Patient Observation Experience: Key Outcomes and Highlight Points

During the ongoing experiences and demands of living and working within the NHS during the COVID-19 Pandemic, NHS and NHS Improvement published new guidance for NHS providers to help support them to plan and organise their workforce during unprecedented times of demand, capacity and staffing shortages. In my role of Head of Quality and Clinical Governance I took part in supporting a ward which at that time had over 80 capacity of COVID-19 positive patients. Experiencing first-hand the diversity of patients and patient needs on that ward it was agreed that I, could re-visit to participate in patient observation, accompanied by the Patient Experience and Engagement Manager. Observation of patient experience is discussed in this essay and some the key outcomes of the observation exercise and highlights points are also analysed. 

The process of the patient observation was explained to the Lead Nurse and it was agreed that the observers would spend no longer than 30 minutes undertaking the observation exercise followed by time feeding back to relevant ward staff. The observers ensured staff understood the purpose of the exercise and made certain all were given the opportunity to ask questions and seek any clarification. Reassurances were provided by the observers in order to establish firm expectations of the process and any anticipated outcomes of their time on the ward. The observers were assigned a six-bedded male COVID-19 positive clinical bay for the 30 minute exercise. Three of the six patients were observed as requiring enhanced support an 82 year old gentleman with language barriers (patient A), a 68 year old gentleman who had experienced a stroke some 12 weeks earlier (patient B) and a 99 year old gentleman with visual and hearing impairments (patient C). Whilst this paper focuses on some general overall observations of care and patient experience, predominantly the readers attention is directed to the observations made of the three key patients. The clinical environment required strict adherence to infection, prevention and control (IPC) procedures the bay door remained closed at all times, staff entering the bay wore full IPC protection apron, gloves, mask and face visor. Social distancing was mandated and there was a full visiting restriction in place. Both observers agreed that this had an apparent adverse impact on the experience and well-being of the patients. In particular the observers both agreed that the environment of the clinical area was oppressed and unwelcoming. There were no activities or entertainment for the patients and the only conversation was between the patient and the care provider. Staff were restricted in human contact due to PPE and social distancing requirements. Faces could not be seen and conversations were stifled by the wearing of face masks and visors. 

Observer 2 in particular felt this had led to the restricted nonverbal communication between the patient and the care provider. The presenting environment was undoubtedly in direct comparison to that described and promoted by Nightingale. Nightingale suggests factors such as good lighting, ventilation and positive stimulation has a direct impact on positive health-related outcomes. On only a few occasions could the care provider be heard introducing themselves to the patient prior to the delivery of care. All patients were referred to by their chosen name, however not all the patients were invited to participate in conversation. Both observers noted the obvious limited verbal communication with Patient B. The NHS Constitution guides us to the importance of delivering patient centred care. Both observers agreed that where communication between the patient and the care provider was observed staff were polite, courteous, and patients were treated with respect and individual needs were acknowledged. During the observation period a Registrar entered the bay to undertake clinical reviews. The Registrar was observed to engage with the patients and both observers noted the Registrars personal response to each of the patients and their vulnerabilities. 

Observer 1 in particular noted the positive impact of personal connection between the patient and the Registrar which is also supported by Duckett, K., who tells us of the importance of the humanistic quality of the care provider and describes the importance of the behavioural interaction between the care provider and their patient. Patient A was displaying signs of emotional distress. The Registrar demonstrated humanistic quality and empathy and took time to sit with the patient to understand what the issue was and what mattered most to patient A. Language was an obvious barrier but the Registrar was compassionate in his non-verbal communications, he spoke slowly and clearly and clarified at appropriate points that the patient had understood and was happy with decisions regarding his ongoing plans of care. The impact of good communication and shared decision-making on the patient experience was evident to both observers. The response to this interaction from the patient was powerful. From a distressed and apparent confused individual emerged a more content and settled person, thank you for listening and for helping me. Patient B was a quiet unassuming gentleman. The observers had already been informed by the healthcare team that the patient had suffered a stroke and was fully dependant on those caring for him. The gentleman appeared frail and elderly and was not participating in conversation. Unlike the interactions observed with the other patients, observer 1 noted how patient B often had his care needs undertaken in silence. During one interaction a student nurse was observed taking time out of her routine of work to engage with patient B and to seek assurance if he had everything he needed. This single, person centred interaction initiated a very emotive conversation which included the request for a telephone call with his wife. This was a direct reflection of the power of treating the patient as a person as presented to us by Goodrich and Cornwell. As well as the physical constraints caused by COVID-19, patient C had the additional limitations of sight and hearing impairments. Every member of the care providing team observed in interaction with patient C did so with a clear understanding and empathy of the environmental and physical barriers presented before the patient. The observers both agreed that time was taken to appropriately respond to the individual needs of the patient, acknowledging and understanding the other persons vulnerability and acting and responding in a way that was meaningful to the individual. As healthcare professionals we need to proactively seek out and identify the personal needs of the patient. We must redirect our focus from being entirely on the clinical needs of the individual and put equal emphasis on understanding the significance of patient-centred care. Well, they look or touch and feel and put their hands on your shoulders. Well you know, people, they respond to that it makes you feel like a human being. I know they are busy, but the small things show they care. Feedback was undertaken on completion of the exercise between the observers, the lead nurse, the student nurse and the Registrar. Key themes such as environment, communication and person-centred care along with considered recommendations were discussed. Whilst we look forward to a future in healthcare beyond COVID-19, leaders in the NHS must not deviate from person-centred care. Leaders must not lose sight of the importance of empowering clinicians to understand how to improve their communication skills while wearing a mask and to continually seek out ways to demonstrate empathy and forge connections with those we care for. 

Maintaining appropriate health care environments does not mean we cannot provide environments which support the welfare of those being cared for remembering that at times we may need to alter or adjust the environment to meet the diverse needs of the patients. In order to provide the best understanding of what it is like to experience and be on the receiving end of us as care providers we must listen to, talk to and communicate with those we are caring for. The patient will tell us what good feels like and above all they will guide us to understand what matters the most to them. I found this to be a powerful excise, one in which I questioned and continue to question how often I, both as an individual and as a leader, have encouraged people to see or hear the person behind the patient. This exercise reinforced to me the importance of recognising and acting on diverse needs and the difference this can make to an individual and their experience of care. Reflecting on what I have learnt from this from a leadership perspective, I also realise the importance of demonstrating the humanistic quality and realising the difference this makes to those on the receiving end of ourselves.