Following analysis, making interpersonal connections was identified as an overarching theme central to helping participants meet their health and wellbeing needs and/or those of others. Figure 2 presents five main themes representing the different contexts in which these connections were made, from understanding self, to linking with individuals, communities, services or wider systems. A summary of key factors that enhanced and hindered participants’ connections and experiences of HSC across these contexts is included in Figure 3 .
Overview of themes.
Factors that enhanced and hindered connections and experiences of HSC.
Participants across all groups discussed their experiences of understanding and coping with changing health and wellbeing needs or supporting others to do so.
Service user [n = 6] and informal carer [n = 7] participants’ understanding of their changing health and wellbeing needs, were shaped by their connections with others. They felt their experiences of accessing HSC could be challenging. Some HSC staff had focussed on service users’ medical conditions that were sometimes unrelated to their presenting complaint, suggesting some staff may not be adopting a person-centred approach to care:
[Caitlin, quoting her Gastric Surgeon’s referral letter, gestures air-quotes] ‘Met with Caitlin, slim lady with Multiple Sclerosis, and I recommend that you give her a stoma’ [Catlin pauses, furrows brow and rolls eyes] …that’s when I was an [gestures air-quotes again] ‘MS person’ and nothing else.” Caitlin, service user, HSCP 1 .
All informal carer participants [n = 5] highlighted the impact their caring role had on their health and wellbeing, and their own need for person-centred support in their caring role. However, informal carer Anisha described an encounter with a Social Worker who exhibited a judgemental attitude, questioning her commitment as a wife and her role as an informal carer, when she raised the prospect of becoming unwell herself and the potential that she might not be able to care for Arthur:
“The quote I got thrown back at me was, ‘a good wife would do that for her husband’, and I thought, yeah, if a good wife’s here type of thing but, I didn’t say it, I should’ve said it really or, maybe I should’ve just turned round and said, ‘well, I’m nae a good wife then!’, you know [crosses arms, frowns].” Anisha, informal carer, HSCP 1 .
Informal carers [n = 5] also highlighted the negative impact that increased stress, as a result of their caring responsibilities, had upon their wellbeing. They reported low mood, depression, emotional strain and physical exhaustion. Staff member participants [n = 7] acknowledged their role in supporting service users and informal carers whilst their health and wellbeing needs were changing.
Service user and informal carer participants emphasised a need for support from HSC staff with their changing health and wellbeing needs. They wanted reassurance and support from staff to feel empowered to make decisions about their care, and to access information to help them cope:
“We get an appointment with them, just to go through things… they [HSC staff] don’t make up your mind for you but, they give the necessary information to allow you to come to a sensible decision… you canna make a decision on anything, if you don’t have the facts, you know.” Arthur, service user, HSCP 1 .
For service users and informal carers, coping with changing health and wellbeing needs was also linked to being able to attend to practical tasks, such as managing finances, personal care, eating and drinking, managing continence, housework and shopping tasks. For some, getting ‘out and about’ to meet others [n = 3 informal carers] and contact with HSC staff [n = 4 service users], promoted engagement with communities and social contacts. However, all service user participants [n = 6] reported feeling lonely and isolated, and this was a source of concern for their informal carers [n = 3] and staff members [n = 2].
Participants’ shared their experiences of fostering connections to build supportive relationships, which enhanced their health and wellbeing.
For all participant groups, connecting with others across HSC services, organisations and sectors to build a supportive relationship was facilitated through face-to-face interactions. Staff member [n = 4] and service user [n = 2] participants highlighted co-location of services as a means of promoting this. An interpersonal or ‘friendly’ connection was perceived by all participant groups as a necessary foundation for building supportive relationships. Commonalities between individuals was a key quality of these connections. Service user Donna, who had carers supporting her for a number of years, offers an example of this when she described her experiences of her need to connect with her HSC carer:
“She’s [Donna’s Carer] chatting to me when I’m showering and I, I find out about her family and things, chat about her family and, you know, that sort of thing… … I considered them as friends [her carers] and, I mean, I have a carer now, who’s been coming for over four years, in this company, and, I mean, she’s really efficient and, you know, I’m made to feel really comfortable and all that but, I mean, I said to her one day, do you think of me as a friend, or just another client [hesitates, looks down]… she [the carer] said, ‘well, just another client ’. Donna, service user, HSCP 2 .
During the interview, Donna’s non-verbal body language suggested she was disappointed with the disparity between the meaning her HSC carer had placed on the relationship and her own perceptions of it. For all participant groups, supportive relationships were fostered over a period of time, from a place of trust between two individuals, services or sectors. The opportunity to build up a trusting bond was afforded through continuity of contact between these groups, leading to a perception of more collaborative supportive relationships and HSC practices.
Key characteristics required for fostering a supportive relationship, as perceived by all participant groups, included personal attributes of empathy, trust, discernment and reliability:
“I think Beverley works well because I can, I can count on her… I know that she’ll be there and that, that she won’t, you know, she won’t turn up sometimes and not others, that’s really quite important to me.” Barney, service user, HSCP 1 .
Furthermore, when service user and informal carer participants were looking to foster a supportive relationship with HSC staff, they also wanted those staff to be knowledgeable about their condition and circumstances. All participant groups looked to share information, offer support and reassurance when communicating within supportive relationships. However, communication was perceived as challenging across HSC organisations and sectors. All participants [n = 14] attributed this to inefficient methods of communicating across organisational boundaries, with some staff members [n = 5] reporting system-wide data protection issues when trying to share information about those whom they were supporting.
Service user and informal carer participants’ experiences of connecting with communities helped them with practical tasks and to maintain social contacts, which were perceived to improve their health and wellbeing. Communities were defined by service user and informal carer participants as local geographical areas, meaning people who lived nearby. They also described communities, where people had a common interest or role such as a religious church group or a group of informal carers.
Service users and informal carers reported that members of their communities provided valued reassurance and support. Some informal carers [n = 2] asked members of their communities to ‘check-in’ with their service user, and service users asked them to help with local grocery shopping and putting their rubbish bins out for collection [n = 2]. Connections that service users and informal carers had with people in their communities were often perceived as more cohesive than those they had with people from statutory HSC services. They attributed this to community members’ in-depth knowledge and understanding of their needs:
“People that support me, are often people who are integrated into the local community so, people know them, erm, and they kind of know me so, that’s quite important to me, like… they know what I need and they, they know that I can’t walk too far so if, for example… I’d went and got some very heavy shopping; they would pick it up and put it in the car for me.” Barney, service user, HSCP 1 .
However, for service user Grant, connecting with people in his community had become more challenging as local populations increased and neighbourly knowledge diluted:
“The village is expanded so much, everybody before knew who I was and knew who the kids were but, no… you don’t know all the people now, you see, and there isn’t that contact, village contact, if you like… I don’t think it’s that open, er, neighbourly kind of care that used to be. The people probably are more dependent on, er, trained professional people.” Grant, service user, HSCP 1.
People in his community no longer had knowledge of his circumstances, leading to reduced informal support and to Grant feeling disconnected from his community.
Social contact with others had a positive influence on mental health and wellbeing. Previous knowledge of a service users’ circumstances helped community members to connect with them socially. All informal carers [n = 5] felt their service users’ social contact with others should be encouraged to promote mental wellbeing. Although service users wanted to maintain and make new social contacts [n = 4], when informal carer Esther encouraged service user Eddie to have social contact with others, he reminded her that he also needed time to himself:
“He’ll [Eddie] sort of remind us, ‘I’m in my 70s! I actually quite like just sitting on my own sometimes and, like just having, having a wee [small] rest and taking it easy’.” Esther, informal carer (talking about her father, service user Eddie), HSCP 2.
This highlighted disparity between the expectations of some informal carers and service users, with relation to service users’ desire and need for social contact with others.
Communities played a vital role in supporting service users, promoting connections and supportive relationships with people who knew and understood their circumstances. Maintaining and making connections with other service user and informal carers offered an opportunity for participants to share their experiences and access information about their condition or caring role, whilst offering peer support and social contact. However, not all service users and informal carers wanted to connect with communities of people who had similar circumstances or conditions [n = 2]. They reported anxieties around their future, and a risk of mis-matched expectations between treatment and progression of their condition:
“My dad [Eddie] was sort of freshly diagnosed, he was sort of advised [by another person who also had Multiple Sclerosis] not to go along [to the support group], that he might find it a bit upsetting because there would be people there further along in the disease, in wheelchairs and really unwell. So, I think he sort of put off going” . Esther, informal carer, HSCP 2.
Service user participants who did attend these groups [n = 3], felt supported because they were able to exchange accounts of treatment options, discuss symptoms and disease progression, and connect with people who knew and understood their circumstances. However, it also presented challenges in other areas as highlighted through an anecdotal account from staff member Catherine:
“I suppose it’s a great charity that patients, erm, get a lot out of [the support group], I’m sure. Sometimes their [the third sector organisation] opinions can be quite forceful, and we have to look at treatment options from an evidence-based practice [point of view] as opposed to perhaps what’s purported by the – [third sector organisation].” Catherine, staff member, HSCP 1.
Participants’ experiences of connecting with HSC services helped them maintain and promote their health and wellbeing, with availability, access, coordination and utility of HSC relevant to their needs.
Service user [n = 4], informal carer [n = 4] and staff member [n = 6] participants described their experiences of accessing HSC services, reporting fragmentation and reduced availability. It was important to all participants that service users and informal carers had timely access to services, such as physiotherapy and General Practitioners (GP). Service users [n = 6], informal carers [n = 5] and staff members [n = 7] reported reduced access to respite services, a need for greater flexibility in the way services were delivered, and reduced access to HSC services because of perceived obstructive ‘gatekeepers’:
“But there’s a woman in [location] who, you have to convince that you’re in need of the services.” Barney, service user, HSCP 1.
Some service users [n = 3] and informal carers [n = 3] attributed reduced access and availability of services to financial constraints, and inflexible ways of working across HSC systems. Service user Barney perceived HSC as a ‘post-code lottery’, where services were available in some areas but not others and where the nature of individual HSC staff members influenced care. However, when participants could gain access to services at a time when they thought they needed them, they felt supported and that their health and wellbeing needs were being met.
“She [GP] gives us [Barney and his wife] such good support. It seems to me to be a bit of a lottery [access to a supportive GP], it depends very much on the nature of the, of the particular GP.” Barney, service user, HSCP 1.
All participant groups were looking for further clarity on the way HSC was set up and organised across their services. Service users [n = 4] and informal carers [n = 5] perceived that having a named point-of-contact helped them achieve this:
“Having a Care Manager [as a named point-of-contact] that, you know, coordinated things, that would refer you if you needed physio or OT or anything like that, that worked very well.” Donna, service user, HSCP 2.
However, not all service users had a point-of-contact. For some, this led to a perception of reduced levels of access to care and coordination. Service users and informal carers were not always involved in planning their own care, leading to them feeling disempowered. When they were involved in planning their care, they felt it was more efficient and timelier. They sought the support of HSC staff to plan for the future in order to ensure their changing health and wellbeing needs would be met. However, service user Arthur and his informal carer Anisha felt their Social Worker had demonstrated a short-term view and lack of pre-emptive planning of their care. Anisha explained that this made her feel as though she had fraudulently requested potentially unreasonable support; her non-verbal communication during the interview portrayed a sense of anger and distaste:
[crosses arms, purses lips, raises eyebrows and clicks tongue on the roof of her mouth] “It made me feel, almost fraudulent, as though I was asking for something that I shouldn’t have been asking for at that stage, or at this stage.” Anisha, informal carer, HSCP 1.
Participants’ use of HSC services to meet their health and wellbeing needs were varied. Some service users and informal carers were able to meet their needs through regular contact with a GP, specialist or wheelchair service. For some service users and informal carers, use of HSC was more challenging. They encountered lengthy waiting times and thought their care was not always appropriate, resulting in them using similar private sector services at their own expense.
“The waiting list is 15 weeks [for physiotherapy input], which isn’t handy if you can’t walk down the stairs! I couldn’t get away from it being sore… I think 15 weeks of that I would just be round the bend.” Caitlin, service user, HSCP 1 .
In addition, time constraints of support visits exerted negative pressure on service users and staff members relationships. For some staff members [n = 3], the relationships they formed with more experienced colleagues were instrumental in helping them to feel supported and boosting their confidence in their role.
Participants’ experiences of working together across HSC services and systems to promote and maintain health and wellbeing needs highlighted their understanding of ‘integration’. They acknowledged the positive effect that integration could have on HSC services, with pooled information and resources to promote better outcomes for service users and informal carers. However, ‘integration’ appeared to be an abstract concept to many participants (across all groups). Abigail reported a lack of clarity about structural changes, and a lack of communication and preparation for progressing them:
“Integrated HSC started up here maybe a couple of years ago, we were never really given a lot of information about it, naebody [nobody] ever came to speak to us about it and, to be quite honest, we’re nae [not] really sure how it’s supposed to work ‘cause naebody’s ever discussed it with us… I think a lot of our Locality Managers now are HSCP, as opposed to being health board.” Abigail, staff member, HSCP 1.
Services were reported as disjointed, adopting unsafe communication and information sharing practices when bureaucratic processes did not meet the needs of HSC staff, the services or their HSC system. Some staff member participants [n = 6] suggested they needed further information about other HSC services working with people they were supporting. For staff member Debra, personal safety was compromised. She felt she had been placed at risk because of a communication breakdown that left her feeling vulnerable and uncomfortable:
“I had a patient who was very sexually inappropriate towards me, erm, I was just on my own in his house, so I called the Community Nursing staff to let them know [that the person had been inappropriate] but, they’d known about this for a long time and they had already made him double-visits [where two members of staff attend at the same time]. So, I’d been going in for months without knowing this, that was communication breakdown, it wasn’t nice what happened, and that could’ve been prevented had communication been that little bit better or, had we all been on the same system [electronic information system] and that would’ve flagged up for me. That would’ve saved a lot of uncomfortable feeling for myself [looks towards the floor, laughs uncomfortably, hesitates] … so.” Debra, staff member, HSCP 2.
She felt that, had communication in the HSC system been better (through a joined-up electronic information system) this situation could have been avoided, mitigating risk for staff. Promoting trust between people within HSC systems helped to strengthen their supportive relationships and communication, and collaboration was achieved when people were experienced, knowledgeable and flexible in their approach to working with others.
Findings of this study support the need for significant investment in facilitating and protecting the allocation of HSC staff time to help them develop supportive relationships with service users, informal carers and other staff across HSC systems. This is based on the understanding those in the relationship maintain contact or interaction over a period of time through continuity [ 19 , 20 , 21 ]. Participants highlighted several key characteristics that they perceived as important in interpersonal connections and supportive relationships, which are represented in a typology below ( Figure 4 ).
Typology of interpersonal connection and supportive relationships in HSC.
In addition to the key characteristics of interpersonal connections and supportive relationships, participants across all groups outlined what they perceived as their health and wellbeing needs ( Table 4 ).
Health and wellbeing needs in HSC.
Findings of this study suggest models of HSC should promote the principles of interpersonal connection outlined above, and encourage supportive relationships between service users, informal carers and HSC staff members as a foundational principle of HSC. The concept of connection, through continuity of contact with someone who offers support, has long been acknowledged in relevant models and frameworks as a fundamental principle of PCC for people who access HSC services. Continuity has been advocated across a variety of contexts for many years, to help reduce admissions to hospital, lower HSC costs, and promote Service User and staff satisfaction [ 22 , 23 ]. Findings of this study support a significant investment in facilitating and protecting the allocation of HSC staff time; it can help them to develop supportive relationships with service users, informal carers and other staff across HSC systems.
Many existing frameworks, theories and concepts identify key principles for integrating, improving and delivering HSC and PCC [ 5 , 24 ]. Some key theories were considered when interpreting participants experiences in this study. It is suggested that the findings outlined add to these. When interpreting participants’ experiences of fostering connections and relationships in a care provider-receiver context, behaviours linked to applications of Bowlby’s Attachment theory across the lifespan, were instrumental [ 25 , 26 , 27 ]. To further acknowledge the influence of connection in an HSC environment, a ‘blended’ theoretical lens was adopted. Caring Theory [ 28 ], Person-centred Care [ 29 ], Relationship-Based Care theories [ 30 ] and evidence informed propositions about experiences of people who access HSC [ 5 ] were combined. Figure 5 , blends these key theoretical constructs and contextual influences that were important to study participants.
Theoretical and contextual influences: People-centred Relationship-based Care.
These theories and propositions intersect as People-centred Relationship-based Care, reflecting the key concepts of ‘integrating HSC’, as identified by the study participants: people, services and systems being ‘connected’ through supportive relationships; encouraging knowledge and understanding between people who access and provide HSC; being involved in making decisions about their own care or role, and working together to meet a shared desire for truly individualised care.
In an online engagement event, members of the public, HSC service users, and informal carers, offered their insights on how this study’s findings might be applied to HSC practice in their local areas [n = 12] (July 2021). They were clear that they wanted their services to provide streamlined and holistic HSC, regardless of organisational or sectorial boundaries. The concepts of People-centred Relationship-based Care have been framed from the viewpoint of participants and entitled ‘My People-centred Relationship-based Health and Social Care’ (PRHSC) ( Figure 6 ).
My People-centred Relationship-based Health and Social Care (PRHSC).
The PRHSC model and its underpinning theories add an original perspective to key concepts of integrating HSC, as perceived explicitly by the people who are at the very centre of accessing and providing it (service users, informal carers and staff members). Furthermore, it could be argued that it could complement existing models of IHSC, for example, the International Foundation for Integrated Care’s nine key conceptual ‘Pillars of Integrated Care’ [ 31 , 32 ]. The PRHSC model’s underpinning blended theories ( Figure 5 ) align closely with fundamental human rights, contributing to social justice by promoting equality and inclusion [ 33 ]. They highlight key insight into participants’ perceptions of integrated care in HSC practice. The application of the PRHSC model should be tested across different groups of people who access HSC in a variety of settings, to establish reliability and the viability of its use. Further exploration of the potential transferability of findings beyond HSC would be warranted across wider communities. For example, industries or public service sectors where elements of caring are incorporated, such as policing or education. It could be argued that these communities may also benefit from a deeper understanding of interpersonal connections and supportive relationships to inform the caring elements of their work.
The active part that members of the public and key stakeholders played in developing ideas, study design and refining interpretations, is key to the credibility of these findings. A further strength is its multi-case embedded design, which allowed multiple perspectives of participants’ reality to be represented in the data within each case. Reflexivity incorporating reflection, curiosity and consultation with key stakeholders and the research team, underpinned the entire research process thereby increasing the trustworthiness and transferability potential of these findings.
A potential limitation to the transferability of these findings is the contextual nature of HSC with the study population being from two HSCPs in one region in Scotland. In line with the ethics panel recommendations (Section 2.2.4), people who have learning disabilities or profound mental health issues were excluded from this study. This is recognised as a limitation and including these communities could have added depth of understanding and promoted relevance to wider practice areas [ 34 , 35 , 36 ].
The overarching purpose of this study was to explore and better understand the health and wellbeing needs, experiences and relationships of people who accessed HSC and the individuals who supported them at home. Interpersonal connections that developed into supportive relationships were perceived by participants in all groups as instrumental in helping them feel able to cope with their changing HSC needs and roles. Supportive relationships promoted reassurance, information sharing and reduced anxiety; when they were lacking, it negatively impacted upon their experiences of HSC. This study highlights that connections, relationships and cross-sectoral working are important and entirely necessary for integrating HSC services. It is important that policy makers and HSC providers recognise the contribution communities can make to HSC; those communities come in many forms, and one model of integrating HSC does not fit all. No one person or service can provide the whole care-package, and all those who access and provide HSC need to have an equal voice. If the integration of HSC is to be improved, we as a society, must be clear on what is expected of HSC services and systems, and how we prioritise the limited resource across all contexts of HSC to meet health and wellbeing needs.
Prof Anne Hendry, Senior Associate, International Foundation for Integrated Care (IFIC), Director, IFIC Scotland , Honorary Secretary, British Geriatrics Society, Honorary Professor, University of the West of Scotland, UK.
One anonymous reviewer.
This paper has been produced to summarise and further disseminate findings of the lead authors PhD study; co-authors were part of the supervisory team. The full thesis is available here: https://doi.org/10.48526/rgu-wt-1677988 . PhD studentship was co-funded by Robert Gordon University and NHS Grampian. Funding for the publication of this paper was provided via the same studentship fund.
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Case studies to help you to reflect on your practice. These case studies will help you to reflect on your practice, and provide a summary of reflective models that can help aid your reflections and make them more effective. Templates are also provided to guide your own activities. Remember, there is no set way to reflect and you can adapt these ...
Health and Social care: Unit 5 Case Studies Section 1 Nusrat Patel Nusrat Patel is 19 years of age and has learning disabilities and epilepsy. She has recently left her residential school and now lives full time with her mother. Nusrat's mother has recently given up work to care for her, but is finding this very stressful. Nusrat's father
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Methodologically speaking, for my PhD I have adopted a single case-study research design and for my internship, I adopted a multiple-case study design. In summary, my knowledge on the topic and the methodology required to explore was useful as a starting point, but the internship aims required me to take my expertise a step further.
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Josef lives in a small town with his mother Dorota who is 39. Dorota was diagnosed with Bi-polar disorder seven years ago after she was admitted to hospital. She is currently unable to work. Josef's father, Stefan, lives in the same town and he sees him every few weeks. Josef was born in England.
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Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research.1 However, very simply… 'a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units'.1 A case study has also been described as an intensive, systematic investigation of a ...
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