Discharge decision-making in the Acute Medical Unit for older people Annabel Rule Specialist Occupational Therapist – Elderly medicine Imperial College Healthcare NHS Trust NWL Research Symposium 20.09.2017 Email a.rule@nhs.net Twitter @annabelrule

This project; PhD research project Research Aim; Objectives; Completed during a 4 year clinical academic studentship Supervised by Professor Jo Adams and Professor Jackie Bridges Research Aim; To explore and understand the processes by which discharge decisions are made for older people returning to the community from an acute medical unit. Objectives; To understand the context within which discharge decisions are made Explore the impact of the context of the acute medical unit on those involved in discharge decision-making (patients, staff and relatives). Identify the characteristics of the process of discharge decision-making on the AMU Explain the impact of the context of the acute medical unit on the practice of discharge decision-making Explain the impact of this process on those involved in discharge decision- making (patients, staff and relatives)

Background to the project; Discharge decision-making for older people Societal context; - Independence ideal - Identity of ‘older people’ Policy context; - Shared decision-making - Involvement - Choice Research context; - Poor experiences - Lack of involvement - Lack of acknowledgement of the older person in acute care Clinical context One 58 bed AMU in a large tertiary hospital in the South of England. Serves a large population from both urban and rural areas. From Jan 2013 – Jan 2014 saw 11,976 admissions of people aged over 65. Aims for length of stay of ≤ 48 hours. Weicht (2010) Cohen (1994) BGS (2012) DH (2010) Bridges et al (2010) Maben et al. (2012)

Methodology and Methods Savage (2006)

Findings – the Context Key themes Pace-focussed Acute Medical Unit Everyday battles Disjointed processes Impact; Guilty patients – using resources, time, space Patients self-efface and silence themselves – become “patient patients” Relatives – try to negotiate confusing system and advocate for patients Health professionals – low staff morale – negative culture – anti-change. Undervalued, disempowered

Findings – The Context “they probably didn’t realise how I really felt because … they’re so busy, I wouldn’t have chatted to them about myself” Mrs Andrews “But when it was in the paper how busy they were, not to go there if you can help it … go and see your GP … I never intended to go there at all” Mrs South

Findings – the practice of discharge decision-making Behaviours and approaches in decision-making Staff; bed-seeking, escalating, requiring back-up, categorising and re-categorising, discuss qualitative judgements as factual assertions – dichotomies – authoritative voice Relatives; advocating, chasing Patients; minimise their own opinions/preferences, ‘patient patients’, passive voice Impact Staff – reduced professionalism, element of guilt, allocate any blame to “the organisation” Relatives – increase burden as assumptions made Patients – experience = processed

Findings – decision-making processes “They were looking for beds and uh I was only too pleased to help out there” Mr Gilo “slung me out” – Mr Gilo “got rid of me” – Mr Gilo “Bundled me up” – Mrs Adams “Shunted into another area” – Mrs Andrew’s daughter “trying to get rid of everybody” – Mrs Delahey “get rid of me” – Mrs Norway “kicked out” – Nurse 1 “shoved out” – Mrs Adams

Discussion Williams’ (2001) Pace – Complexity dynamic. AMU prioritises pace over complexity Is it realistic to expect involvement and shared decision-making in a pace focussed environment? Can we re-configure care to focus on complexity efficiently? Do we need re-configure our policy rhetoric as a society? Relational approach to ethics, autonomy and care Or is involvement possible in NHS care?

Thank you for listening! Any questions? References; BGS (2012) Quality and Care for Older People with Urgent & Emergency Care Needs “Silver Book”. London: The British Geriatrics Society Bridges et al. (2010) Older people's and relatives’ experiences in acute care settings: Systematic review and synthesis of qualitative studies. International journal of nursing studies 47(1): 89-107 Cohen (1994) Self Consciousness: An Alternative Anthropology of Identity. London: Routledge DH (2012) Health and Social Care Act 2012: Chapter 7, Explanatory Notes. The Stationery Office Maben et al. (2012) ‘Poppets and parcels’: the links between staff experience of work and acutely ill older peoples’ experience of hospital care. International journal of older people nursing 7(2): 83-94 Savage (2006) Ethnographic evidence the value of applied ethnography in healthcare. Journal of Research in Nursing 11(5): 383-393 Weicht (2010) Embracing dependency: rethinking (in) dependence in the discourse of care. The Sociological Review 58(s2): 205-224 Williams et al. (2009) Relational practice as the key to ensuring quality care for frail older people: discharge planning as a case example. Quality in Ageing and Older Adults 10(3): 44-55 With thanks to; Professor Jo Adams Professor Jackie Bridges Contact: Annabel Rule Specialist Occupational Therapist Elderly medicine Imperial College Healthcare NHS Trust Email a.rule@nhs.net Twitter @annabelrule