. A staff view in Burgundy was that the CTP template was not suited to the regular updating of risk assessments. Most service users talked of their safety having been considered and attended to, sometimes giving specific examples of this in action (e.g. through removal of objects and the use of observations), even though risk assessments and management plans were often not actively discussed with them. Others did, however, talk of feeling unsafe in hospital and of asking for more staff.
RESULTS: CROSS-CASE ANALYSIS
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Organisational context
Staff across sites talked of their awareness of overarching principles underpinning care (e.g. recovery) and of demands for quality, and of specific new initiatives (e.g. the introduction of peer support workers in Dauphine, the use of audit through AIMS in Languedoc, and the introduction of the Measure in the Welsh sites). Staff also spoke of pressures in the system. These included expectations to secure speedy transitions from hospital into the community, high levels of need and limited resources. Centralisation of hospital services was mentioned in one site (Burgundy) as having made it harder for carers to maintain contact.
Recovery
Definitions and understandings of recovery varied among staff, service users and carers, as did views of the role of hospital care in promoting this. Participants, in many cases, were also aware of the disparate meanings of‘recovery’. Some staff (e.g. in Artois) viewed recovery as problematic in the inpatient context, saying that that this raised expectations or was too poorly understood to help effective care planning. In Languedoc, some antipathy to the idea of recovery was reported by some staff who challenged both its meaning and utility. When some service users said that hospital had helped (e.g. to stabilise medication), others complained of having been largely left to their own devices or subjected to containment. The use of tools to aid recovery (e.g. Recovery Star) were occasionally mentioned (e.g. in Burgundy), but in most cases these were either not deployed or were described as being more suitable out of the acute hospital care context. Service users and carers revealed a range of views around recovery, from the cure of symptoms and to the prospects of life without medication to the idea of coming to terms with difficulties.
Personalisation
The term‘personalisation’ was not a familiar one, with few revealing knowledge of personal budgets, although across sites there was certainly recognition of the idea that care and services should be oriented to the individual. Although some staff talked of inpatient care as being person centred, there was also widespread recognition of the challenges to this [e.g. tensions between different approaches to providing care, the fact that staff only get to know people as patients and the relative (un)availability of resources]. Within and across sites, there were differences in service user views and experiences of individually tailored care. Some were clear that hospital had been pivotal in their care, and that their personal needs and wishes were attended to. Others were equally clear that their care had not been personalised, or talked of their care at home being more personalised. Carers gave positive accounts of care provided, citing this when asked as having been tailored.
Summary of key barriers and facilitators
Good communication and positive relationships were seen as important by staff, along with regular reviews of service user needs. Time to spend with service users to develop therapeutic relationships was also cited as key, along with good integration and communication with community teams and workers. Less administrative work was asked for, along with more staff, closer collaboration between workers and service users and better management of discharges in timely fashion.
Chapter 6 Discussion
Introduction
In this chapter, we draw on the key findings from both the within-case and cross-case analyses and discuss some of the key issues that have emerged in relation to recovery-focused, personalised care planning. We make connections between the interconnected macro/meso/micro levels and focus on comparisons between this study of inpatient services and our previous study of community services.19,20We summarise
the impact of public and patient involvement in the study and identify the strengths and limitations of the work. We conclude with recommendations for research and implications of our findings for practice.