ANNEX FOUR: CASE STUDY 3: USING ACTION LEARNING TO PROMOTE QUALITY END OF LIFE CARE IN NURSING HOMES
Action learning was used in a study aimed to promote quality end of life care in eight independent nursing homes using a structured tool, an integrated care pathway ( ICP), for the last days of life 35. Action learning was used to support co-researchers in an action research study to make learning more deliberate and enhance the quality of data collection.
Two key champions from each care home joined the Action Learning set which met on a monthly basis throughout the course of a year. They were encouraged to bring to the set an issue or problem related to the project that they wanted help with exploring. The main function of set members in an action learning set is not to offer advice, but rather to help individuals to understand their situation better, by exploring through reflection, and to challenge assumptions underlying these reflections in order to decide the best course of future action.
Each Action Learning Set comprised people from different care homes which allowed the participants to develop relationships and share experiences with others outside their own immediate care setting. Each set meeting was held at a hospice and lasted approximately three hours. On average this enabled two or three individuals to present their issues at each meeting. Detailed notes were written up after each set meeting and these were fed back to set members prior to the next session. In addition the set explored issues around process which enabled them to reflect on their own skills as facilitators.
The types of issues that were raised in sets included the use of power and examples of decisions being made without consultation of key individuals. It became evident that a model of care that participants named 'striving to keep alive' was prevalent in the nursing homes. One feature of this was the appearance of the fluid balance and feeding chart at the bedside in most of the homes when the resident became frail and confined to bed. From the notes, it could be seen that these charts were filled in until the day the resident died, even when it had become clear that the resident was no longer swallowing because they were dying. It seemed that there was an unspoken expectation that good nursing care involves making people better by encouraging them to drink, even when they are dying.
The discussions in the sets showed that there were complex values and beliefs about death and dying that underpinned the ease at which people felt they could make decisions about whether or not someone was in the last days of life. This 'striving to keep alive' went so far as to see death as a failure. One participant also talked about the close relationships she often had with residents. Given this relationship between staff and residents it was often difficult to openly acknowledge that a resident was dying.
Through the process of questioning participants were able to unpick the issues and explore what they were really about. They were able to identify their own learning and begin to consider strategies for action. They acted as co-analysts, played a key role in shaping the development of the themes for the research and in identifying key strategies for change based on their learning. An analysis of all of the transcripts from the set meetings produced a number of key learning points or themes.
It is instructive to compare this approach to data that would be gleaned from in-depth interviews. Action Learning raises questions about why people act in a particular way and uses this understanding to examine participants own actions and develop strategies about what they can do to change the situation. This makes actions more meaningful to the individuals. In studies where in-depth interviewing is the main source of data collection, it may be possible through careful questioning to get at the heart of issues by challenging assumptions, beliefs and values, but the purpose of doing this is to gather rich data rather than to help the person learn from the reflective experience in a deliberate way. The interviewer in this situation may not have a responsibility to help the person learn from this situation and consider other options and actions.
Key issues that emerged for the analysis was the emotive nature of death and dying for staff, particularly given their close relationship with residents, the complexity of communication around end of life care, and the challenging issue of responsibility and how staff could move towards a more shared understanding of the concept of responsibility. The outcomes of each set presentation fed directly into both the research and development. Action research thus made a practical link between the processes of research, development, improvement, and continuous learning.
For more information: Contact Belinda Dewar bdewar@qmuc.ac.uk