Cacoca

Bea Fac

Kingb Un

International Journal of Nursing Studies 50 (2013) 1247–1258

A R

Artic

Rece

Rece

Acce

Keyw

App

Cari

Cari

Com

Olde

Rela

*

m.r.

002

http

ring about caring: Developing a model to implementmpassionate relationship centred care in an older peoplere setting

linda Dewar a,*, Mike Nolan b

ulty of Education, Health and Social Sciences, Hamilton Campus, Caird Building (Room 2.3), Almada Street, Hamilton ML3 0JB, United

dom

iversity of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AUU, United Kingdom

What is already known about the topic?

� Relational knowledge is important in delivering highquality care particularly in care settings for olderpeople.

T I C L E I N F O

le history:

ived 28 June 2012

ived in revised form 18 November 2012

pted 27 January 2013

ords:

reciative inquiry

ng

ng conversations

passion

r people

tionship-centred care

A B S T R A C T

Aim: This study actively involved older people, staff and relatives in agreeing a definition

of compassionate relationship-centred care and identifying strategies to promote such

care in acute hospital settings for older people. It was a major component of a three year

programme (the Leadership in Compassionate Care Programme, LCCP) seeking to integrate

compassionate care across practice and educational environments.

Background: Compassionate caring and promoting dignity are key priorities for policy,

practice and research worldwide, being central to the quality of care for patients and

families, and job satisfaction for staff. Therapeutic relationships are essential to achieving

excellence in care but little is known about how to develop and sustain such relationships

in a culture that increasingly focuses on throughput and rapid turnover.

Approach and methods: The study used appreciative inquiry and a range of methods

including participant observation, interviews, story telling and group discussions to

actively engage older people, relatives and staff. A process of immersion crystallization

was used to analyze data with staff as co-analysts.

Findings: The study adds considerably to the conceptualization of compassionate,

relationship-centred care and provides a model to aid staff deliver such care in practice,

based on ‘appreciative caring conversations’ that enable all parties to gain two forms of

‘person and relational knowledge’ about ‘who people are and what matters to them’ and

‘how people feel about their experience’. Such knowledge enables staff, patients and carers to

‘work together to shape the way things are done’. The study generated a model called the 7

‘C’s that captures in detail the factors necessary to promote ‘appreciative caring

conversations’.

Conclusions and implications: The study demonstrates that engaging in ‘appreciative caring

conversations’ promotes compassionate, relationship-centred care but that these

conversations involve practitioners taking risks. Such ‘relational practices’ must therefore

be valued and accorded status. Staff require appropriate support, facilitation and strong

leadership if these practices are to flourish.

� 2013 Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +44 7511106411.

E-mail addresses: belinda.dewar@uws.ac.uk (B. Dewar),

nolan@sheffield.ac.uk (M. Nolan).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0-7489/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.

://dx.doi.org/10.1016/j.ijnurstu.2013.01.008

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–12581248

� The type of relational processes and practices thatsupport compassion and caring require the developmentof skilled interpersonal relationships.

What this paper adds

� A new practice model for compassionate relationship-centred care that helps to clarify both the meaning ofcompassion and how it can be achieved in everydaypractice with patients, relatives and staff.� Central to the model is the articulation of caring

conversations that represent an advanced and highlyskilful form of relational practice.

1. Introduction: compassion, a concept looking for adefinition

Concerns about standards of hospital care for olderpeople have been apparent for decades (Norton et al.,1962; Townsend, 1966; Robb, 1967) and recent interna-tional literature suggests that rather than being amelio-rated these concerns are being exacerbated as levels offrailty and acuity rise (Clarfield et al., 2001; Youngson,2008; Edvardsson et al., 2010). Therefore as Clarfield et al.(2001) rightly assert, this is now an ‘internationalproblem’. This paper describes the development of amodel of compassionate relationship-centred care, thatwhilst developed in the UK has global relevance.

Despite over a decade of effort to improve the care ofolder people in the UK (Davies et al., 2007; HAS, 2000,1998; DoH, 2001, 2006; Nolan et al., 2001) several recenthigh profile reports indicate that unacceptable standardsof hospital care for older people remain prevalent(Abraham, 2011; Care Quality Commission, 2011; Nichol-son and Oliver, 2012; Tadd et al., 2011). Consequently,considerable policy and practice attention has been givento promoting dignity and models of practice that arecentred around relationships (Darzi, 2008; DoH, 2009,2012; Goodrich and Cornwell, 2008; Scottish Government,2011), with compassion being identified as a core valueunderpinning the National Health Service in the UK (DoH,2009).

Yet what compassion means in this context and how itcan be achieved in everyday practice is far from clear.Without greater clarity compassion is likely remain littlemore than a rhetorical and political device which tripseasily off the tongue but remains elusive, particularly in ahealth care culture that is dominated by productivity,efficiency and effectiveness, and promotes quick fixsolutions to the ‘caring problem’ (Finfgeld-Connett,2008; Goodrich and Cornwell, 2008; Watson, 2006;Youngson, 2008). The current focus on metrics (Pattersonet al., 2011) has spawned a plethora of ‘tools’ to measurethe ‘caring’ dimensions of practice (Watson, 2006, 2009)and whilst these go some way towards identifying thoseaspects of care that matter to people, they fail to capturethe complex ‘relational practices’ necessary to achievecompassion (Parker, 2008; Williams et al., 2009). Further-more, although recent initiatives in the UK such as‘Releasing Time to Care’ (NHS Centre for Improvement

‘Schwartz’ rounds (Goodrich and Cornwell, 2008) tacitlyacknowledge the importance of caring they do notnecessarily support frontline staff to develop sustainablereal time strategies to ensure high quality care in day-to-day practice.

Making explicit what compassion comprises of andhow it can be realized is challenging due to its largely‘invisible’ nature’ (Liaschenko and Fisher, 1999). Writing ofhealth care in the US these authors stress the importance of‘relational knowledge’ to ensuring high quality care.Others in the UK have started to identify the ‘relationalpractices’ necessary to achieving compassionate care(Parker, 2008; Williams et al., 2009; Smith et al., 2010).This paper describes a study that more fully articulates thetypes of relational knowledge that underpins compassionfrom the perspectives of older people, relatives and staffand considers how such knowledge is generated and usedin practice in the form of ‘appreciative caring conversations’(Dewar, 2011). It presents the most comprehensive modelyet developed of the behaviours staff need to engage in toencourage such conversations. It begins with a briefconsideration of a systematic narrative synthesis thatdelineated the key dimensions of compassion beforeconsidering the background to the study on which thispaper is based.

2. Compassion: we know what we say but what do wemean?

Prior to the empirical work, a comprehensive narrativesynthesis of the extant literature on compassionate careusing the key terms caring, compassionate care, dignity,relationship-centred and person centred care, was under-taken (see Dewar, 2011 for a full account). A pragmatic andinclusive approach was adopted with Medline, CINAHL,PsycLit and Index to Theses being the principal sourcesused to identify policy documents, theoretical and researchliterature, discussion and opinion pieces and newscommentary. Over 500 items were obtained for reviewand critical appraisal.

The resultant synthesis revealed that consensus as to adefinition of compassion was lacking and that there was nocomprehensive model indicating how it could be achievedin practice. However, key attributes were identifiedincluding: recognizing vulnerability and suffering; relatingto the needs of others; preserving integrity and acknowl-edging the person behind the illness (Dewar, 2011). Inessence therefore compassion primarily involves anawareness of another’s feelings, an appreciation of howthey are affected by their experiences and interacting withthem in a meaningful way (Dewar et al., 2011). Therefore,compassion can be considered as having four essentialcharacteristics:

1. a relationship based on empathy, emotional support andefforts to understand and relieve a person’s distress,suffering or concerns;

2. effective interactions between participants, over timeand across settings;

3. staff, patients and families being active participants in

and Innovation, 2011) and internationally, such as decision making; and

4. cbr

comsonet a200200SchOrbtherelapra

streachthenotper(Sc‘int200stu

necexp(BrMcet

adoaimproProundLotas

Napwapap200

2.1.

uniLCCdolAppvalthaCoo200to

praon

posmecasAI a

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–1258 1249

ontextualized knowledge of the patient and familyoth individually and as members of a network ofelationships.Adapted from Lown et al. (2011).The relational processes and practices that support

passion require the development of skilled interper-al relationships (Cash, 2007; Congressi, 2006; Criggerl., 2006; Dewar et al., 2010; Jull, 2001; Kanov et al.,4; Kim and Flaskerud, 2007; Macleod and McPherson,7; Milner, 2003; Peters, 2005, 2006; Schantz, 2007;ultz et al., 2007; Torjuul et al., 2007; Von Dietze and, 2000; Youngson, 2008). However, what is absent from

extant literature is a model that articulates how suchtionships can be established and enabled to flourish inctice.Current models of person and relationship-centred caress the importance of ‘knowing the person’ in order toieve a human connection often defined as ‘being with’

patient (Dewing, 2004). However, as Dewing (2004)es this highly skilled activity requires specific inter-sonal competences rather than technical expertisehultz et al., 2007). We need to understand how sucherpersonal competence’ can be understood (Doane,2). That was one of the primary aims of the present

dy.To do so the study, as with others, recognized theessity of actively involving staff, patients and families inloring the intricacies of compassionate care in daily care

own Wilson, 2009; Dewing, 2004; Koloroutis, 2004;Cormack, 2003, 2004; Meyer and Owen, 2008; Nolanal., 2004; Tresolini et al., 1994; Watson, 2006) andpted an appreciative inquiry approach to achieve this. The study was a core element of a comprehensivegramme called the ‘Leadership in Compassionate Caregramme’ (LCCP), a three-year action research projectertaken by Edinburgh Napier University and NHS

hian with the goal of establishing compassionate carean integral aspect of all nursing practice (Edinburghier University and NHS Lothian, 2012). The first author

s a member of the LCCP research team. The study that thiser reports took place between January 2008 and January9 on a 24 bedded mixed-sex ward for older people.

Design/research approach

In recognition of the high quality of care it provided thet in question was awarded ‘beacon’ ward status in theP programme and it was important that the metho-

ogy adopted built on what was currently working well.reciative inquiry (AI) starts by exploring what people

ue in what they do and how this can be built on rathern focusing on problems (Cooperrider et al., 2003;perrider and Whitney, 2000; Kowalski, 2008; Reed,7). In this study AI was combined with action researchensure an emphasis on developing and evaluatingctice change. A collaborative approach, which focusedreal time feedback, and reflection and evaluation onitive attributes to develop practice, were central to thethodology (Dewar and Mackay, 2010; Egan and Lan-ter, 2005; Kavanagh et al., 2008). The four principles for

and collaborative (Cooperrider and Srivastva, 1987). Theseprinciples were woven into all aspects of the study. AItypically involves a number of phases described in Table 1.The basic process of AI is to begin with a groundedexploration using a range of methods to identify the ‘‘bestof what is’’ (discovery phase), subsequently visioning anddebating with a range of stakeholders articulates ‘‘whatmight be’’ (dream phase), followed by working together todevelop ‘‘what could be’’ (design phase) and finallycollectively experimenting with ‘‘what can be’’ (destinyphase) (Moore, 2008). In the design phase, cycles of changeare developed which are then implemented and evaluatedin the destiny phase. In addition the principles ofrelationship-centred inquiry and action research wereapplied which included: understanding what was happen-ing and developing practice with all key stakeholders, andworking in democratic and participative ways to supportpeople to develop practice. The first author acted as anappreciative inquirer working on the ward for one yearapproximately two days a week. The challenges andbenefits to using this approach are described more fullyelsewhere (Dewar, 2011).

3. Participants

A range of staff including registered nurses, non-registered care staff, allied health care professionals andmedical staff (n = 35 i.e. 85% of staff), patients (n = 10) andfamilies (n = 12) took part in the study. Staff were asked toinvite patients and families to take part and deciding who toinclude was pragmatic based on factors such as, how wellpatients were at the time and whether the lead author waspresent on the ward that day. The sampling is therefore bestdescribed therefore as purposive (Creswell, 2003).

4. Ethical considerations

The research was approved by the University EthicsCommittee. Due to its emergent design ongoing processconsent was used whereby consent was continuallyrenegotiated (Dewing, 2007; Winter and Munn-Giddings,2001). Where participants were from potentially vulner-able groups (e.g. those with a serious or terminal illness)discussion took place with both the health care profes-sionals involved in their care, and their family member,about the nature of the study and the extent to which theyshould be involved in data generation activities.

5. Data generation and analysis

A range of methods were used in data generation. Theseincluded: the collection of stories using emotional touch-

Table 1

Phases of appreciative inquiry.

� Discovery (finding out what is working well),

� Dream (exploring where people want to be),

� Design (developing activities designed to achieve the dream) and

� Destiny, working to sustain these developments over time

(Cooperrider and Whitney, 2000).

nts, in which the storyteller identifies how they feel

re that inquiry is appreciative, applicable, provocative poi

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–12581250

about different aspects of their experience (Bate and Robert,2007; Dewar et al., 2010); structured observation; photo-elicitation where participants use images to sum up howparticular experiences felt (Dewar, 2012; Dewar et al., 2011;Hansen-Ketchum and Myrick, 2008); exploration of beliefsand values through group discussions; informal observa-tions and discussions captured as field notes. This multi-method approach ensured that different perspectives on thesame issue were explored and served to minimize thelimitations of any one method. Data was continuallyfeedback to participants throughout the study through avariety of creative methods including reading quotes orobservation excerpts at staff handover, and displayingemergent analysis in key areas in the ward for comment andcritical discussion. Emergent analysis informed further datageneration and the design of interventions throughout thestudy. Different methods were used during the varyingphases of the appreciative inquiry as illustrated in Table 2.Whilst this suggests linearity in reality there was muchoverlap in the process of data generation.

5.1. Data analysis

Data analysis employed immersion crystallization(Borkan, 1999) which involves a participative approachthat progresses through a number of stages: initialdescription of the data; crystallizing the core messagesin data extracts; considering these in relation to all otherdata; reflecting these back to participants; and creativesynthesis and corroboration of the themes. Emergentfindings were analyzed and shared with participants.Patients and families were, on the whole, primarilyinvolved in interviews that explored their experiences ofcare and their suggestions about what would enhance thisexperience. Due to the nature of their illness and the lengthof time they were on the ward they did not participate infollow up discussions.

6. Findings

Detailed analysis of the extensive data identified twokey forms of ‘person and relational knowledge’(Liaschenko and Fisher, 1999) enabling staff, patientsand families to ‘work together to shape the way things are

done’: these were termed ‘knowing who I am and what

matters to me’ and ‘understanding how I feel’. Developingsuch knowledge entailed a complex form of relationalpractice (Parker, 2008; Williams et al., 2009) that involvedengaging in ‘appreciative caring conversations’.

Thus the person and relational knowledge developed bystaff, patients and families during their ‘appreciative caring

conversations’ and that informed compassionate relation-ship-centred care took two broad forms. These areconsidered below.

6.1. Dimension 1: knowing who I am and what matters to me

‘Knowing who I am and what matters to me’ involvedstaff, patients and family members better understandinghow people define themselves and what they see asimportant, including their likes, dislikes, values and beliefs.Such knowledge comprised three subtypes: ‘making a

connection and clicking’, ‘knowing the little things that

matter’, and ‘not assuming how people want to be cared for’.In order to know who people are and what matters to

them staff sought to ‘click’ with the person as soon aspossible. To do so they:

� offered a warm welcome;� shared personal information;� used banter and humour; and� established a shared understanding.

These strategies helped to develop positive relation-ships, laying the foundation for knowing who I am and what

matters to me, as the following data illustrates:

Table 2

Overview of phases and data generation activities.

Phase Activity/data generation

Phase 1 – setting the scene and establishing relationships � Field work including informal observation and informal discussions

� Informal interviews with staff to explore their views about the study

and meaning of compassionate care (n = 35)

Phase 2 – discovery – what is working well? � Structured participant observations (n = 10 events e.g. mealtimes)

� Staff (n = 10) and student nurse (n = 9) stories about experiences of giving care

� Photo elicitation (staff n = 16, patients n = 2, families n = 4)

� Patient (n = 10) and family stories (n = 12) using emotional touchpoints

(Dewar et al., 2010)

� Field work including informal observation and informal discussions

Phase 3 – dream/ideal – what would be the ideal

caring environment?

� Feedback data from discovery phase to staff (n = 14 sessions attended

by 40 staff)

� Beliefs and values group interviews with staff (n = 25 members of staff

attended 8 sessions)

� Field work including informal observation and informal discussions

Phase 4 – design – what do we have to do to achieve

our dream/ideal? Test this out and evaluate the activity?

� Group discussions (n = 26) with staff to generate positive caring practice

statements and action projects

� Field work using informal discussions to monitor impact of any development

activity

Phase 5 – destiny – what has worked well and how can

people be supported to develop further?

� One to one exit interviews with staff (n = 17)

� Action planning for sustainability

actrelainvhavperappoutusehigthebecbe

sou

enapeowa

� k� n

patma

� md� a

mm� a

p

nur

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–1258 1251

I observed one staff nurse greeting a relative that she had

not met before by shaking her hand and introducing

herself. She asked what she should call them and how they

were. She also told them if they had any worries just to ask.

(Observation)

There is a lot of banter here and I get dragged into it. . .. I

like the banter. It’s part of feeling they trust me. I feel

privileged and accepted that they include me in the banter.

(Relative story)

I feel really respected for who I am as a person, not just as a

student. I feel accepted that I am black and I like the fact

that people call me by my name and not ‘the student’.

(Student Story).

Making such connections was part of everyday inter-ions and played an important role in establishingtionships. Although seemingly mundane, they

olved people considering another’s perspective anding the courage to use banter and humour or sharingsonal information whilst also ‘checking out’ theropriateness of the interaction. However, until pointed

to them, participants were usually not aware that theyd these skills, or of their impact. Appreciative Inquiryhlighted the importance of such subtle interactions and

skills involved. However, many staff took time toome comfortable with positive feedback that needed tohandled in a sensitive way in order to avoid the risk ofnding patronizing.Initial connections stimulated further conversationsbling staff to gain deeper insights into what mattered tople. They used this knowledge to ‘shape’ the way care

s provided by:

nowing the little things that matter; andot assuming how someone wants to be cared for.

Therefore by asking questions and ‘being curious’ staff,ients and family found out about the little things thatttered to each other. For example:

any staff valued being thanked at the end of aemanding shift;

relative valued staff listening attentively to hisother’s stories even though they had heard themany times before;

patient appreciated that staff knew which side hereferred to lie on.

Developing such insights was not always easy, as a staffse illustrates below:

A lady had been in for a couple of weeks when she began to

deteriorate. She was quite a proud woman . . . She would

always brush her hair and would put her makeup on. She

got quite poorly . . . and eventually she lost consciousness.

Her husband was coming in every day – they had been

married for over 50 years. One day, when I was giving her a

bed bath. I found her makeup. . . so I thought I would put it

on. I don’t know if she was aware that I was doing this. A

few members of staff went in afterwards and kind of

laughed and said, what is the point, I think they thought I

was a bit daft and slightly time wasting. . . When her

husband came in, he came out of the room and said ‘who

put her makeup on?, she looks lovely, she looks like herself’.

(Staff Story, SS9).

This nurse had asked herself ‘curious questions’ aboutwhat this lady would like, actively considered herperspective and was courageous enough to act on thisknowledge, despite scepticism from her colleagues. How-ever, her actions were vindicated by the very positiveresponse from the patient’s husband and their relationshipsubsequently flourished.

Finding out what mattered to individuals helped tochallenge existing practice:

One thing that is important to me is making sure my hands

are washed after I use the bedpan. This is very rarely

done. . . I ask –‘can I wash my hands?’ and people would

say ‘well you don’t need to because you’ve not cleaned

yourself – we’ve done it for you’. But I like to feel clean – I

like my clothes to be clean, I like my hair to be nice.

(Patient Story, PS10).

This incident surprised staff. Many talked openly abouthow they did not always ask patients about washing theirhands. However, rather than becoming defensive staffquestioned and subsequently changed their practice,showing a degree of humility and recognizing that the‘staff’ do not always know what is best. This helped them todevelop a questioning culture that challenged taken-for-granted practices. The use of AI, with its emphasis on beingcurious and asking unconditional questions, thereforeencouraged a more constructively critical stance.

Not assuming how people wanted to be cared for wasalso key to fully appreciating ‘who people are and what

matters to them’. Initially staff based their care on beliefsabout how they would wish either themselves or a familymember to be cared:

Compassionate care is about caring. It’s about loving,

treating others like you would want to be treated

yourself, going the extra mile. (Staff Comment, Beliefsand values 15).

This personal philosophy of ‘do unto others’ seemsintuitively sound but staff often did not ‘check out’ if theirbeliefs were consistent with patient’s. However, as thestudy progressed and staff became more attentive topatients’ and families’ stories, things changed. This waspotentially threatening, and challenged long-held, iflargely implicit, beliefs:

I’ve really learnt that what I think is important and right

might not be what the patient thinks. . . .I have to take a

step back and think- well that is not what I think but let’s

go with it. I feel more confident with this and that others

will support me. (Staff Comment, recorded during fieldwork, Nov 2008).

The extent to which staff felt comfortable to challengepractice depended largely on the support they receivedfrom colleagues and senior staff, which increased as thestudy progressed. Attention is now turned to the secondtype of person and relational knowledge: ‘Understanding

how I feel’.

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–12581252

6.2. Dimension 2: understanding how I feel

Complementing the above was another dimension ofperson and relational knowledge: understanding how I feel.This required that staff explored the emotional aspects ofcare and involved four types of action:

� ‘recognizing emotion and articulating feelings’;� ‘connecting with others by asking how they are

feeling’;� ‘noticing’ how you and others feel about experiences’;

and� ‘supporting people to hear and respond to feedback’.

As patient describes her feelings below:

You get to know the staff – they are all different and you

react to them in different ways. . .. I like to be independent

and I want help to become independent. Sometimes if I

think staff are being unkind, I have to think why are they

being unkind and when I think it through I think they are

trying to help me. I get a bit annoyed when they are unkind

or make me do things for myself but I understand. I get so

frustrated with myself. (Patient Story, PS7).

Staff were surprised by this account. They hadconsidered this lady to be difficult, demanding andungrateful but her story helped them to understand thecomplex feelings underpinning her responses. Afterhearing this the staff member involved told the patienthow pleased she was to learn about the patient’s feeling,believing that it would help her to ‘be less bossy’. Thus, asstaff and patients shared their true feelings a moreresponsive, connected and stronger relationship ensued.This was valued by staff, patients and families, as thefollowing quotes illustrate:

One of the patients said to me she liked when I was on

because there was no patter with me – she could tell me

anything. (Staff Story, SS11).

One of the students said to me recently that she liked being

on with me because she felt safe – this meant a lot to me.

(Staff Story, SS9).

When we are in visiting we give him a drink . . .Staff said he

maybe takes it a bit better from me as he knows my voice.

(Relative Story, RS4).

Staff sometimes say thanks to me because I have been

looking out for Janet (another patient) when they have

been busy. They know I will come and tell them if she

wanders off. (Patient Story, PS9).

Connecting with the feelings of was encouraged by theuse of emotional touchpoints, whereby people selectedboth positive and negative words to capture how they arefelt about a significant event:

I felt out of my depth when I was here at night initially.

unsure of what rules and regulations applied, . . . was it still

OK to use the kitchen, or if you went out of the building

would you be able to get back in?. At times we felt like

intruders and we were unable to speak to staff about our

concerns (Relative Story, RS1).

Such comments challenged staff and they neededsupport not to personalize things. However, staff beganto appreciate the need for consistent and specificinformation and the importance of allowing patients andtheir families to share their experiences of being inhospital. In response to the above story staff and relatives‘co-designed’ a booklet for patients and relatives about‘being here at night’.

Developing person and relational knowledge involvedpeople making connections, engaging emotionally andreflecting on the insights gained to better understand theexperience of the ‘other’. These processes caused uncer-tainties and had the potential to create tensions but alsoled to opportunities to challenge existing practice and toforge more responsive relationships between all groups.The data highlighted that seemingly mundane interac-tions were imbued with subtle meaning and significance,and that the type of knowledge gained needs to berecognized and celebrated as it plays a central role in theway that everyone ‘works together to shape the way things

are done’.

6.3. Working together to shape the way things are done

‘Working together to shape the way things are done’ madepeople feel involved and empowered but also meant takingrisks. This required an environment that: encouragedpeople to be open and honest; acknowledged theconstraints under which they operated; and helped themto find potential solutions. With such support staff,patients and families were better able to accept compro-mises based on a full understanding of the situation:

One lady hated the commode and yet it took a nurse half an

hour to help her to the toilet. We couldn’t always do this

and the patient got exhausted doing this more than twice a

day. . .. We needed an agreement about the way forward.

This was about walking, maybe once a day but at other

times using the commode – coming to a compromise and

reviewing this on a regular basis. I think we all felt more

comfortable with the situation. (Staff Story, SS12).

Working with me to shape the way things are done

sometimes required staff to overcome organizationalconstraints to compassionate care:

One of the patients was blind and agitated, we asked what

was important to her, she replied ‘Being read a chapter from

the Bible, John 14’ . . . there were no longer any Bibles. . . they

had been removed because of equality and diversity issues

and infection control. Staff went to the Chaplaincy Centre

and managed to retrieve one . . .. following discussions with

the chaplain, copies of Bibles and Korans were reinstated in

all wards. It would have been easy for staff to give up but

they persevered demonstrating that the organisation could

be challenged, based on person knowledge. Working as a

team to deliver on this were key attributes to a successful

outcome (field note, June 2008).

Creating and using the types of relational knowledgedescribed above required a certain type of relationalpractice that was termed, ‘engaging in appreciative caring

conversations’ (Dewar, 2011).

6.4.

meperwoprocurreasubinvwameothillulink

discgrecomappanastaftionplaconinv

attremothrepcrucenfull

to gandcen

7. B

que‘sticou

wit

7.1.

to

fee

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–1258 1253

Engaging in appreciative caring conversations

‘Engaging in appreciative caring conversations’ was thedium via which everyone, especially staff, generated thesonal and relational knowledge that enabled people tork as partners in shaping the way things were done. Thecess of AI with its emphasis on appreciation, beingious and not making assumptions, collaboration andl time feedback reinforced and raised consciousness oftle elements of these conversations. For example,iting staff to share their experiences of good works useful for data generation, but in addition, it acted as aans of consciousness raising, something recognized byers (Christiansen, 2008; Gardner et al., 2001). Thisstrates how inquiry and intervention are inextricablyed.

As confidence grew staff used the strategies weussed in their day to day conversations and developed

ater awareness which enhanced their ability to providepassionate relationship-centred care. The process of

reciative caring conversations was explored further bylyzing the findings of the exit interviews (n = 17) fromf that identified specific attributes of these conversa-s. Detailed analysis of the extensive data, in which staff

yed a major role, revealed that apparently simpleversations belied the complexity of the processesolved (see Dewar, 2011 for a fuller account).Underpinning these conversations were seven essentialibutes which were: being courageous; connectingotionally; being curious; collaborating; consideringer perspectives; compromising; and celebrating. Theseresent the 7 ‘C’s’ of caring conversations, which arecial to the delivery of compassionate relationship-tred care. Each of these attributes is considered morey below.As noted already, staff often had to ‘take risks’ in orderenerate the person and relational knowledge needed

not surprisingly therefore ‘being courageous’ wastral to caring conversations.

eing courageous

A willingness to take risks, feeling confident to askstions, working with uncertainty and the ability to

ck up for’ changes to established practices requiredrage, as staff were aware:

The biggest thing for me about doing the work on the

project is feeling much more aware about how I behave,

being braver to ask patients and families more direct

questions, being stronger in sticking up for the things I

believe in and being much clearer about what it is we do

well around here. (Staff exit interview 8).

Being courageous was vital to connecting emotionallyh patients and their families.

Connecting emotionally

Connecting emotionally was about staff inviting peopleshare their feelings and being aware of their own

progressed so did awareness of the importance of creatingan emotional connection between patients, staff andfamilies and this became a regular feature of dailyinteractions:

It has made us more aware of the bonding with the patient.

You are not just showering someone, you are using the

opportunity to talk to them about how they feel, I think we

are much more aware of this. We know more about the

little things that matter to them and this is talked about

more. (Staff exit interview 2).

Making an emotional connection became a specific aim,not only for staff, but also for patients:

I think patients feel more able to say what they would like

now – they are more often asked and able to tell I think.

(Staff exit interview 12).

Staff now questioned how patients felt about their careand became more comfortable about sharing them theirown thoughts. This enabled people to be more ‘curious’and to explore issues that previously would have beenglossed over.

8. Being curious

This involved asking questions about the feelings andexperiences of others as a means of challenging existingassumptions and finding alternative approaches. Such‘curiosity’ became embedded into the working practices ofstaff:

Staff question practice more and check things out with

patients. This feels like a normal thing to do now. In the

past people might have been a bit on the defensive with

questions like this. (Staff exit interview 9).

Staff now both supported and challenged each other toconsider new ways of communicating that became alegitimate and important part of the way in which staffinteracted:

People talk about care more. They question things, but in a

nice way. One of the staff nurses will say now – ‘how could

you have said that in a different way’. The project has kind

of given us permission to say this kind of thing. (Staff exitinterview 6).

As a consequence staff now worked together morecollaboratively.

9. Being collaborative

This meant talking together, involving people indecisions, bringing others on board, and developing ashared responsibility. The project had clearly enhancedopportunities for collaboration, not only between staff butalso patients and families:

We have not always asked patients and families what they

think – we tend to think that we have to have all the

answers. We don’t and have found that patients come up

with things we might not have thought about. (Staff exit

interview 11). lings about the emotions of others. As the project

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–12581254

Such collaboration inevitably meant that the perspec-tive of others was given greater attention.

10. Considering others’ perspectives

This involved exploring another’s point of view,acknowledging that they may not hold the same beliefsas you and feeling comfortable to discuss any differences inan open way.

Another key thing the project has brought out is

highlighting that we make a lot of assumptions about

things and we need to be much better at checking things

out. This has been one of the biggest things for me. (Staffexit interview 3).

Acknowledging differences required the ability tocompromise.

11. Compromising

This was about striving for consensus through discus-sion and reflection, and involved being prepared to ‘giveand take’:

We are more open now about saying what we can and

can’t do. The project has helped us to say what we feel,

and our opinion has counted in decisions about care. It

has not all been about what the patient thinks and wants

because sometimes this can be unrealistic. (Staff exitinterview 7).

Central to the success of the ‘appreciative caring

conversations’ was that these conversations were valuedand celebrated.

12. Being celebratory

Meant making a conscious effort to explore what workswell and why, to let people know that their contribution isvalued:

I try to commend people for good things more now. Before,

I think when I thought people did things well, I didn’t say

anything because I just thought it was part of their job. I do

try to say these things more to people. (Staff exitinterview 17).

The above comprise the 7 ‘C’s of appreciative caringconversations, which have at their heart the courage totake risks. Without the courage to step outside of the‘comfort zone’ of taken-for-granted practices little elsewould happen. Being courageous therefore is the pre-eminent attribute and enables people to ‘engage emo-tionally’ another essential attribute that means patients,family members and staff ask questions such as those inTable 3.

Asking such questions and engaging in appreciativecaring conversation creates connections between people,the environment, actions, perceptions, ideas, feelings,events, beliefs and contexts and these are used to shapecare in hitherto unacknowledged ways. Supporting people

facilitation inherent in the approach of appreciativeinquiry.

It must be remembered that the study ward had alreadybeen awarded ‘beacon’ status which suggests a highstandard of care. Therefore, whilst some of what isdescribed above may have been happening prior to theproject it was far from the norm, and was not openlyacknowledged and promoted. Skilled facilitation inherentin appreciative inquiry helped to make explicit thepreviously tacit practices of a few, it gave a name andstatus to what was happening, enabling it to be shared andopenly communicated: it helped appreciative caring con-

versations to become part of the ‘culture’ of practice on thestudy unit. The need for a skilled facilitator should berecognized, if such approaches are to be developed andintroduced more widely.

In developing a model for the delivery of compassionaterelationship-centred care the study identified three keydomains, these were:

‘Appreciative Caring Conversations’ (as captured by the 7‘C’s) which allowed the development of person andrelational knowledge providing insights into knowing

who I am and what matters to me and understand how I

feel, that facilitated the relational process of working with

me to shape the way things are done.Fig. 1 illustrates the elements of this model and their

inter-relationships. The model applies equally to staff,patients and families.

The findings of this study (Dewar, 2011), and particu-larly the 7 ‘C’ s of caring conversations, highlight thecomplex but subtle interactions that are necessary todevelop the type of knowledge and understanding toensure that all parties experience compassionate relation-ship-centred care.

13. Discussion

The long-standing international concerns about thequality of hospital care for older people (Brundtland, 2003;Mullan, 2009; Norton et al., 1962; HAS, 2000; Young et al.,2003) have, despite concerted efforts over the last decade,appeared resistant to change. Debates in a number ofcountries in the developed world reflect enduring tensionsbetween the ‘metrics’ and ‘meaning’ of a system predicatedon the goal of cure when the majority of users have long-term conditions (Tresolini et al., 1994; Patterson et al.,2011). Patterson et al. (2011) have recently argued thatconsequently there are competing cultures in operation,

Table 3

Questions to support engagement in appreciative caring conversations.

� What matters to you most whilst you are in hospital?

� Tell me something that will help us to care for you here?

� How do you feel about your experience?

� What helps you to feel up beat and well?

� How would you like us to respond if you are feeling low?

� Who/what are the most important people/things for you?

� What worries/concerns do you have?

� What things have worked well for you here?

one based on efficiency and effectiveness, that operates

to have the courage to ask such questions requires skilled

witrec

heatatirepproas ssitumutionthisnarideintrundpra

upo(LiarecWilandacksouappout‘rel

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–1258 1255

hin a ‘perform or perish’ culture and another whichognizes the need for a ‘relational and responsive’ model.The challenges of promoting compassionate care withinlth care systems that are judged primarily on quanti-ve measures of throughput (Patterson et al., 2011)resents what Heifetz (1994) has termed a ‘wicked’blem. Addressing wicked problems is very challengingolutions have to consider a range of complex factors, inations where boundaries are unclear and there areltiple stakeholders who may hold conflicting assump-s and beliefs. The extant literature would suggest that

is certainly the case with compassionate care. Therative synthesis preceding the study (Dewar, 2011)ntified key attributes of compassionate care (seeoduction) but it also revealed that there is limitederstanding of how they can be achieved in day-to-day

ctice.In seeking a way forward, the study reported here drewn the concepts of person and relational knowledgeschenko, 1997; Liaschenko and Fisher, 1999) and more

ent writings on relational practice (Parker, 2008;liams et al., 2009) to explore the types of knowledge

practices that might promote compassionate care. Itnowledged the ‘wicked’ nature of the problem andght to address this by using an Appreciative Inquiryroach involving staff, patients and relatives in teasing

the dimensions of compassionate care, and theational practices’ that support it.

This is essential for as Williams et al. (2009, p. 18) notethat:

‘If we are truly to ‘transform’ the patient (person)experience of health care and to provide care withcompassion and dignity then ‘relational practices’ mustbe more fully explored, their nature more clearlyarticulated and they need to be recognized as a corecompetency within all health and social care disciplines’

We would argue that the model described here goes along way towards addressing this challenge. Parker (2008)defines relational practices as those activities necessary to‘develop and sustain interpersonal relationships’ within aspecific context and sees emotional connection andcollaboration as essential characteristics. As will beappreciated these are consistent with two of the 7 ‘C’sidentified in the present study. However the 7 ‘C’srepresent a far more complete, subtle and nuancedunderstanding of the day-to-day reality of deliveringcompassionate relationship-centred care than other extantmodels. Whilst this model requires further developmentand testing, it has started to articulate the supportiveenvironment necessary if ‘players’ are to have the courageto take the risks necessary to engage in the ‘appreciativecaring conversations’ that are the route to compassionatecare. We would argue that such conversations represent anadvanced and highly skilful form of relational practice thatis often not fully recognized, promoted or celebratedwithin the culture that currently dominates acute settings.

Fig. 1. A model of compassionate relationship centred care.

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–12581256

Such conversations have not yet been recognized as a ‘corecompetency’, nor has the need to promote experientialknowledge, been fully valued.

Williams et al. (2009) contend that if relationalpractices are to flourish then they have to be accordedvalue and status, to be adequately resourced and staff needto be emotionally supported if they are to feel safe toengage in the ‘deep conversations’ necessary for compas-sionate care (Youngson, 2008). This study has provided farmore insights into the precise nature of such ‘deep’conversations and the conditions necessary for them toflourish.

The findings are consistent with the recommendationsof the Tresolini et al. (1994) that identified the range ofknowledge, skills and values required to achieve healthcare that is ‘relationship-centred’. These are captured inTable 4.

However the Task Force acknowledged that a means ofdelivering such ideals in practice had yet to be developed.Building on this work the development of relationship-centred care in the UK has been led by Nolan andcolleagues (Nolan et al., 2004, 2006) who highlightedthe interconnections and interdependency inherent in careand captured these in the ‘Senses Framework’. This modelis underpinned by the belief that all parties involved in careshould experience relationships that promote six ‘senses’,namely: security, belonging, continuity, purpose, achieve-ment and significance. This framework has been exten-sively and rigorously tested in a range of careenvironments (Davies et al., 2007; Faulkner et al., 2006)but nurses and other practitioners need additionalguidance about interacting with older people and theirfamilies in ways that best support relationships. The kindsof relational knowledge and practices captured in thispaper provide the ‘fine detail’ of how compassionaterelationship-centred care can be realized in practice.

Central to Nolan et al.’s (2006) vision of relationship-centred care is the creation of an ‘enriched environment’.The study upon which this paper is based found that insuch an environment practitioners develop a feeling of‘learned hopefulness’ (Dewar, 2011). Better understandingthe relationship between an enriched environment andlearned hopefulness for all parties marks the next step inconceptualizing the conditions necessary to make com-passionate relationship-centred care a reality. This is thefuture challenge for as the world’s population ages andbecomes increasingly frail improving the care of frail olderpeople is a matter of global, national and personal concern.

Conflicts of interest

None declared.

Funding

Funding for PhD was from NHS Lothian, Edinburgh.

Ethical approval

The Research Ethics and Governance CommitteeEdinburgh Napier University 06/SNMSC/069.

References

Abraham, A., 2011. Care and Compassion? Report of the Health ServiceOmbudsmanon ten investigations into NHS care of older people[online]. Fourth Report of the Health Service Commissioner for Eng-land; session 2010–2011. HC 778. The Stationery Office, London.Available at: http://www.ombudsman.org.uk/__data/assets/pdf_file/0016/7216/Careand-Compassion-PHSO-0114web.pdf (accessed on05.02.12).

Bate, P., Robert, G., 2007. Bringing User Experience to HealthcareImprovement: The Concepts Methods and Practices of ExperienceBased Design. Radcliffe Publishing, Oxford.

Borkan, J., 1999. Immersion/crystallization. In: Crabtree, B.F., Miller, W.L.(Eds.), Doing Qualitative Research. 2nd ed. Sage, Thousand Oaks, CA,pp. 179–194.

Brown Wilson, C., 2009. Developing community in care homes throughrelationship centred approach. Health and Social Care in the Com-munity. 17 (2), 177–186.

Brundtland, G., 2003. Health, dignity and human rights. In: KeynoteAddress 7th Conference of European Health Ministers. WHO, Geneva.

Care Quality Commission, 2011. Dignity and Nutrition Inspection Pro-gramme: National Overview. Newcastle upon Tyne: Care QualityCommission. Available at: http://www.cqc.org.uk/sites/default/files/media/documents/20111007_dignity_and_nutrition_inspection_report.pdf (accessed on 05.02.12).

Cash, K., 2007. Compassionate strangers. Nursing Philosophy 8 (2), 71–72.Christiansen, B., 2008. Good work – how is it recognized by the nurse?

Journal of Clinical Nursing 17 (12), 1645–1651.Clarfield, A.M., Bergman, H., Kane, R., 2001. Fragmentation of care for frail

older people: an international concern: experience form three coun-tries, Israel, Canada and the United States. Journal of the AmericanGeriatric Society 49 (12), 1714–1721.

Congressi, L., 2006. Four days in a strange place. Journal of Health ServicesResearch & Policy 11 (2), 122–124.

Cooperrider, D., Srivastva, S., 1987. Appreciative inquiry in organizationallife. In: Pasmore, W.A., Woodman, R.W. (Eds.), Research in Organiza-tional Change and Development, 1. JAI Press, Greenwich, CT, pp. 129–169.

Cooperrider, D., Whitney, D., 2000. A positive revolution in change:appreciative inquiry. In: Cooperrider, D., Sorenson, P.F.J., Whiney,D., Yaeger, T.F. (Eds.), Appreciative Inquiry: Rethinking Human Orga-nization Towards a Positive Theory of Change. Stipes Publishing LCC,Champaign, IL, pp. 3–27.

Cooperrider, D.L., Whitney, D., Stavros, J.M., 2003. The AppreciativeInquiry Handbook. Lakeshore Communications, Bedford Heights, OH.

Creswell, J.W., 2003. Research Design: Qualitative Quantitative and MixedMethods Design, 2nd ed. Sage, London.

Crigger, N.J., Brannigan, M., Baird, M., 2006. Compassionate nursingprofessionals as good citizens of the world. Advances in NursingScience 29 (1), 15–26.

Darzi, A., 2008. High Quality Care for all: NHS Next Stage Review FinalReport. Department of Health, London.

Davies, S., Atkinson, L., Aveyard, B., Martin, U., McCaffrey, S., Powell, A.,2007. Changing the culture within care homes for older people. In:Nolan, M., Hanson, E., Grant, G., Keady, J. (Eds.), User Participation inHealth and Social Care Research – Voices, Values and Evaluation.Open University Press, McGraw-Hill Education, Maidenhead, pp. 50–68.

Department of Health, 2001. The National Service Framework for OlderPeople. Department of Health, London.

Department of Health, 2006. The Dignity Challenge. Department ofHealth, London.

Department of Health, 2009. The National Health Service Constitution.Available from: http://www.nhs.uk/choiceintheNHS/Rightsand-pledges/NHSConstitution/Documents/nhs-constitution-interactive-version-march-2012.pdf (accessed 05.06.12).

Department of Health, 2012. Developing the Culture of CompassionateCare: Creating a New Vision and Strategy for Nurses, Midwives andCare Givers. https://www.wp.dh.gov.uk/commissioningboard/files/2012/10/nursing-vision.pdf.

Table 4

Knowledge, skills and values for relationship-centred care.

� Willingness to negotiate and compromise;

� Willingness to see another perspective;

� Promoting and accepting the emotions of others;

� Sharing personal information;

� Openness to other ideas;

� Sharing insights when things are not going so well; and

� Recognizing what people are good at.

Dew

Dew

Dew

Dew

Dew

Dew

Dew

Doa

Edin

Edv

Egan

Faul

Finf

Gard

Goo

HAS

Han

Heif

Jull,

Kan

Kav

Kim

Kolo

Kow

Lias

Lias

Low

Mac

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–1258 1257

ar, B., 2012. Using creative methods in practice development tounderstand and develop compassionate care. International PracticeDevelopment Journal 2 (1), 1–11.ar, B., Pullin, S., Tocher, R., 2011. Valuing compassion through defini-

tion and measurement. Journal of Nursing Management 17 (9), 32–37.ar, B., 2011. Caring about caring: an appreciative inquiry about

compassionate relationship centred care. Unpublished PhD Thesis.Edinburgh Napier University, Edinburgh.ar, B., Mackay, R., 2010. Appreciating compassionate care in acute

care setting caring for older people. International Journal of OlderPeople Nursing 5 (4), 299–308.ar, B., Mackay, R., Smith, S., Pullin, S., Tocher, R., 2010. Use of

emotional touchpoints as a method of tapping into the experienceof receiving compassionate care in a hospital setting. Journal ofResearch in Nursing 15 (1), 29–41.ing, J., 2004. Concerns relating to the application of frameworks to

promote person-centredness in nursing older people. InternationalJournal of Older People Nursing 13 (3a), 39–44.ing, J., 2007. Participatory research: a method of process consent with

persons who have dementia. International Journal of Social Researchand Practice 6 (1), 11–25.ne, G.A.H., 2002. Beyond behavioural skills to human involved pro-cesses: relational nursing practice and interpretive pedagogy. Journalof Nursing Education. 41 (9), 400–404.burgh Napier and NHS Lothian, 2012. Leadership in Compassionate

Care Programme. Final Report. Edinburgh Napier University, Edin-burgh.ardsson, D., Koch, S., Nay, R., 2010. Acute Care and older people:challenges and ways forward. Australian Journal of Advanced Nursing27 (2), p53–p60., T.M., Lancaster, C.M., 2005. Comparing Appreciative Inquiry to

action research: OL practitioner perspectives. Organization Develop-ment Journal 23 (2), 29–49.kner, M., Davies, S., Nolan, M.R., 2006. Development of the combinedassessment of residential environments (CARE) profiles. Journal ofAdvanced Nursing 55 (6), 664–677.geld-Connett, D., 2008. Meta-synthesis of caring in nursing. Journal ofClinical Nursing 17 (2), 196–204.ner, H., Csikszentmihalyi, M., Damon, W., 2001. Good Work: When

Excellence and Ethics Meet. Basic Books, New York.drich, J., Cornwell, J., 2008. Seeing the Person in the Patient; the Pointof Care Review Paper. King’s Fund, London., 2000, 1998. ‘‘Not because they are old’’: An Independent Inquiry intothe Care of Older People on Acute Wards in General Hospitals. HealthAdvisory Service, London.sen-Ketchum, P., Myrick, F., 2008. Photo-methods for qualitativeresearch in nursing: an ontological and epistemological perspective.Nursing Philosophy 9 (3), 205–213.etz, R., 1994. Leadership without Easy Answers. Harvard UniversityPress, Cambridge, MA.

A., 2001. Compassion: a concept exploration. Nursing Praxis in NewZealand 17 (1), 16–23.ov, J.M., Maitlis, S., Worline, M.C., Dutton, J.E., Frost, P.J., Lilius, J.M.,2004. Compassion in organizational life. American Behavioural Scien-tist 47 (6), 808–827.anagh, T., Stevens, B., Seers, K., Sidami, S., Watt-Watson, J., 2008.Examining appreciative inquiry as a knowledge translation interven-tion in pain management. Canadian Journal of Nursing Research 40(2), 40–56., S., Flaskerud, J.H., 2007. Cultural competence column: cultivatingcompassion across cultures. Issues in Mental Health Nursing 28 (8),931–934.routis, M., 2004. Introduction. In: Koloroutis, M. (Ed.), Relationship-

based Care: A Model for Transforming Practice. Creative HealthcareManagement, Minneapolis, MN, pp. 1–22.alski, K., 2008. Appreciative inquiry. Journal of Continuing Education

in Nursing 39 (3), 104.chenko, J., Fisher, A., 1999. Theorizing the knowledge that nurses usein the conduct of their work. Scholarly Inquiry for Nursing Practice 13(1), 29–41.chenko, J., 1997. Knowing the patient. In: Thorne, S.E., Hays, V.E.(Eds.), Nursing Praxis: Knowledge and Action. Sage, Thousand Oaks.n, B., Rosen, A., Marttila, J.J., 2011. An agenda for improving compas-sionate care: a survey shows about half patients say such care ismissing. Health Affairs 30 (9), 1772–1778.leod, R., McPherson, K.M., 2007. Care and compassion: part of person-centred rehabilitation, inappropriate response or a forgotten art?Disability & Rehabilitation 29 (20–21), 1589–1595.

McCormack, B., 2003. A conceptual framework for person centred practicewith older people. International Journal of Nursing Practice 9 (3),202–209.

McCormack, B., 2004. Person-centredness in gerontological nursing: anoverview of the literature. International Journal of Older PeopleNursing in conjunction with Journal of Clinical Nursing 13 (3a),45–53.

Meyer, J., Owen, T., 2008. Call for an international dialogue on quality oflife in care homes. International Journal of Older People Nursing 3 (4),291–294.

Milner, J., 2003. Compassionate care nursing with meaning: incorporatingholism into nursing practice. Chart, Journal of Illinois Nursing 100 (6),4–6.

Moore, M., 2008. Appreciative inquiry: the why: the what? the how?.Practice Development in Health Care 7 (4), 214–220.

Mullan, K., 2009. Patients not Numbers People not Statistics. PatientAssociation, London.

NHS Institute for Innovation and Improvement, 2011. Rapid ImpactAssessment of the Productive Ward: releasing time to careTM. NHSInstitute for Innovation and Improvement, London.

Nicholson, D., Oliver, D., 2012. Care and Compassion? Report of the HealthService Ombudsman on 10 Investigations into NHS Care for OlderPeople. Crown Publishers. http://www.dh.gov.uk/en/Publication-sandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_124343.

Nolan, M.R., Davies, S., Brown, J., Keady, J., Nolan, J., 2004. Beyond personcentered care: a new vision for gerontological nursing. InternationalJournal of Older People Nursing 13 (3a), 45–53.

Nolan, M.R., Davies, S., Grant, G., 2001. Working with Older People andTheir Families: Key Issues in Policy and Practice. Open UniversityPress, Buckingham.

Nolan, M., Brown, J., Davies, S., Nolan, J., Keady, J., 2006. The sensesframework: improving care for older people through a relationshipcentred approach. Getting Research into Practice (GRiP) Report No. 2.Project Report. University of Sheffield, Sheffield.

Norton, D., McLaren, R., Exton-Smith, A.N., 1962. An Investigation ofGeriatric Nursing Problems in Hospital. National Corporation forthe Care of Old People, London, reprinted in 1976 by ChurchillLivingstone.

Parker, V.A., 2008. Connecting relational work and workgroup context incaregiving organizations. The Journal of Applied Behavioural Science38 (3), 276–297.

Patterson, M., Nolan, M. Rick, J., Brown, J., Adams, R., Musson, G., 2011.From metrics to meaning: culture change and quality in acute hos-pital care for older people. Report from the National Institute forHealth Research Service Delivery and Organisation Programme.Available from: http://www.sdo.nihr.ac.uk/files/project/93-final-report.pdf (accessed 11.02.11).

Peters, M.A., 2005. Reflections on compassion. International Journal forHuman Caring 9 (2), 71.

Peters, M.A., 2006. Compassion: an investigation into the experience ofnursing faculty. International Journal for Human Caring 10 (3), 38–46.

Reed, J., 2007. Appreciative Inquiry: Research for Change. Sage, ThousandOaks, London.

Robb, B., 1967. Sans Everything: A Case to Answer. Thomas Nelson andSons, London.

Schantz, M.L., 2007. Compassion: a concept analysis. Nursing Forum 42(2), 48–55.

Scottish Government, 2011. The Healthcare Quality Strategy for NHSScot-land. Scottish Government, Edinburgh Available at http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf (accessed06.06.12) (online).

Schultz, R., Hebert, R.S., Dew, M.A., Brown, S.L., Scheier, M.F., Beach, S.R.,Czaja, S.J., Martire, L.M., Coon, D., Langa, K.M., Gitlin, L.N., Stevens,S.A.B., Nichols, L., 2007. Patient suffering and caregiver compassion:new opportunities for research, practice, and policy. Gerontologist 47(1), 4–13.

Smith, S., Dewar, B., Pullin, S., Tocher, R., 2010. Relationship centredoutcomes focused on compassionate care for older people withinin-patient care settings. International Journal of Older People Nursing5 (2), 128–137.

Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., Read, S., 2011.Dignity in Practice: An Exploration of the Care of Older Adults in AcuteNHS Trusts. Her Majesty’s Stationery Office, London Available at:http://www.sdo.nihr.ac.uk/files/project/SDO_FR_08-1819-218_V01.pdf (accessed on 05.02.12).

Torjuul, K., Elstad, I., Sorlie, V., 2007. Compassion and responsibility insurgical care. Nursing Ethics 14 (4), 522–534.

Townsend, P., 1966. The Aged within the Welfare State. G. Bell,London.

B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 1247–12581258

Tresolini, C.P., Pew-Fetzer, Task Force, 1994. Health Professions Educationand Relationship-Centered Care: Report of the Pew-Fetzer Task Forceon Advancing Psychosocial Education. Pew Health Professions Com-mission, San Francisco, CA.

Von Dietze, E., Orb, A., 2000. Compassionate care: a moral dimension ofnursing. Nursing Inquiry 7 (3), 166–174.

Watson, J., 2006. Caring theory as an ethical guide to administrative andclinical practices. Nursing Administration Quarterly 30 (1), 48–55.

Watson, J., 2009. Assessing and Measuring Caring Nursing and HealthScience. Springer Publishing Company LCC.

Williams, S., Nolan, M., Keady, J., 2009. Relational practice as the key toensuring quality care for frail older people: discharge: planning as acase example. Quality in Ageing 10 (3), 44–55.

Winter, R., Munn-Giddings, C., 2001. A Handbook for Action Research inHealth and Social Care. Routledge, London.

Young, J., Forster, A., Green, J., 2003. An estimate of post-acute inter-mediate care need in an elderly care department for older people.Health Society Care Community 11 (3), 229–231.

Youngson, R., 2008. Compassion in Healthcare: the missing dimension ofhealthcare reform? NHS Confederation, London.