Knowing something about the person, who they are, their likes and dislikes, and what is individual to them was something that all participants valued. It seemed to move the care experience from ordinary to excellent.
One staff member talked about the little things that mattered to her when she worked with others, which in turn facilitated teamwork:
I like working with X, we care about the same things. We like things to be organised and for everybody to know what they are doing. Little things, like making sure you go round and clear all the patients‟ tables before lunch so that when you put the tray down you have a clear space. These things are important. It‟s good if you are working with somebody who cares in the same way as you do. (Staff Comment, Observation 8).
Knowing the little things that matter to each other as staff was seen as important but again this was rarely discussed, shared and celebrated.
Reciprocity was evident in data extracts where staff found out something about the patient and used this to enhance the care experience for the patient and themselves:
She (the patient Beth) sometimes becomes agitated and would be searching for keys or a door to get out and go home. One staff member, when finding out about her work in the beauty section of a department store asked her for a hand
massage. Beth was given the hand cream and proceeded to do the hand massage to the staff member. Beth said to the staff nurse that she „had let her hands go‟ and they needed quite a bit of attention. The staff nurse laughed and thanked her for this and asked if she would like her to massage her hands. They both had a thing going – with hand massaging. This really helped Beth to become more relaxed and the staff enjoyed this too. (Staff Story, SS3).
I was able to observe an instance of the hand massaging between staff and this patient during a ward round. Staff made a decision to balance the needs of the patient, who was particularly anxious at this time, the need for the care team to discuss patients, and the risk of this in relation to confidentiality issues where this patient was present at
discussions about other patients. This was a courageous act, as staff might have been questioned about this practice and they needed to feel comfortable to defend their actions. In addition, staff had to make compromises to try to achieve the best experience for all. It was evident that people working in the care environment cared for and about each other. Knowing the little things that mattered seemed to help staff to spot opportunities to adapt their care-giving practice so that it met the needs of patients and families.
A staff nurse talked about how important it was to find out the individual or special aspects that make up the person:
It was a lady we had on the ward she had been in for a couple of weeks and she began to deteriorate. She was quite a proud woman and she took care of her appearance. She would always brush her hair and on the days when she felt well, she would put her makeup on – blusher and lipstick. She got quite poorly … and eventually she lost consciousness. Her husband was coming in every day – they had been married for over 50 years. One day, when I was giving her a bed bath, I was looking in her toilet bag and I found her makeup. I thought she used to put it on herself so I thought I would put it on. I don‟t know if she was aware that I was doing this for her because she was unconscious. ... A few members of staff went in afterwards and kind of laughed and said, what is the point, or that was a bit silly. I think they thought I was a bit daft and slightly time wasting… When her husband came in, he came out of the room and said „who put her makeup on?, she looks lovely, she looks like herself‟. (Staff Story, SS9).
The nurse in this instance was actively considering the perspective of another. There is also evidence of the important contribution that the relative made in validating the
decisions she made. This quote highlights the challenge of valuing person knowledge and the courage to act on it even if others do not share the same philosophy.
In addition, this quote highlighted the challenges of finding out about „the person‟ when they themselves were unable to give this information. Additional skills of looking around, picking up cues, and asking relatives were important, in these instances. If this process is key to compassionate caring it raises issues about potential inequity if, for example, it takes longer to find the little things that matter for a person who is unable to
communicate verbally.
Following a discussion with the staff about their reaction to this story, some commented that they did not know if the lady would continue to like her makeup on while she was ill. They felt that the staff nurse who put her makeup on was making decisions for her that may not be correct. The husband did appreciate that his wife had makeup on, and we discussed whether this was „good enough‟ evidence for staff to continue to do this. What
this situation highlights is how complex the process of „knowing who I am and what matters to me‟ is. What is it we need to know about the person to help us to care for them? Is what we learn fixed in time or does it change depending on the circumstances? And, how do we learn what is important to the person if they cannot communicate this information? Having discussions together about these issues, where people had the courage to ask curious questions of each other, and consider different perspectives, seemed to be important to value and celebrate any decisions made.
One staff nurse shared how the staff had learned details about a patient‟s normal routine and likes and dislikes and tried hard to integrate these into care:
We went to the canteen to get her bacon rolls. These were small things that she missed about home. I suppose it was tapping into things that she would have at home.. … We tried to make it as homely as we possibly could. She liked The Scotsman – we got her a newspaper everyday. We also gave her jobs to do – she folded up the bags for us. She knew at times we were busy and she wanted to help us. She enjoyed this... (Staff Story, SS7).
Considering other perspectives in relation to what would make a difference to the person‟s experience was evident in this extract. The example does raise questions about the reality of the process of knowing who I am and what matters for all patients. Would it be possible to do these „little things‟ for all patients? How do people decide who gets what? These questions are developed further in Chapter 5 where key skills of negotiation and compromise are important in a dialogue where people feel safe to be open and real about expectations.
Staff felt that they found that they gleaned information about what mattered to patients informally through conversations. This was supported by evidence from observations:
Discussion took place at a multidisciplinary team meeting about a lady who was hoping to get home in the near future and a home visit had been planned. There
was a lot of discussion from the occupational therapist, physiotherapist and consultant about this lady, including details about her mobility, and her wound. The consultant then said – „the thing the patient is most worried about is will the chair get through the door – have we checked this out?‟. (Observation 5).
The consultant who led team meetings often made referred to aspects that were important to the patient and raised questions that challenged people‟s thinking. He therefore role modeled a way of interacting that was mirrored by others. There was evidence at team meetings that others volunteered information about the little things that mattered to the patient. This style of leadership from the consultant seemed to be a key aspect in „setting the tone‟ of the way care could be delivered. This raises questions about who we
consider to be key leaders in the multi-disciplinary team and the impact different leaders can make to the progress of change initiatives and the culture of the caring environment.
Staff tried to incorporate little things that mattered to patients into their routine even if it was not necessarily seen by others, e.g. managers/medical staff, as a legitimate part of their job:
One nurse really stood out for me. She took me downstairs for a cigarette. The Doctors might not think this is a good thing but it is good for me – it is all I have left to enjoy now. (Patient Story, PS6).
This highlights risks that staff, and in this instance the patient, felt safe to take in order to enhance the care experience. It seemed, in this example, that the patient and staff member were taking joint responsibility for the action. It was evident however that the intention behind such actions was not just to meet the specific needs of the patient. Staff also got something out of knowing the little things that mattered to people and acting on them.
Thus there was reference not only to the pleasure and appreciation of receiving care that incorporated the little things that mattered, but also to the difference this made to the person providing this care:
I know just how much talc she likes and that she doesn‟t like spray on her body – that she likes me just to spray her clothes. It makes you feel good when you know about these things because you feel you are really giving the care that they want. (Staff Story, SS8).
Staff did gain a sense of achievement when carrying out these acts, however the little things that mattered were not necessarily communicated to the rest of the team. Acting on these little things that mattered to the person was done by some nurses, but not all, thus making care fragmented.
One patient talked about what mattered to her, but felt that this was not known by all staff:
One thing that is important to me is making sure my hands are washed after I use the bedpan. This is very rarely done. Sometimes it is. I ask –„ can I wash my hands?‟ and people would say „well you don‟t need to because you‟ve not cleaned yourself – we‟ve done it for you‟. But I like to feel clean – I like my clothes to be clean, I like my hair to be nice. (Patient Story, PS 10).
This quote surprised staff. Many talked openly about how they did not always do this act for patients. They appeared keen to learn about this rather than be defensive about the criticism, thus demonstrating openness to change. I felt they showed a degree of humility in this situation where they recognised that the „expert‟ does not necessarily know what is best, and that there is a genuine desire to hear and consider other perspectives. This seems to be an important element of the culture, where people were supported to have the courage to own up to mistakes and be interested in learning from them rather than becoming defensive. It may be that AI, with the emphasis on being curious and asking unconditional questions, may have role modeled and thus encouraged this type of open response.