Shadowing

Shadowing involves witnessing everything the patient experiences, observing and recording each step of the process, and then seeking feedback from the patient at each point.

PFCC toolkit: connecting with patients and families

Shadowing is an observation technique that provides an opportunity for a third party to experience and record what happens during interactions along a patient’s pathway, including what they look and feel like. Its aim is to see the care experience through patients’ eyes. It forms a critical part of the PFCC approach.

Shadowing raises staff awareness of the patient experience and the need for change. It helps staff to understand what is working well for patients and their families, and what is not. It can also enable real-time patient feedback, should you choose to work in this way. It might identify issues such as bottlenecks and duplication of effort, as well as elements that are working well and could be replicated.

Ideally, shadowing is carried out by a variety of staff. It is important that senior clinical staff on the team and senior leaders carry out at least some of the shadowing. However, it may also be good for non-health care professionals, such as administrative staff, volunteers or nursing or medical students, or staff from a different care experience who are not familiar with the process to carry out shadowing. They can each bring a different perspective and can view care with a fresh pair of eyes.

There are particular benefits to senior management carrying out the shadowing. By using a mixture of observation and discussion, the process can build up a picture of how the patient moves through the pathway, the speed at which they do so, and the feelings they have about their experience.

I felt the shadowing was very powerful. It made me see things that were always in front of me, that on a day-to-day shift you do not notice. I quickly realised it’s not the big things that we need to look at – it’s the small things that can make such a big difference.

Emma Hughes, Senior Sister/Practice Development Sister, Paediatric Assessment Unit, Walsall Manor Hospital

Key points

  • Shadowing is good for understanding processes of care – especially where patients experience a complex pattern of care with multiple exchanges with staff. It identifies the meaning of the care experience and its various elements for patients. It enables staff to check that the things they want to improve are actually the things that patients feel are important.
  • Shadowing can be carried out by any individual, including clinical and administrative staff and students. Between them, the shadowers build a picture of what care is like for patients. Everyone involved in PFCC should do some shadowing. It is important that senior leaders do at least some of the shadowing so they can see care for themselves. It should not be delegated to the most junior members of staff. 
  • Before you start, decide which part of the care experience you want to focus on. Decide where the shadowing will start and finish, how many patients will be shadowed for each element of the experience, and at what time. For example, you might want to shadow patients at different times of day to see the variation in processes that occurs.
  • Think about how you will hear back from the shadowers, and plan how you will feed back to the areas or staff involved (both positive and negative issues) in real time.
  • Think about what the shadower should focus on: the time waited, the waiting environment, how staff interact with the patient, ease of navigation or the standard of written or verbal information. Give the person doing the shadowing a guiding framework – for an example, see the PFCC Shadowing Field Journal that provides direction but is open to unexpected observations arising.
  • Ethical approval is not generally required for service improvement work, but talk to someone on your local research ethics committee in case any local protocols need to be followed in relation to shadowing.
  • Decide who will feed back on any examples of poor practice and how.
  • Explain shadowing to patients and reassure them that whatever they say to the person doing the shadowing will have no effect on the standard of care they are given. Make sure they give their informed consent, and ask for their contact details if they wish to be updated on progress. Remember, they may be feeling vulnerable or anxious about being involved, or about their health care experience.
  • Talk in advance with key staff in the areas in which the shadowing will take place. Make sure they understand its purpose, and emphasise that its aim is to improve quality, not to assess individual performance. 
  • Design a simple proforma for capturing information, to include: when each activity takes place; patient and shadower reactions to each activity; and further observations.
  • Record information under headings such as: environment, printed information, signposting and movement around hospital, waiting time, and verbal communication. A final space could highlight patients’ views about what went well and what could have gone better, as well as the shadower’s thoughts and feelings about what they saw and heard.
  • Prepare a patient information sheet that you can give to patients before and after the shadowing. It should explain the purpose of the shadowing, how it will work and what will happen to the information collected. You can amend the PFCC Shadowing Field Journal to fit your needs.
  • At all times, the patient’s wellbeing takes precedence over the shadowing. Shadowing should never adversely impact on the care the patient receives, and it will never override the clinical judgement of the person doing the shadowing. If a clinician is the shadower, then their clinical role will override the shadowing role if intervention is required – for example, if a low oxygen saturation has not been noticed, or if a patient is at high risk of falling. Similarly, be compassionate if advocacy is needed – for example, if the patient needs a drink. Speak up for the individual, and record that this was needed.
  • If a number of people are going to shadow patients, meet with them as a team to discuss how the process will work and what they will need to do. Allow time to answer questions, and brainstorm what might go wrong and how to respond. A short practice run or role play will give the shadowers some experience and will allow you to tweak the method if necessary. 
  • After the shadowing, bring the shadowers together to clarify anything you don’t understand, probe more deeply, and discuss any emerging themes. Then, gather up the proformas, and provide opportunities for learning for staff in the areas where shadowing has taken place.
  • Identify one person to collate, analyse and interpret the data collected and sort the information into themes.
  • Bring the team working on the pathway together to discuss the findings and decide how they will feed into both the diagnosis of current practice and the design of your ideal care experience. Remember to identify what works well (and should therefore be retained) as well as what works less well (and should therefore be changed).

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