Exploring the experience of using the WCCAT observation tool in compassionate care practice development.

1. Exploring the experience of using the WCCAT observation tool in compassionate care practice development. First I just want to explain what got me interested in the observation tool. I joined the CC team in November last year and spent the first month really trying to understand how the research project had developed since the start and what had worked well and what would I be doing when I went into the area that I would be working with. Sitting in and contributing to the data analysis was one of the things that helped my understanding of how all the different tools had contributed both to the data around what compassion looked like in the wards and how actions had been taken forward to improve care which arose from this. It was clear to me that the team had varying experiences of using the observation tool and that quite varied actions came out of using it, it also appeared to me that where it had been used with most rigour then this had generated clearer links between observation and action. It was also clear that it could be quite challenging to use, it was this that kept me interested in its potential as a tool.First I just want to explain what got me interested in the observation tool. I joined the CC team in November last year and spent the first month really trying to understand how the research project had developed since the start and what had worked well and what would I be doing when I went into the area that I would be working with. Sitting in and contributing to the data analysis was one of the things that helped my understanding of how all the different tools had contributed both to the data around what compassion looked like in the wards and how actions had been taken forward to improve care which arose from this. It was clear to me that the team had varying experiences of using the observation tool and that quite varied actions came out of using it, it also appeared to me that where it had been used with most rigour then this had generated clearer links between observation and action. It was also clear that it could be quite challenging to use, it was this that kept me interested in its potential as a tool.

2. What is the WCCAT tool? Why use observation? How has the Compassionate Care team experienced using the tool in the programme? Trying it out using a film clip! Discussion of the preparation, skills and support needed to use the WCCAT tool in order to support changes in culture & practice This is what I hope we can cover in this workshop, hopefully having some fun in the middle as we all have a go at observing something and use this, together with the evidence of the teams experience to consider it�s use in practice.This is what I hope we can cover in this workshop, hopefully having some fun in the middle as we all have a go at observing something and use this, together with the evidence of the teams experience to consider it�s use in practice.

3. Workplace Culture Critical Analysis Tool Workplace is quite clear, but Culture? I guess at first different things come to mind from art and opera to cultures in other countries, but here it is the patterns of behaviour and beliefs and relationships in a workplace that are important and that affect the care that is given. Critical can sound just like that, rather negative with connotations of criticism rather than a curiosity about what happens in the environment and why. Analysis because the tool helps us to look at the events and behaviours from a new perspective and to question them. Tool because it�s something that helps you achieve creating something new. Here a tool to help build on the positive things that happen and think about changing those things which do not promote the values we have about caring.Workplace is quite clear, but Culture? I guess at first different things come to mind from art and opera to cultures in other countries, but here it is the patterns of behaviour and beliefs and relationships in a workplace that are important and that affect the care that is given. Critical can sound just like that, rather negative with connotations of criticism rather than a curiosity about what happens in the environment and why. Analysis because the tool helps us to look at the events and behaviours from a new perspective and to question them. Tool because it�s something that helps you achieve creating something new. Here a tool to help build on the positive things that happen and think about changing those things which do not promote the values we have about caring.

4. �Seeing practice, raising consciousness about taken for granted practices and reflecting on taken for granted assumptions are key components of comprehensive observation� McCormack B. Et al 2007 The tool was developed by Brendan McCormack and colleagues and they give a clear description in the introduction to it of how it was developed in order to contribute to �develop sustainable person centred and evidence based workplaces� and form part of a cycle of reflection and action. The reason to use observation as opposed to other ways of collecting information is that it can do just what the quote says, look at what is taken for granted. When staff are asked what they do that benefits patients they often omit those things that they as individuals take for granted i.e. Shake hands with new patients and introduce themselves. Patients become �part of the system� and may not question things that they would in another environment. When stating what they believe should happen staff may not say that some of the time they are unable to achieve it. So observation is a way of noticing those good practices that happen and drawing to light those that may not be as good.The tool was developed by Brendan McCormack and colleagues and they give a clear description in the introduction to it of how it was developed in order to contribute to �develop sustainable person centred and evidence based workplaces� and form part of a cycle of reflection and action. The reason to use observation as opposed to other ways of collecting information is that it can do just what the quote says, look at what is taken for granted. When staff are asked what they do that benefits patients they often omit those things that they as individuals take for granted i.e. Shake hands with new patients and introduce themselves. Patients become �part of the system� and may not question things that they would in another environment. When stating what they believe should happen staff may not say that some of the time they are unable to achieve it. So observation is a way of noticing those good practices that happen and drawing to light those that may not be as good.

5. McCormack et al state that by facilitating processes of reflective learning and action, clinicians can be supported to: �� Become aware of how they practise and the things they take for granted � Develop an awareness of how the system impacts on the way they work � Identify the contradictions between what they espouse and what they do � Challenge the system in which they work to create the potential for better patient care � Actually change how they practice to reflect individual and collective beliefs and values � Continually refine action in light of new understandings gained through reflecting on practice This statement regarding what they hope will be achieved sounds quite challenging and somehow looking at the way we practice does feel challenging even if we state that we are looking for good practice to highlight and are not just looking for problems. The backgroundThis statement regarding what they hope will be achieved sounds quite challenging and somehow looking at the way we practice does feel challenging even if we state that we are looking for good practice to highlight and are not just looking for problems. The background

6. Pre-observation � Observation � Consciousness raising and problematization � Reflection and critique � Participatory analysis and action planning The 5 stages are detailed in the handout of the tool but briefly they involve: Preparing staff building relationships, finding out their beliefs and values about care, gaining management or ethical approval and consent from participants. Preparing the observers, knowing the document, deciding what aspect of care to focus on. Undertaking the observation. Ask any supplementary questions you want to ask of the different participants to check out your understanding of what was observed. Check whether this is is what usually happens, how things are done? Discuss with staff what the observation shows re good practice and with things that do not relate to their beliefs about care see what could be done to improve care. With the staff theme the data and then use these themes to make an action plan. The 5 stages are detailed in the handout of the tool but briefly they involve: Preparing staff building relationships, finding out their beliefs and values about care, gaining management or ethical approval and consent from participants. Preparing the observers, knowing the document, deciding what aspect of care to focus on. Undertaking the observation. Ask any supplementary questions you want to ask of the different participants to check out your understanding of what was observed. Check whether this is is what usually happens, how things are done? Discuss with staff what the observation shows re good practice and with things that do not relate to their beliefs about care see what could be done to improve care. With the staff theme the data and then use these themes to make an action plan.

7. Outcomes It was particularly valuable for picking up language. If you've written it down it's hard evidence, but critiquing language -it's also very personal. It enabled staff to see the things they had done well, recognition and consolidation of good practice. Highlighted the ways staff went out of their way to work with patients in a way that supported their needs and enabled this to be shared with the team. Brought about changes in practice which gave patients more choice Now although I have tried to summarise the process I guess it may already feel a bit complicated to achieve in a busy area, but perhaps still very worthwhile in terms of the possible benefits to be achieved. So next I want to look at the experience of some of the team members and one of the charge nurses involved when they carried out this form of observation. I used the emotional touchpoints process to get their experience and then themed their responses. Language,both + and � �The flip side to that, I've examples where for example the consultant was so pleased to get feedback about his interactions, lots of things came out.� Now although I have tried to summarise the process I guess it may already feel a bit complicated to achieve in a busy area, but perhaps still very worthwhile in terms of the possible benefits to be achieved. So next I want to look at the experience of some of the team members and one of the charge nurses involved when they carried out this form of observation. I used the emotional touchpoints process to get their experience and then themed their responses. Language,both + and � �The flip side to that, I've examples where for example the consultant was so pleased to get feedback about his interactions, lots of things came out.�

8. Emotional feelings of the team undertaking observation. �Enthusiastic because it's getting at the subtleties of practice in a way that beliefs and values doesn't. When staff are not able to articulate specifically what it is they do, but observing in practice is different, you pick out the stuff, particular elements of compassionate care i.e. the handshake.� �Needed, I felt that they needed that from me. I felt welcomed and they needed that to happen, to unpick the meetings in order to help them out. And to some extent that made me feel trusted, that I wasn�t going to pull them to shreds.� �Frustrated and disappointed because despite careful preparation of staff, always checking out as I went along, not being a distant observer. I tried to make people at their ease and primarily fed back those things that went well and asked questions when I fed back, i.e. "could you tell me more about when you use honey, love, poppit?" Despite that staff honed in on the negative. I was kind of frustrated that despite that process they still hone in on the negative.� �As time went on I enjoyed doing them.�

9. �I did feel quite scared as I knew staff were very anxious about it so I felt tense, though determined that we were going to do it, although staff felt we shouldn�t.� �Unsure, Curious as to what it will reveal.... I was hopeful that it was going to come up with stuff.� �On my part I had to be incredibly thoughtful. I was anxious not to let people down. I do think there are times in which we make people think in a way they�ve never thought before and I hope we are able to support them.� �Then brave because you take risks, even leaving them in a folder is taking a risk because you couldn't support the debate that might happen.�

10. The WCCAT tool: �It has an academic feeling, it�s a substantial piece of work. It�s a heavy thing to be working with, daunting� �The whole thing (the WCCAT tool) is quite unwieldy, I had to prepare a sheet to help myself, I was unfamiliar with the tool, I needed things to help. As time went on I was more familiar with it and confident, I could be more flexible.� �About the documentation, it would have been helpful to have half a page in layman�s terms. Learning what you write down, I had pages, some of it irrelevant, I tried to write it all down but some of it was not useful. You need to practice it then you are more confident.�

11. I was unsure within the framework, learning opportunities as a heading, the questions weren't always specific, they don't always capture the implicit. Do I go through each section? i.e. MDT team meetings the question of team effectiveness applied otherwise its less strong. As time went on I was able to accentuate 3 or 4 and leave others. Initially it took time to get it clear in your head. In the introduction to the tool it doesn't really say that, that you can be flexible. In terms of bringing someone alongside to do it, hold those questions in their head, they observed, made notes and mapped it against those questions later. I did it with a different person each time, so they never got familiar with it.

12. Practicalities: To feedback to the whole ward team, important issues came from this. It was exhausting, how to do this given shift patterns etc. If people just read things they only focus on the negative, it goes in the file and is not very successful. So we would take forward actions but not everyone would understand where it came from, i.e the milk jugs arose from observation and a story but if staff hadn't been there when it was discussed then they wouldn't understand the action. I had to be inventive, take a bit of observation, have a column for the discussion so that they could see the comments and the debate that came out of it. Record all of it, even the negative comments. I had to think creatively so that they could make the link between the Observation - Discussion - Actions. Not just do an observation sheet and record that.

13. Other issues: Power relationships � �Initially challenged, particularly because I knew of one nurse who almost begged me not to do it and I still did it, afterwards she got a lot of positive feedback. It took for that to happen until people understood and came on board.� Gaining consent from everyone Overcoming resistance of staff The wider culture: �Staff did feel nervous, like going to an exam. Two people watching you. Maybe better doing it unknown? It feels like the hand hygiene audit, but we did get over it.� � It's about the culture that exists of looking for the negative. �

14. Conclusions?