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Rehabilitation - You can't treat someone until you’ve walked a mile in their shoes

Physios are encouraging all staff on a ward to take part in a research study in which they step into patients’ shoes. Chris Mahony reports

Physios in Winchester, Hampshire, are spreading the message about empowering hospital patients and the benefits of ‘recovery coaching’.

Encouraging patients to be self-confident, to set themselves ambitious but achievable goals and to be as active as possible throughout their recovery underpins the physiotherapy ethos.

However, physios are only with their in-hospital patients for a relatively small part of the week.

From August, patients on a 28-bed rehabilitation ward at Winchester Hospital will benefit from the therapy ethos round the clock through the piloting of a ‘recovery coaching’ scheme devised by senior rehab physio Kay Johnson and her occupational therapist (OT) counterpart.

The pilot will run in tandem with a service improvement project based around the recovery coaching.

Ms Johnson says: ‘Coaching has been used in mental health but not in acute rehab settings.’

In a research project that starts over the summer, ward staff will be trained in recovery coaching – thinking and acting in ways that improve patients’ independence and confidence, helping them  prepare for discharge (preferably to their own home) and a return to routine daily life.

All ward staff from healthcare assistants to doctors will complete the training over a two-week period.

They will all be expected to use the recovery coaching model in their work between August and Christmas before its impact is evaluated (see ‘The pilot in detail’, over).

From admission, the patients – and where appropriate their carers and relatives – will be encouraged to do things that will speed up their recovery and bring discharge closer.

Patients are partners

Beverley Harden, Hampshire Hospitals NHS Foundation Trust’s associate director of workforce and education and a physio by background, explains: ‘This is teaching the language of rehab to others.

We wanted 24-hour rehab provided by a multidisciplinary team in a ward context. In reality, this means patients doing things for themselves when they can.

‘We say to the patients from the moment they arrive that we are going to work with them but recovery is their responsibility as well. So much of this is communication – coaching patients, carers and staff to improve the independence of patients.

We will be talking to carers and relatives, encouraging them to take the patient for a walk or to the café for a cup of tea when they visit rather than sitting by the bed for three hours.’

In her research proposal, Ms Harden said the project will ‘change the quality of the conversations’ between staff and patients and ensure the patients are partners in their own care – rather than passive recipients.

Walking in patients’ shoes

She suggests recovery coaching requires staff to ‘walk in the shoes of the patient’ and to ‘work with rather than do [things] for the patient’.

For Ms Harden coaching to improve independence and recovery will be an important tool in meeting the demographic pressures of an ageing population and more people with multiple long-term conditions and complex needs.

‘Improving independence during a hospital stay should be a priority as our population ages but it is not happening enough in the acute sector.

That means too many older people in particular are transferred to care homes costing around £1,000 a week or are unable to leave hospital or come back as emergency admissions.

‘This pilot will tell us if by changing the language and approach on the ward we can promote independence and recovery and improve the patient experience.

‘Coaching has been used in areas such as mental health and long-term conditions in the community but this is taking it upstream into the daily care of patients in hospital.’

Ms Johnson says the idea came out of a brainstorming session she had with her OT counterpart, Jane Packer.

‘I work very closely with the senior OT and we recognise the overlap of therapy. We wanted to get everyone using a rehab approach “24/7” even when therapists are not here.

There is no point us doing rehab if the rest of the multidisciplinary team, whose training differs, do not have the same approach.’

Their idea was greeted enthusiastically by Ms Harden who has a health coaching background. She guided it through the research approval process, securing Health Foundation funding to work with the University of Winchester which will evaluate the project and outcomes by next March.

Clifton rehabilitation ward was chosen because there is already an emphasis on rehab – many of its patients have come from other parts of the trust having made a partial recovery.

She says: ‘Patients come here to be more active and with such an emphasis already on rehab the pilot results are probably going to be less dramatic than on another ward.

However, if we make a difference here then we can really claim we will make a difference on medical wards and other parts of the hospital.’

Doing more with less  

Brimming with enthusiasm in an office on Clifton Ward, Ms Johnson adds: ‘Rehab should not start on the rehab ward – it should start on admission to hospital.

We are celebrating what we do well and trying to get a consistency of approach across the multidisciplinary team.’

Ms Johnson admits that the challenge to the NHS to do more with less was a factor in developing the project – she expects that the evaluation will show recovery coaching produces shorter hospital stays for the trust while improving job satisfaction amongst its workforce.

Both Ms Johnson and Ms Harden reject suggestions the timing of a project aimed at getting patients to do more for themselves sits ill with the Francis report on Mid Staffordshire and its focus on neglect and apparent indifference from healthcare staff on the  wards.

Ms Harden’s research proposal does note as a risk the need ‘to ensure that training reinforces that coaching is undertaken in a way that keeps care and compassion at the heart of the dialogue’.

The research proposal calms any nerves by noting that coaching theory ‘very much supports care and the training will emphasise and reinforce this’.

Ms Johnson says: ‘We are not taking care out of healthcare – we are empowering the patient. We are establishing goals with them and this fits in with the government’s quality agenda.’

Ms  Harden goes further, seeing recovery coaching as the embodiment of the patient empowerment and compassion Francis called for: ‘This is perfect for Francis because it is about empowerment and making care both compassionate and patient-centred.

‘Recovery coaching keeps the responsibility for recovery with the patient and raises their awareness of this but within a supportive, caring and compassionate ward environment.’

The aim is to make every conversation and every action count in terms of encouraging recovery and independence.

For therapists of both the physio and OT variety, much of the recovery coaching training will reinforce their professional training and their current working style.

Ms Harden acknowledges, however, that for other professions, trained to focus primarily on how they can care for someone better, some degree of change in thinking will be required.

CSP professional adviser Clare Claridge welcomes the project on several fronts: ‘This is a really good example of physiotherapists driving change – they’ve looked at a problem and considered how altering a very established way of running a ward could improve the quality of care and clinical outcomes.

‘It is really interesting that this is based on how allied health professionals approach care as enablers and with patient-centred goals.

This is about recognising the different approach we bring to a ward or service – the emphasis we put on enabling and empowering patients – and using education to establish a 24-hour rehab environment through a team approach.’

It will be an exciting time for physios on the ward, as Ms Harden notes: ‘Physios will see more of the good work they do being perpetuated by other professions and by families and carers.’ fl

The pilot in detail

The University of Winchester study will test the hypothesis that a coaching approach to be used by all staff will result in older patients on a rehab ward retaining higher levels of independent function and self-efficacy.

They should be able to return home sooner while feeling more confident. The pilot will run for nine months – including pre-intervention and post-intervention data collection.

A baseline dataset will be collected through daily living scores (using the elderly mobility scale and Barthell Index) on admission and discharge.

Self-efficacy scores will also be recorded. This information is already collected on the ward and will cover around 60 patients at both pre-intervention and post-intervention stage.

Around 15 patients and carers will be interviewed by university researchers on admission.

Length of stay and care needs on discharge will be important elements of the evaluation.

Qualitative data will be collected after several months of coaching activity through semi-structured interviews with patients and nursing staff.

Patient interviews will focus on the patient’s experience of coaching and how it has been implemented.

This will include exploring their understanding of the key phrases, concepts and ideas of recovery coaching.

Nurses will be asked about their experiences of the training, the implementation of recovery coaching and what they see as the benefits or limitations of the approach.

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