Humanising relational knowing: an appreciative action research study on relationship-centred practice on stroke units.

Abstract

Over the past two decades, NHS stroke services in England have improved the organisation of hospital-based stroke care, leading to improved outcomes after a stroke. However, this drive for improvement has not always been informed by a holistic view of stroke recovery and rehabilitation. Stroke survivors and their carers ask for individualised, person-centred care, with less focus on the physical aspects of their recovery (Stroke Association 2013; Luker et al. 2015). Despite a plethora of national recommendations on person-centred care, there is little actual ‘know how’ on achieving this within stroke services. An appreciative action research (AAR) method was used to develop a relationship- centred care (RCC) approach within a stroke unit setting. It was a two-phase study conducted on two combined acute and rehabilitation stroke units in the south west of England over 20 months. The first phase objectives were to explore and describe participants’ meaningful relational experiences and the processes that supported them. The objective of phase two was to take the processes learnt from phase one and explore whether these could be translated to a second stroke unit. Data were generated from 17 interviews, 400 hours of observations, 10 staff discussion groups, and the researcher’s reflective diary. Initial co-analysis using sense-making with participants was part of the AAR process, with this analysis informing the subsequent phases of the AAR cycles (Cooperrider et al. 2005). Further in-depth analysis was conducted using immersion crystallisation to confirm and broaden the original themes (Borkan 1999). Data analysis was informed by relational constructionist and humanising/lifeworld-led care perspectives (McNamee and Hosking 2012, Galvin & Todres 2013). Data described that participants (patients, relatives and staff) all valued similar relational experiences around human connections to support existential well-being. The AAR process supported changes in self, and the culture on the stroke units, towards an increased value placed on human relationships, including colleague relationships among staff. The processes that supported human connections in practice included: i. sensitising to humanising relational knowing through appreciative noticing; ii. reflecting and sharing these experiences with others to co-create a relational discourse; iii. having the freedom to act, enabling human connections. Developing processes to support humanising relational knowing revealed the complex, experiential and constantly changing nature of this way of knowing. Open reflective and reflexive spaces, created by animation and facilitation, were important to support staff to maintain sensitivity towards relational knowing within an acute care context. The outcomes from this study build on existing humanising/lifeworld-led care theories through: developing orientations for practice that support relational knowing, and; proposing development of the RCC model to include humanising values of embodiment, insiderness and agency.