Working together to reduce the burden

This morning @ciplowright tweet prompted me to consider a time in my career when 12 hour shifts were de rigueur, how the discipline influences teamwork and outcomes for the people we worked with, and how group development theory made sense of practice then and now.

As a newly qualified learning disability nurse, I worked in the south of England in a residential service associated with specialist educational service for young people with learning disabilities and complex health and social care needs. I worked in a multi-field nursing team, with adult, children’s, mental health and learning disability nurses. As a novice, I was supported to find my feet, make mistakes and errors, learn from these and develop my practice, in a warm family like staff team – preceptorship some years before it was introduced.

We worked 12 hour shifts, and back then the argument that ‘continuity of care’ was paramount and that longer shifts reduced staff changes offering the individuals some sort of ‘normalcy’. However, I quickly picked up on the fact that the young people — not unsurprisingly — preferred members of staff and they – like me – were doing their own growing up and learning from the consequences of their choices. This created some days where disagreements, disharmony and dissonance hung in the air throughout that 12 hour shift.

Around this time I discovered Tuckman and his stages of group development (1965), and reflected on how this impacts on health care teams. In this context I found the process of forming, storming, norming, performing and adjourning particularly reassuring. As it gave me a framework for identifying what would work, at what times, with whom, and when tempers frayed this could be explained either by storming, or something more ingrained, which could relate to the workbased culture.

Since that time, much of my work has focused on people with learning disabilities accessing hospital care either providing direct facilitative support as a community nurse, or through supporting our frontline hospital ward teams to ensure timely diagnostics and treatment and compassionate care. What is clear to me through this extended period is that people with learning disabilities rely more heavily on the good working relationships of the ward staff and the carers and care-workers, more so than any other group of patients.

Carers and care-workers for people with learning disabilities ought not be thought of as ward visitors in the same way as for other patients. However they can also not be considered a replacement for ward staff as they will not know the Ward context, nor the health conditions that people admitted there might be experiencing. However they will likely know the individual patient, their communication idiosyncrasies, and how to engage the person in some of the less comfortable healthcare procedures that might happen on the ward.

Through working with Wards and local stakeholders a framework and a suite of tools has been developed to support the swift integration and performing of a team around the patient with learning disabilities. Along with the use of these tools, there is a certain set of competences and personal attributes to have this occur effectively and efficiently. This is service that is provided across organisational boundaries and as such traditional hierarchical forms of management are less effective. While facilitation and it’s many hues appears to identify the competences and skills required for cross boundary working, it is more recent review and consideration of the elements of systems leadership that has provided an appreciation of the personal attributes required to ensure the care is timely, person centred, safe and effective.

Through use of these tools, competences and attributes, those responsible for coordinating care are better able to draw on the resources of a greater number of people, therefore reducing the burden on the few. Whether this mitigates all the challenges of 12 hour shifts remains to be seen.