PreparationsBeforethe observation, a table listing the senses on one side with space for commentsto be recorded on the other (appendix A) was produced. An unstructured approachwas taken (Gillham, 2008)) to appreciate and explain cultural behaviour (Mulhall,2003). An ‘additional remarks’ section was included to ensure all observationswere captured. Priorto the observation, the observers liaised closely with the Outpatients Managerand the Nurse in Charge (NIC), to explain the reason for the session; to checkwhere to position ourselves to avoid disturbing patients; and to discuss theopportunity to provide feedback at the end. Thesecond observer was chosen because of their different background from theprincipal observer. Observer B had worked in the Trust for over 25 years,initially as a clinician and now in a corporate role, as a patient experiencelead.
Due to the differences in age, profession and credentials, there was theopportunity for both individuals to bring a unique perspective to the exercise. ObservationsTheobservation commenced as soon as the observers entered the waiting room. Althoughthey were familiar with the place, as it is used as a thoroughfare daily, itwas only when the observation was taking place that they noticed certainaspects for the first time. These were subsequently examined in greater detail.The observers acquired overt non-participatory roles. Thewaiting area was filled with over 60 patients, their guardians and siblings.
There was a noticeable range in patients’ ages (new-borns to teenagers) andtheir physical medical complexity (some patients were in wheelchairs and had atracheostomy, whilst others were happily running about). This was reflective ofthe variety of specialist and general clinics taking place. Physicalenvironment Theroom was rectangular, with two entrances located at either end. Leading offfrom the waiting area were a number of corridors on which 28 clinic rooms werelocated.
On entering the waiting room, both observers felt overwhelmed by thevolume of noise and the number of people occupying it. Dixon et al (2010) notethat hospitals are operating close to capacity due to difficulties in expandingfacilities and securing the appropriate staffing levels. Theoverall ambiance was not conducive to patients and their families feeling atease. There were no activities for children, there was no specific informationrelaying wait times and despite having televisions, the sound was off, makingthe films playing difficult to follow.
One lady was heard saying, ‘We’ve had towait ages for bloods, with nothing to do… I’m not sure how much longer we willbe.’ Researchinto the importance of the physical environment on patient experience is somewhatinconclusive. Cusack et al (2010) found that paintings on display contributedpositively to outpatient experience. This research suggests that it isimportant for patients to have a relaxing and comforting environment in whichto wait.
However, in a survey conducted by Larkins et al (2013) there was lowimportance associated with the physical environment on patient experience. Evenwhen dissatisfaction was found in various environmental factors it did notaffect overall patient experience in the same way as a negative interactionwith a clinician. Staff interactionswith patients Duringthe session, the interactions between staff and patients were closely watched.
Both observers noticed one Healthcare Assistant (HCA) repeatedly calling out apatient’s name, trying to locate them. There was an increased level of frustrationin her tone on each occasion. After three attempts she sighed, dropped her headand turned her back on the onlookers. This stood out to both of the observersas the behaviour was not in line with the Trust’s value of ‘compassion’.
Itlater transpired that the patient had been sitting at the other end of thewaiting room and had not heard their name be called. Incontrast, Observer B noticed that the receptionist immediately made eye contactwith each patient as they approached the desk. She consistently smiled, gaveclear directions and used hand gestures to explain processes to families. Lunenburg(2010) offers a possible explanation for the difference in levels ofcommunication. He suggests that the physical set up of a room can inhibit orfacilitate good communication and proximity is key to successful communication.The HCA was trying to operate over a large busy waiting area, rather than inclose proximity like the receptionist. Thereceptionist was able to provide a more person-centred approach which isregarded as equal to the best quality of care (Edvardsson et al, 2008).
Browallet al (2013) note that patients want to be seen as unique people, to haveopportunities for good encounters with staff, fellow patients and familymembers. However, it is important to note that this study was into the needsand wants of cancer patients, which could be different from those of childrenand their families. ReflectionsItis clear that there were some differences when interpreting the observations. Both observers noted the presence of emptyfood packets on the floor. Observer A felt that this implied the waiting areawas not being cleaned regularly enough. Observer B, however, felt that this didnot significantly impact patient experience and was to be expected in a busy roomfull of children. Due to the current financial pressure on the NHS and changesin patients’ preferences, NHS organisations are expected to work in new ways, increaseproductivity and improve efficiency (NHS England, 2014). In the current climateof funding constraints, priority is given to clinical, urgent and critical services.
Therefore, practically implementing changes which incur incremental cost arehard to justify, when the net benefit on patient experience is uncertain. Zemkeet al (2000) believe in exploiting the benefits of diverse viewpoints, passionsand inspirations. They suggest ‘difference deployment’ as a way of drawing onthe strengths of people from different generations and backgrounds. RecommendationsFeedingback to the Outpatients Manager and the NIC was a crucial step to ensure thatthe learning from the activity could be used to encourage change. Providing educationalprogrammes or quality improvement guidance alongside feedback has been shown toincrease its effectiveness (Brown et al, 2009). Brown et al (2009) also suggestthat staff particularly appreciate receiving real-time feedback.
Therefore, theobservers discussed potential service improvements and agreed on a singlerecommendation. Thewaiting area was functional but lacked toys and activities to engage children.As play can reduce children’s anxiety around medical visits (Burns-Nader and Hernandez-Reif,2015), implementing designated areas with age appropriate activities and gameswas suggested. This would improve the overall patient experience, help to putcaregivers at ease and can be employed relatively quickly. As this observationis only reflective of Outpatients on that day, to warrant re-designing thepathway and investing additional resources, more evidence needs to becollected.
Further ReflectionsTheobservers felt proud and comfortable relaying the positive points from theobservation. They felt that negative feedback could undermine the authority ofthe service manager and it was inappropriate to make too many suggestions of howto improve their service area, without spending extensive time in thedepartment. Care was taken to be constructive, concise and direct, rather thancritical. ConclusionsInconclusion, through undertaking this observation in a clinical service area,both observers felt an increased understanding of the Outpatients process.Where improvements could be made, there will be learning as a result of honestfeedback. Bothobservers recognised the importance of viewing processes from the patient’sperspective (Bowling et al, 2012); the link that to meet patients’ needs, theirperspective needs to be taken into consideration; and to encourage jointdecision making with patients (McIver, 2006). As Coulter et al (2014) describe,’analysis of patients’ subjective experience is essential in appreciating whatis working well in healthcare, what needs to change and how to go about makingimprovements.
‘ Action PlanItwas agreed that both observers would continue to regularly conduct unstructuredpatient observations. These will provide insight into the whole picture and capturethe influence of both the physical and emotional environment on patientexperience (Mulhall, 2003). Involving different professionals as observers too,will help draw on different experiences, insights and diversity to betterunderstand how people interpret situations. McIver(2006) suggests that health professionals and service users have differentviews on the most important indicators of good quality care. Therefore, a shortsurvey will also be prepared to ask patients in the waiting room at the time ofobservation for their views. This will be used in conjunction with theobservation to provide a deeper understanding of patients’ experiences,expectations and needs.
These steps will help promote continuous improvementaligned to patients’ needs rather than on misdiagnosed patient preferences.