12 Hours In ER
A new perspective on the demographic holding the label of ‘hardest to engage’ and why that’s simply not true. Findings from a 12 hour shift on an Elderly Rehab ward, why these patients are breaking all assumptions, and what its like to be their HCP.
At 31 I may be too old to go to work with my mum for a day. She thought so! But I was determined to understand what life was like for a nurse day to day. I wanted to be able to fully appreciate what HCP and patient engagement could really look like in an environment where it has been assumed that patients aren’t engaged with their healthcare and don’t use technology. Something which I have always believed to be bollocks!
Firstly, a bit about my mum, Rachel. She’s a nurse that in my opinion, has worked in some of the toughest nursing roles available. She has worked in palliative care for most of her career and now works in elderly rehabilitation. Working with the patients Pharma are convinced are some of the the hardest to engage, and my mum would agree with you wholeheartedly.
Mum spends her days trying to motivate elderly patients to complete their exercises, and get better from hip replacements, falls, operations etc. so they can go home. This is a frustrating role and one that requires immense patience (something which mum does not demonstrate outside of the professional environment!) and dedication from the clinical staff.
I spent the day following my mum and some of the doctors and physio’s around the elderly rehab ward on a 12 hour shift. I learnt a lot through this experience so I make no apologies for the length of this article. This is what I found out:
12 hours is a really long time!
I’m by no means shy to working long hours, but usually at a desk, in front of a computer, invariably with headphones in. 12 hours in front of emotional relatives and patients, doing drug calculations, and coaxing elderly patients in to completing their regimes, some of which had no interest in being rehabilitated, was soul destroying and hard work.
I asked my mum and her colleagues what helps them stay motivated and engaged with their work, and after the predictable bravado of ‘it pays the bills’ they all stated, in various ways, that the work they do can make a difference to someones life and that gives them enormous satisfaction.
Never underestimate the value of a cup of tea …
As much as I believe that health technology can improve and augment most aspects of healthcare, it should never be underestimated the value of face to face communication.
Many of the patients I saw were depressed, lacked motivation and felt like they were a burden to others (including the HCPs looking after them). The nurses I spoke to agreed that just spending some time with patients, talking to them and trying to understand who they are really can really help in the recovery and rehabilitation process.
“Patients begin to feel noticed in a world where predominantly they feel invisible”
Frustratingly though HCPs felt that they lacked the time and resources to be able to do this properly and dedicate extra time to an individual patient.
“Many patients here are depressed and would really benefit from counselling or psychological support services. We are nurses and are under-resourced and not trained to deliver this level of care appropriately”
As a result it became clear that some HCPs shied away from having more personal discussions with patients as they knew there was a problem, but felt they weren’t trained, or the appropriate person to fix it and therefore would ultimately let the patient down.
Compassion-fatigue is a thing.
I saw this from both nurses and doctors, and it certainly wasn’t because the HCP didn’t care, far from it.
It seemed to me that it’s because the HCPs are so emotionally invested in the wellbeing of their patient and despite their best efforts, the patient is sometimes not as motivated as the HCP to get well. This is frustrating and naturally can lead to the HCP being increasingly disengaged with that patient. HCPs are humans too!
But compassion fatigue was multifaceted, and sometimes it was simply because the HCPs themselves were exhausted. We all know the NHS is under-staffed, it would be pointless to write any more about this, but the wider impacts of this staffing issue is plain to see when HCPs are too tired to engage fully with their patients. The patients can also see this in their HCPs and so also, sometimes feeling a little hurt, disengage.
HCPs need support programmes too
HCPs are disenfranchised with their work and not because of the patients.
They are expected to work crazy hours (sometimes with only a few hours between shifts), they are invariably not given the tools, training or access to information to feel like they are making the right decisions for the patients care, and yet they are expected to always get it right.
There is little funding available for investment in HCPs from their institutions beyond the minimum required. This means that some of the free value-add support services provided by Pharma, as well as HCPs bringing their own devices to work (tablets and smartphones for example), are now seen as necessary essentials for HCPs to do their job.
“Imagine going to work Becky, and your boss saying to you, so here is your office, but there is no laptop, phone, chair, desk, access to the internet, paper or pen. You turn to your boss and ask how you are supposed to work and they just shrug and say ‘you’ll find a way’ and walk out. You’re left in an empty room with no means of doing the job you were employed to do. It’s not as extreme as that obviously, but thats what it sometimes feels like. You’re left with patients and clinic staff looking to you for the answers and you don’t always have the tools or information to be 100% sure. It’s not very motivating to be so unsupported, but you turn up every day because of the patients, they need and rely on you”
Yep, that brought it home: it’s unlikely that someone is going to die because I don’t have a laptop to send an email to a client by a certain time (I’m in fact not Jason Bourne), but for these guys, if they don’t have the right training or the right tools and information to do their job, someone could die, and thats something to really think about.
Elderly people ARE interested in technology
One of the reasons I was excited about going to work with mum was to get an opportunity to understand elderly people in a situation where I believe health technology could have a massive impact on their care.
I get challenged by clients all the time on the appropriateness of technology to support elderly patients ‘but old people don’t use smartphones.’ All of the latest research suggest this is an archaic viewpoint, with around 71% of older UK adults owning a smartphone and 89% using a smartphone daily in 20171. Having been on the wards with patients older than those in the study above, I can now say with even more certainty than before that the smartphone is a big part of anyones life, irrespective of their age.
Many of the patients I saw would be using their phone or iPad/tablet to FaceTime/Skype their loved ones. They passed the time using their device to download puzzle apps and even googled things the doctors were saying to them – sometimes not waiting for the doctor to leave!
A few of the patients on the elderly rehab ward had forms of Dementia or Alzheimer’s.
Technology was helping these patients to connect with their loved ones on the one hand, and through access to information, connect with their HCPs on another. What if we could link all of these together? Giving the patients more clarity in an environment where things can feel uncertain and scary. Helping them and their loved ones to understand what is going on, and keep a track of their progress. Whilst linking the HCP in to the loop to see how their patients are managing with their exercises and rehabilitation plans? All of this is possible with such little effort given technology that is already available and being used.
So what did I really learn?
Well firstly, me and mum were both right! Based on my school trip, I still think that elderly patients can definitely be engaged in their healthcare through technology, they already are, but I can now see why mum feels that trying to engage these patients is complex and my ‘fancy apps’ (her words, not mine) aren’t the answer to all their problems (again her words, but she’s right!)
Secondly, ‘engagement’ is as much about the patient as it is about the HCP. What is the point of a patient being engaged in taking ownership of their healthcare, completing QoL scores and tests, if the HCP isn’t equally engaged?
This is not just a matter of medical education. We need to be putting just as much effort in to understanding the HCPs sat in front of the patients, and what their needs, motivations, desires and frustrations are, as we currently are putting in to the patients. If we can begin to solve some of these issues, beyond trying to show them an eDetail full of data (which they said they only sit through because they get free sandwiches!), we will be making great strides to help improve the environment in which they work in, and give much more time back to the patient/HCP relationship.
Thirdly, that patients of all ages are already using technology to manage their healthcare. It may be at a more basic level for the patients that I saw, Wikipedia for example. But they are using it, and it is already changing the conversations that the patients are having with their HCPs. Patients are asking different questions to the ones that I expected, and indeed asking questions at all! Sure, some of them aren’t as forthcoming as others, but the fact is that they are beginning to own much more of their healthcare by having more access to information.
And lastly that you should never underestimate the carer. I saw many loved ones visit their relatives over the course of the 12 hours I spent on the ward with my mum. Many of these relatives were daughters or sons of the patients, and they all had questions of the HCPs too.
The main motivation for the patients to get better was the love of their families and friends, and yet there is a gulf between the information imparted to the patients (some of which had dementia and so were unable to retain or fully understand all of the information) and that given to the carers, who in many cases were the driving force behind the patients engagement with their HCP and their healthcare.
Using technology already being used by the patients, carers and HCPs we can do so much more to connect the carers and include them more fully (with the patients permission of course) in to the patients immediate care team. This would help bridge the knowledge gaps and ensure all parties are connected and working together in the best interests of the patient.