SISTEMA DE CARGOS Y ABONOS 49.1. HORIZONTE DE LIQUIDACIÓN

The final part of the analysis process was in the application of Mezirow’s (1991b) stages of critical reflexivity that enabled the development of theories from practice. The stages are outlined in Table 10.

Table 10 Critical reflexivity

(From Mezirow, 1991b) Descriptive What happened? What is important? Who is it important to? Affective Awareness of thoughts and feelings

Judgemental Awareness of value judgements. What was good and bad? Conceptual What concepts or ideas were being used?

Discriminate Awareness of decision-making and actions

Psychic What has been learned? How could situation develop? Theoretical Making sense of the situation and generating theories.

Critical reflexivity was applied during the listening stage. Thoughts and feelings that challenged assumptions, identified relevant concepts, decision-making and subsequent learning were all acknowledged. These all led to generating the key theoretical messages.

This systematic development of new knowledge was carried out alone without the team. There was some concern that this was moving away from the participatory process; however, there were two reasons that made this acceptable. Firstly, it respected the team members’ clinical commitments and the ‘need to get back to practice’ secondly, it gave an opportunity to look at the whole data set. This stage was more structured and in some ways felt like a backward step. However, with hindsight it has given reassurance and confidence that theories were developing from the critical reflection as well as the psychoanalytic process of listening, hearing and interpretation.

This synthesis resulted in the development of a framework for improving the experience of hip fracture care. Developing practice involved understanding and applying the beliefs of different paradigms at each phase of the

development. In each phase the role as facilitator was influenced by, and responded to, the culture, context, and leadership style. The actions and interactions at each stage resulted in the raising of awareness and understanding of the process of improving the experience of hip fracture care. Interestingly and unexpectedly, the development section strengthened and validated the method taken, by giving rationale for each phase of the development process.

One example of the outcome of this process of generating knowledge from practice is illustrated in Table 11 the remainder are in Appendix 21 to demonstrate how this process was carried through. The headings of critical reflexivity are inserted vertically (violet) and matched against the headings from the conditional matrix inserted horizontally (blue). Findings from Table 8 were inserted. Validation of the workshop data (orange) is inserted into the first column to describe what happened. Then each box was completed (black). The entries in pink indicate how the situation was developed and validate the method chosen for this study. The theoretical messages (green) developed were principles derived from this practice situation and the process of development.

Table 11 Phase 1 – Risks Critical reflectivity (Mezirow, 1991b) Conditional matrix (Miles and Huberman, 1994) Descriptive

What happened, what is important, who is it important to?

Affective

Awareness of my thoughts and feelings about the situation

Judgemental Awareness of value judgements What was good and bad?

Conceptual What concepts or ideas are being used or could be used. Discriminate Awareness of decision making and actions Psychic What has been learned? How could the situation be developed?

Theoretical

Using experience to generate own theories – to make sense of things What principles or strategies have I derived from this situation?

Culture (Causes) Top down, driven by guidelines, targets and pathways, targets have to be met, fixed quickly, boxes must be ticked

Lots of work gone into EBP guidelines but psychosocial hidden and ignored

Strong physical and functional measures performance. Little about experience Positivist approach – distorts reality Measured, quantified, functional, task orientated

Creates false safety, doesn’t value experience Needs research to raise awareness of other perspectives

Hip fracture care was driven by guidelines that were dominated by the positivist paradigm; consequently focuses on evidence-based, measurable criteria. Context Byzantine organisation

Fragmented, into service divisions; focuses on surgery and rehabilitation, omits feelings, becomes emotionally detached, mechanical rigid and reactive Many specialist healthcare professionals working in different services. Pathway divided for management purposes Working alone allows for professional autonomy. Feel isolated, have no help. Reduction in consensus and continuity React to problems Technical structural functionalism Professionals make decisions and deliver on priorities Fear of system Focus on meeting own professional priorities. Working together Specialist healthcare professionals work independently delivering fragmented services; there is little collaboration between the various teams and service delivery units involved. Leadership/

Intervening condition

Driven by fear and blame; told what to do; judgemental of each other; lack of time; dependent on actions of others,

Group

knowledgeable in their field of practice but only EBP appears valued; authority with managers, lack of autonomy

Aiming to manage and control risk but can be inflexible and undermining. Focus on tasks

Transactional Projection and rationalisation Blame

Creates ‘them and us’

Controls

Tells, not listening

Control process not person. Listen +++

The system appears to only see the clinical and management

perspectives and functions by encouraging the management of risks, by enforcing control and monitoring performance. Phenomena Unhappiness, anger,

frustration, getting worse lack of positive regard, isolation, need to get out or burn out

Conflict, hidden emotions raises anxiety and reduces trust

Lacks feelings, low morale, burnout

Stress and coping Problem solving or defence

mechanisms

Hidden stress that influences behaviour Enable expression of stress/anxiety Highly stressful environment as a result of conflicting values between efficiency and compassion

Critical reflectivity (Mezirow, 1991b) Conditional matrix (Miles and Huberman, 1994) Descriptive

What happened, what is important, who is it important to?

Affective

Awareness of my thoughts and feelings about the situation

Judgemental Awareness of value judgements What was good and bad?

Conceptual What concepts or ideas are being used or could be used. Discriminate Awareness of decision making and actions Psychic What has been learned? How could the situation be developed?

Theoretical

Using experience to generate own theories – to make sense of things What principles or strategies have I derived from this situation?

Action/interactions Dissonance

Lip service, priorities, do what is important not what it urgent Who’s success? Fuzziness Missing the point Perception, targets are an excuse Chaos Mixed messages Inconsistency Distress Scrutiny Criticism

Gets tasks done Appears to lack caring Confusion Lack of information Lack of understanding Task orientated Loss of dignity and respect Communication and record keeping Creates language – focuses on prosthesis not person Leads to unintended loss of dignity and respect Professionals know best Needs values clarification To cope healthcare professionals become emotionally detached, depersonalising the situation. Defence mechanisms are used to cover up the anxiety and discomfort experienced

Consequences/ Conflicting values Competing demands Discomfort, can never satisfy needs

Unresolved leads to stress

Appear uncaring and disrespectful I fear the blame Person hidden, therefore nursing is hidden as -Advocate for patient -Wishes to reduce conflict Defence mechanisms Dissonance and anxiety = projection and rationalising Blame Blame others ‘them and us’

Unintentional impact Behaviour due to release of feelings lack of support or lack of self-awareness Listen to the experience

Rationalising actions and blaming the system are defence mechanisms that distort reality leading to a breakdown in communication; lack of information, confusion and lack of understanding Reflection and action Social systems as a defence against anxiety Fractured service – has a stroke needs

attention to weak side

Research from 50’s still persists

Needs attention

Pattern very clear but many are blind to this

Criticism and monitoring increases anxiety and the problem

Psychodynamics Positive approaches and management control are not going to improve this.

This is stressful workplace needs social support and action.

Accept the situation as it is

By accepting the situation as it is, reducing fear and enabling collaboration the sharing process will raise awareness and improve understanding