Presupuesto

Navigating assessment to contain complexity, includes the use of a prioritised and separated approach to care.

‘Time is something that everybody lacks these days. Because you cannot do everything for everyone all the time. But we try to do what is more important.’ (Physician 39)

‘You cannot always do what you want, you know, time ... I think the frustration is not having enough staff.’ (Senior nurse 20)

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The physician mentions that sometimes professionals have to prioritise, or focus on what is most important. Prioritising care can be seen as a strategy to manage and meet a large number of potentially competing demands, which will be presented in section 4.3.3. Prioritising is a way of working where constant decisions are made on what to do first and what to put on hold:

‘I understand they cannot wait on any particular person because they have got more than one person to look after.’ (Patient 11)

‘You could be having three admissions in your area. So you are going to do the important ones or you get as much as you can.’ (Senior nurse 20)

The decision on what is prioritised may differ per profession though:

‘Our priorities as nurses are sometimes different from the priorities of the junior doctors. Where the junior doctors kind of just want to get through and see all the patients for that day, but I want a TTO [medication to take home].’ (Junior nurse 33)

Nonetheless, all professionals usually prioritise acute medical issues above chronic or social issues:

‘Obviously we need to address medically, um, is the priority.’ (Senior nurse 9)

‘If an ECG is needed urgently then that goes on top of everything else. It just overrides ... like leg dressings.’ (Junior nurse 30)

‘I mean physiotherapy came and took me to walk from here to there and back during the day and that was all the physiotherapy I had that day. Which is not enough. ... They said: “well, you are not here for that reason”.’ (Patient 11)

Social issues are addressed once the patient is medically fit and not before:

‘We are aware of patients before they are actually medically stable for discharge, although we can’t actually start the discharge planning until they are.’ (Allied HCP 28)

‘I personally have to see people who have to be medically stable, for me to have any input with them.’ (Allied HCP 36)

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Another aspect of care that is often not prioritised is the time to ‘have a chat’ between patients and professionals. This includes chats around topics that are not health care related, such as children and grandchildren:

‘I haven’t got the time as such to sit with a patient and make sure they are OK, and they’re happy and their needs have been met.’ (Junior nurse 30)

‘You haven’t got time to have a little bit of a chat, you know, it is like ships in the night. You just don’t have the time to have little bit of a chin wag with them.’ (HCA 47)

All these examples show how navigating is steered by prioritising care. Resources and time are limited and therefore professionals aim to focus on what is most important. These decisions are shaped by the demands that need to be met, such as the need for written evidence, the need for speedy discharges and the need to guarantee patient safety. Each moment may require a different approach due to the priorities that are steering the process along.

‘They are telling you the patient isn’t well. You are not going to wait for the notes and things, you need to get on the phone to the doctor.’ (Senior nurse 20)

When looking at this quotation by senior nurse 20 it shows how sometimes a situation requires a quick response from professionals due to acute medical issues.

Another strategy professionals can use to manage competing demands, apart from prioritising, is by separating care processes. This links to prioritising as it means professionals can prioritise certain separated aspects of a care process in order to keep a number of processes going. Separating can be found in a task-centered approach to care, which was touched upon earlier in relation to the use of jobs lists.

The data suggested how patients felt rather frustrated by the separation of care:

‘I had to lie flat and not move at all until I had the brace fitted. Nobody knew how to fit the brace up here. So they called ... surgical appliances to come up and show them ... and it was more than 24 hours later when they came up .... I got really frustrated and angry.’

(Patient 8)

‘Everything seems to be in a separate little box ... one department that is my department and outside that you have got to get in touch with somebody else.’ (Patient 13)

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When looking at the task-centred approach it becomes clear professionals sometimes focus on isolated jobs that need doing, rather than on comprehensive care processes:

‘Because I have tick boxes, so if there is a job doing, I put a box. And once I have done it I tick it.’ (Junior nurse 22)

‘So any jobs for the doctors I put on there, on the list, and they can tick it off. And jobs for the nurses, doctors put on there, or I can put it on there as well.’ (Junior nurse 29)

Care processes seem to be pulled apart in jobs to do to make it easier for professionals to manage the workload they have to carry.

Separating of care is potentially due to the specialisation and the hierarchical approach within the care system. Specialisation refers to the increase of disciplines, each focusing on one specific area of care. Hierarchy includes the different levels of professionals within one discipline. During observation of a board round the relationship between different disciplines and separation of care became clear:

‘At times different conversations were going on at once … the ward nurse quickly said to the ward doctor that he should review the IV antibiotics today and he said he would, while the consultant was saying that the CT was clear, and the discharge coordinator asking the physio what she thought about the mobility.’ (Field notes 10)

However, specialisation and hierarchy was also linked to specialist care and advanced knowledge, as well as support for junior professionals:

‘I fine tune it. I think as I said, often the nurse on the ward have probably, had a look at that already but ... they don’t go into as much detail as I do.’ (Senior nurse 14)

‘I remember when I was newly qualified it would be more of a panic and then I would have to go to the senior nurses again, to sort of get their experience in.’ (Junior nurse 7) A separated approach appeared to influence the way patients experienced the process of their admission, including the assessment process. It results in different people holding different information. This has an effect on the way information is shared and on the way an assessment process is navigated, and this is especially linked to the role of coordinator, as will be discussed within the theme ‘Networking’. The knowledge gained and understood by different people has to be pulled together, and in some way it has to align in order to provide comprehensive care.

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4.3.3 Managing competing demands

The senior nurse in this quotation spoke about the demands professionals have to deal with when working on a ward for older people. When relating this to the assessment process this holds true as there are aims to be met through the process that is undertaken. Navigating then, is a way to reach the destination, or destinations. It is a way to steer through the process to meet the demands. Everyone involved has different aims. First the patient aims, and then the aims from professionals and the organisation or the system will be addressed.

Patients have a number of expectations during their admission. Whether their stay has felt as a positive one, is closely linked to their expectations having been met. From the patient data, a number of expectations were found including sorting out the problem, providing answers, encouraging independence, being listened to, being cared for, and having their needs met:

‘They are doing their best to try and sort the problem and get to the root of it and why it is.’ (Patient 4)

‘They were good to me; they took care of me ... most of them made my stay pleasant’ (Patient 6)

‘They care, they have got the compassion. And that is a very important thing in a nurse isn’t it. To have compassion.’ (Patient 8)

‘I just want them to mend my knees and send me home really.’ (Patient 10)

‘They need to listen.’ (Patient 10)

Professionals also mentioned or implied a number of aims they seemingly wanted to meet. The main ones found in the data are around caring for the patient and keeping them safe, producing evidence of practice, and being a respected member of the team:

‘I think the most important thing is that the patient is safe.’ (Senior nurse 9)

‘It does make me feel better, it makes me feel that they [colleagues] know that I am actually doing my role properly.’ (Allied HCP 23)

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‘Whatever you are doing, you are putting it down on paper. It is your evidence.’ (Junior nurse 24)

Most of the aims above will also be held by the organisation, such as patient safety, providing evidence, and make sure the patients are well looked after. However, there is one organisational aim in particular, which was mentioned to have an impact on patient care:

‘I think because they are so honed in on discharge.’ (Senior nurse 13)

‘Then there is pressures from outside that want patients to be discharged quickly or why are they not going, we are busy at the A&E, why are these patients still here.’ (Physician 39)

The pressure on hospital beds seems to result in a demand to speed up care process, including the navigation process through which patients are assessed.

4.3.4 Summary

In this section the elements of assessment were presented for each step of the process, which are knowing, understanding and if needed, acting. Each step can be undertaken in a different way by incorporating a variety of elements. Professionals included different ways of working as they navigated their way through assessment processes. These ways of working included formal and informal ways, visible and invisible ways, and a separated, prioritised approach to care processes dividing them into isolated tasks. By incorporating all these approaches, different demands were met at different times. The use of a variety of elements and ways of working, showed how professionals aimed to contain the complexity of the navigating process.

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4.4 Theme: Networking