1). The Role of Shadowing:
From the very first learning event the importance of shadowing was emphasised by the Point of Care Foundation to participating teams. The booklet distributed at the start of the first session introduced shadowing to the teams:
What is patient shadowing?
As part of the pre-work phase of the programme, we are asking you to understand where care systems and processes currently prevent staff from providing excellent care. Key to this is developing an understanding of what patients’ experience as they move along the pathway and through the hospital.
One way to do this is through partnering staff or volunteers with patients, following them through the care pathway from the beginning to the end and reporting on their experiences. From a practical point of view, this may involve shadowing different parts of the pathway with different patients.
Patient shadowing enables real-time feedback to be obtained from patients, it raises staff awareness of the patient experience and it helps staff to understand what is important to patients and their families, not just what staff think is important.
(PFCC learning event materials: learning event 1)
When programme team members at the Point of Care Foundation were asked in interviews which part of the PFCC was essential the team consistently emphasised the shadowing component as the most important to the successful implementation of the PFCC:
“Interviewer: In terms of when you think about Patient and Family Centred Care, what is it that you think is critical, that does worry you if they don't do?
I mean, shadowing.
Interviewer: Anything else?
The shadowing, definitely, because I think that is really the crux. That's what changes people's minds. The shadowing's really key to making sure that they get it, and that actually… All the teams turned up at the celebration event, and they said, 'We thought we were going to be working on X, Y and Z, and then we went through this process, and by actually eventually trusting in the process, we ended up working on completely different things.' It's so powerful, because we know that what we've worked on are the real priorities. We know that we've used that time really well, we've made a really good difference than if we'd just gone ahead and done things anyway. I know there's been a little bit of resistance. Some of the teams, they come and ask you, 'Well we work in the service every day? We know what the problems are, we know what it's like, we don't need to.' I worry about converting that kind of attitude, and unless they actually do the shadowing then they won't get it. I think that, definitely.” (Programme Team member 2)
Therefore, one theme that figured largely in the evaluation of the programme is the role of shadowing in fulfilling the aims set out by the programme and the ways in which teams have dealt with and responded to shadowing. The aim of the programme was to enable practitioners to process and interpret care situations with empathy towards patients and families as needed and as they arise. To achieve this, shadowing was adopted as the key ‘mechanism driving change’. Effective shadowing should have the role of helping staff to “walk in patients’ shoes” and become aware of things that could improve services based on their observations. The following quotation provides an illustration based on a staff experience of shadowing a patient in his side room:
“On one side, there's a staff toilet and on the other side there's a patient’s toilet! For a patient who is very unwell like that, very poorly, we would leave the door open, but it meant it was very noisy and the supper trolley came. Somebody brought a hot meal which was inappropriate, and I looked around the room when the nurses had left, the last IV bag was still there and it was really - we should have taken that out. It was very informative and I realised we needed to buy some proper door stops and not be propping the door open, and things like that. I was there, I was able to help give him some symptom management because he wasn't very comfortable. That was helpful for his care. It was very interesting, and it was very interesting watching the communication as well.” (Hospital 2, Practice Development Nurse)
Clearly evident here is the potential of shadowing as a means to increase staff awareness of the services they are delivering. In order for shadowing to take effect care practices must stand out to staff when they have not previously. Or to put it another way, staff must feel what DiGioia (2010 p.541) describes as the ‘urgency and empathy’ and the transformative effect of shadowing. The following quote reflects the experience of shadowing as described by a staff member:
“I think that's really where the shadowing helped. That really sort of helped open people's eyes. I think taking a step back and being able to look in on something that you don't normally look in on - you are in the throes of it - I think really helped the team identify where they thought things could improve in terms of patient experience. Hopefully over time, because it's come from within - and I think that's one of the fundamental things over the two years is trying to find your champion from within the team, as opposed to feeling like you're doing something on top of somebody. It very much is sort of grassroots grown up.” (Hospital 2, End of Life Nurse)
Rather than describing shadowing as being a sudden and abrupt ‘lightbulb moment’ staff seem to describe shadowing as a more gradual process of becoming aware of their service in a new way.
2). Emotional Responses to Shadowing:
The overwhelming emotional resonance that staff experience when undertaking shadowing of end of life care services is a consistent theme in the evaluation findings:
“I just thought, oh gosh, it is such a stripped-back experience. The poor man in his gown and his incontinence pad and you just feel… I felt it was very impersonal. The table was there and there was his watch and he did have a mobile phone. His watch and his mobile phone were on the table, and you think, he's not able to use those anymore and these are the bits of him as a person.” (Hospital 2, training lead)
This emotional response to shadowing is one that was seen throughout this research and was demonstrated and reported back throughout the learning events. Staff often talked at the events about close personal experiences of family members who had passed away and the care they received. In addition, the emotional power of shadowing was cited by staff at events as initiating many transformative effects. By the end of the programme a celebration event was held where all participating services demonstrated successful improvements made. Some examples included: changing parking arrangements for family members visiting relatives receiving end of life care; reorganising various administrative procedures; assessing the visibility of sensitive wording around the ward; introducing the use of symbols such as butterflies to communicate sensitive information; and rearranging the layout and upkeep of rooms, waiting areas or family rooms (examples drawn from PowerPoint presentations and posters put together by participating teams and presented during the celebration event).
3). Anxieties to Shadowing:
The findings point to several elements of shadowing that staff found caused anxiety, chiefly the concern that partaking in shadowing consisted of putting colleagues under scrutiny:
“So the feedback process after we'd done the shadowing, I think that people felt quite exposed about what might come and what might be seen and what might be shared. There was a lot of nervousness around the shadowing, but people embraced it.” (Hospital 2, End of Life Nurse)
For those expressing this concern, staff members were not always optimistic about shadowing and may have had some fear as to what to expect from shadowing. This was also compounded if staff were being asked to do shadowing by more senior members of a team.
“Shadowing is the thing that generates massive anxiety and I remember being asked several questions about that.
Interviewer: what kinds of questions were you asked?
‘What were they asking? Consent. What happens if you see something that you're not comfortable with or isn't good practice? I suppose they were the things that come immediately to mind.” (Hospital 1, Consultant)
Here we see the anxiety that shadowing caused to many staff members, especially in the face of service hierarchies. For example, the staff expected to do the shadowing were often junior nurses and administrative staff. One important question raised by this finding is the extent to which team dynamics play a part in how something like shadowing is received by those working in services (an observation which is increasingly made in the quality improvement literature Dixon-Woods et al., 2012).
4). Resistance to Shadowing:
A further challenge for the implementation team was that several staff members in the sites felt that they could not complete shadowing at all. A range of issues may have contributed to non-completion of shadowing. We have grouped these into two categories. The first involves ‘personal resistance’ to shadowing including some of the constraints whereby services felt it impossible to do shadowing. The second involves ‘managerial resistance’ to shadowing, reflecting the attitudes of some teams whereby they felt unable to shadow.
4a). Personal Resistance:
In terms of personal resistance to shadowing, some staff members felt that it would not be practical for them to go out and complete shadowing:
“Well, very early on we were talking about end-of-life care for people who lived complex lives, so we were talking about people with substance misuse issues, that might be homeless, that might be in and out of street homelessness as well as the hostel system. We felt that there was a range of challenges to our project around our personal safety, if we were shadowing people in some of those environments if they were drinking and drugging. I think we spent a lot of time, didn't we, going I'm not sure how helpful that would be, sitting on the street with street drinkers, having a shadowing experience, because we weren't focused in a hospital environment with a clear direction…quite quickly we decided that shadowing some of those service users probably would be quite risky.” (Hospital 5, Focus group participant)
This point alludes to the complexity of shadowing and staff reluctance to try it. The way it is presented here is that the service would find it impractical to carry out the shadowing exercise. In addition to safety aspects, there was a concern that some of the service users may not feel comfortable with being observed (although for those who tried shadowing this assumption was found to be largely unfounded). The programme team acknowledged the difficulties with this service user group, but felt that there would be opportunities (for example when service users came for consultations) for staff to try shadowing. At the learning events the teams heard from previous sites where shadowing had been undertaken and were given an opportunity to work through how they might use shadowing in their setting. At one such event, a participant from an earlier PFCC cohort who had not done shadowing reflected that, seeing how others had successfully conducted shadowing in end of life care, her team had perhaps not been sufficiently open to trying the approach, assuming it would be too difficult in end of life care. She reflected that, if she had another opportunity she would try harder to include shadowing in improvement work. Introducing shadowing for some services can involve a process of adaptation and there continued to be a tension between the ways in which shadowing was presented as achievable and essential to the approach, and the ways services might need to adapt shadowing in order to be culturally, socially or politically acceptable.
4b). Managerial Resistance:
The second category links to this point by suggesting not only that staff may find shadowing impractical, but also that managerial staff might demonstrate deeper resistance to undertaking shadowing. For example, at one site the team described their decision not to shadow:
‘We didn't do any shadowing, we were very clear that we don't think that for us that would be an appropriate thing to do at the time. We'd looked at it and we looked at it quite seriously, but for us, shadowing end-of-life patients, and for us a lot of our patients choose to come to die in our service because we have known them for a very, very long period of time. We're a regional service, tertiary referral service, some of our patients travel quite a long distance to come to us after their families and we didn't feel it would be appropriate to put this added thing on to the families.’ (Hospital 3, Matron)
This quote again highlights the difficulties around shadowing, particularly in contexts where staff have a strong feeling that they know their patients well and already have a good understanding of what they need in terms of service improvement. The perception of shadowing as an ‘added thing’ or burden for patients was not supported at other sites where shadowing was undertaken with patients. The concern is that in some cases staff may be missing an opportunity to see their services ‘afresh’ through shadowing and to challenge their perceptions with regard to what was best for the patients and what might be the more critical improvement priorities.
What is developed further here however, is the concern amongst many participants about the impact that shadowing can have upon services. Not only is shadowing a concern for those planning it, but also those being observed and those called to do it. The introductory booklet given out to participating service teams at the beginning of the programme clearly states that in order to ensure that an observation doesn’t “feel threatening and judgemental” care must be taken when carrying out shadowing (‘Phase 2 Booklet’ PoC learning resource). The message can get lost once teams begin to plan the logistics or carry out the observation. Shadowing in this context takes on an extra dimension of highlighting ethically charged and sensitive areas of the services seeking to use it as a tool.
As a result, despite the emphasis on shadowing in the programme materials, training sessions and support visits and calls, in both the first phase and the second phase of the research several sites had not completed any shadowing activities and many of the sites that had completed shadowing had done so partially with the task of shadowing being done by more junior staff. For example, staff reported difficulties in persuading more senior colleagues to undertake shadowing.