Translating theory into practice: using Action Research to introduce a coordinated approach to emotional care

"It depends on the people!" - A qualitative analysis of contextual factors, prior to the implementation of digital health innovations for chronic condition management, in a German integrated care network

Objective

Integrated care and digital health technology interventions are promising approaches to coordinate services for people living with chronic conditions, across different care settings and providers. The EU-funded ADLIFE project intends to provide digitally integrated personalized care to improve and maintain patients' health with advanced chronic conditions. This study conducted a qualitative assessment of contextual factors prior to the implementation of the ADLIFE digital health platforms at the German pilot site. The results of the assessment are then used to derive recommendations for action for the subsequent implementation, and for evaluation of the other pilot sites.

Methods

Qualitative interviews with healthcare professionals and IT experts were conducted at the German pilot site. The interviews followed a semi-structured interview guideline, based on the HOT-fit framework, focusing on organizational, technological, and human factors. All interviews were audio recorded, transcribed, and subsequently analysed following qualitative content analysis.

Results

The results of the 18 interviews show the interviewees' high openness and motivation to use new innovative digital solutions, as well as an apparent willingness of cooperation between different healthcare professionals. Challenges include limited technical infrastructure and large variability of software to record health data, lacking standards and interfaces.

Conclusions

Considering contextual factors on different levels is critical for the success of implementing innovations in healthcare and the transfer into other settings. In our study, the HOT-fit framework proved suitable for assessing contextual factors, when implementing IT innovations in healthcare. In a next step, the methodological approach will be transferred to the six other European pilot sites, participating in the project, for a cross-national assessment of contextual factors.

Implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings: a pilot RCT and feasibility study

Background

Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable.

Objectives

To assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care.

Design

Pilot cluster randomised trial (CRT) and associated process and economic evaluations.

Setting

Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n = 4) or control (n = 2).

Participants

Patients (n = 639), staff (n = 211) and visitors (n = 188).

Intervention

CLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity.

Main outcome measures

Quality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy).

Data sources

Structured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities.

Results

The pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study.

Limitations

Findings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention.

Conclusions

Use of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation.

Trial registration

Current Controlled Trials ISRCTN16789770.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported inChapter 2was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Örebro and the Karolinska Institutet.

A qualitative study of clinical champions in context: Clinical champions across three levels of acute care

Objectives:

To compare activities and field descriptions of clinical champions across three levels of stroke centers.

Methods:

A cross-sectional qualitative study using quota sampling was conducted. The setting for this study was 38 acute stroke centers based in US Veterans Affairs Medical Centers with 8 designated as Primary, 24 as Limited Hours, and 6 as Stroke Support Centers. Key informants involved in stroke care were interviewed using a semi-structured approach. A cross-case synthesis approach was used to conduct a qualitative analysis of clinical champions’ behaviors and characteristics. Clinical champion behaviors were described and categorized across three dimensions: enthusiasm, persistence, and involving the right people.

Results:

Clinical champions at Primary Stroke Centers represented diverse medical disciplines and departments (education, quality management); directed implementation of acute stroke care processes; coordinated processes across service lines; and benefited from supportive contexts for implementation. Clinical champions at Limited Hours Stroke Centers varied in steering implementation efforts, building collaboration across disciplines, and engaging in other clinical champion activities. Clinical champions at Stroke Support Centers were implementing limited changes to stroke care and exhibited few behaviors fitting the three clinical champion dimensions. Other clinical champion behaviors included educating colleagues, problem-solving, implementing new care pathways, monitoring progress, and standardizing processes.

Conclusion:

These data demonstrate clinical champion behaviors for implementing changes to complex care processes such as acute stroke care. Changes to complex care processes involved coordination among clinicians from multiple services lines, persistence facing obstacles to change, and enthusiasm for targeted practice changes.

Compassionate care intervention for hospital nursing teams caring for older people: a pilot cluster randomised controlled trial

OBJECTIVE

Compassionate care continues to be a focus for national and international attention, but the existing evidence base lacks the experimental methodology necessary to guide the selection of effective interventions for practice. This study aimed to evaluate the Creating Learning Environments for Compassionate Care (CLECC) intervention in improving compassionate care.

SETTING

Ward nursing teams (clusters) in two English National Health Service hospitals randomised to intervention (n=4) or control (n=2). Intervention wards comprised two medicines for older people (MOPs) wards and two medical/surgical wards. Control wards were both MOPs.

PARTICIPANTS

Data collected from 627 patients and 178 staff.

EXCLUSION CRITERIA

reverse barrier nursed, critically ill, palliative or non-English speaking. All other patients and all nursing staff and Health Care Assistant HCAs were invited to participant, agency and bank staff were excluded.

INTERVENTION

CLECC, a workplace intervention focused on developing sustainable leadership and work-team practices to support the delivery of compassionate care.

CONTROL

No educational activity.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary-Quality of Interaction Schedule (QuIS) for observed staff-patient interactions. Secondary-patient-reported evaluations of emotional care in hospital (PEECH); nurse-reported empathy (Jefferson Scale of Empathy).

RESULTS

Trial proceeded as per protocol, randomisation was acceptable. Some but not all blinding strategies were successful. QuIS observations achieved 93% recruitment rate with 25% of patient sample cognitively impaired. At follow-up there were more total positive (78% vs 74%) and less total negative (8% vs 11%) QuIS ratings for intervention wards versus control wards. Sixty-three per cent of intervention ward patients scored lowest (ie, more negative) scores on PEECH connection subscale, versus 79% of control. This was not a statistically significant difference. No statistically significant differences in nursing empathy were observed.

CONCLUSIONS

Use of experimental methods is feasible. The use of structured observation of staff-patient interaction quality is a promising outcome measure inclusive of hard to reach groups.

TRIAL REGISTRATION NUMBER

ISRCTN16789770.

Patient Evaluation of Emotional Comfort Experienced (PEECE): developing and testing a measurement instrument

OBJECTIVES

The Patient Evaluation of Emotional Comfort Experienced (PEECE) is a 12-item questionnaire which measures the mental well-being state of emotional comfort in patients. The instrument was developed using previous qualitative work and published literature.

DESIGN

Instrument development.

SETTING

Acute Care Public Hospital, Western Australia.

PARTICIPANTS

Sample of 374 patients.

INTERVENTIONS

A multidisciplinary expert panel assessed the face and content validity of the instrument and following a pilot study, the psychometric properties of the instrument were explored.

MAIN OUTCOME MEASURES

Exploratory and confirmatory factor analysis assessed the underlying dimensions of the PEECE instrument; Cronbach's α was used to determine the reliability; κ was used for test-retest reliability of the ordinal items.

RESULTS

2 factors were identified in the instrument and named 'positive emotions' and 'perceived meaning'. A greater proportion of male patients were found to report positive emotions compared with female patients. The instrument was found to be feasible, reliable and valid for use with inpatients and outpatients.

CONCLUSIONS

PEECE was found to be a feasible instrument for use with inpatient and outpatients, being easily understood and completed. Further psychometric testing is recommended.

Implementing action research in hospital settings: a systematic review

Purpose

– Health care organizations and hospitals in particular are highly resistant to change. The reasons for this are rooted in professional role behaviors, hierarchical structures and the influence of hidden curricula that inform organizational culture. Action research (AR) has been identified as a promising bottom-up approach that has the potential to address the significant barriers to change. However, to date no systematic review of the field in health care exists. The paper aims to discuss these issues.

Design/methodology/approach

– A systematic review of the literature was conducted. Studies were reviewed with regard to the four stages of AR; problem identification, planning, implementation and evaluation.

Findings

– Only 19 studies were identified that fit the inclusion criteria. Results revealed significant heterogeneity with regard to theoretical background, methodology employed and evaluation methods used.

Research limitations/implications

– Only studies published and written in the English language were included.

Practical implications

– The field of AR interventions would benefit from a theoretical framework that has the ability to guide the methodology and evaluation processes.

Originality/value

– This is the first systematic review of AR in hospitals.

An oasis in the hospital: the perceived benefits of a cancer support center in a hospital setting offering complementary therapies

AIMS

The aim of this study was to explore and describe the experiences of persons attending a cancer support center, providing emotional support to cancer patients through self-selected complementary therapies offered free of charge through qualified volunteer therapists. A grounded theory methodology was used. Sources of data were 16 semistructured interviews with persons attending the center. Interviews were digitally recorded and transcribed verbatim. Analysis was conducted using the constant comparative method.

FINDINGS

The overarching theme that emerged in this study was the benefits attributed to attendance at the cancer support center. The center was described as an "oasis" in the hospital, and three aspects relating to this were identified: (a) facilitating comfort, (b) increasing personal control, and (c) helping make sense of the cancer experience.

CONCLUSION

A drop-in center offering complementary therapies appeared to enable coping with the diagnosis and treatment of cancer by facilitating comfort and increasing perceptions of personal control. The center also helped some participants to make sense of their experience with cancer. This research has provided a unique insight into the ongoing emotional needs of cancer patients, and directions for further development and research into the provision of holistic care for patients within a hospital setting.

Participatory action research in the implementing process of evidence-based intervention to prevent childhood obesity: project design of the "Healthy Future" study

OBJECTIVE

To describe the design of the developmental project Healthy Future that aims to implement a new evidence-based program for the prevention of childhood obesity and collaboration and sharing of work between specialist and community health care professionals in parts of a county in western Norway.

METHODS

Comprehensive participatory planning and evaluation (CPPE) process as an action-oriented research approach was chosen, using mixed data sources, mixed methods, and triangulation.

DISCUSSION

A bottom-up approach might decrease the barriers when new evidence-based childhood prevention interventions are going to be implemented. It is crucial not only to build partnership and shared understanding, motivation, and vision, but also to consider the frames of the organizations, such as competencies, and time to carry out the interventions at the right level of health care service and adapt to the overweight children and their families needs.

CONCLUSION

The developmental process of new health care programs is complex and multileveled and requires a framework to guide the process. By CPPE approach evidence-based health care practice can be delivered based on research, user knowledge, and provider knowledge in the field of childhood overweight and obesity in a certain context.

Measuring relational aspects of hospital care in England with the 'Patient Evaluation of Emotional Care during Hospitalisation' (PEECH) survey questionnaire

OBJECTIVES

To first, validate in English hospitals the internal structure of the 'Patient Evaluation of Emotional Care during Hospitalisation' (PEECH) survey tool which was developed in Australia and, second, to examine how it may deepen the understanding of patient experience through comparison with results from the Picker Patient Experience Questionnaire (PPE-15).

DESIGN

A 48-item survey questionnaire comprising both PEECH and PPE-15 was fielded. We performed exploratory factor analysis and then confirmatory factor analysis using a number of established fit indices. The external validity of the PEECH factor scores was compared across four participating services and at the patient level, factor scores were correlated with the PPE-15.

SETTING

Four hospital services (an Emergency Admissions Unit; a maternity service; a Medicine for the Elderly department and a Haemato-oncology service) that contrasted in terms of the reported patient experience performance.

PARTICIPANTS

Selection of these acute service settings was based on achieving variation of the following factors: teaching hospital/district general hospital, urban/rural locality and high-performing/low-performing organisations (using results of annual national staff and patient surveys). A total of 423 surveys were completed by patients (26% response rate).

RESULTS

A different internal structure to the PEECH instrument emerged in English hospitals. However, both the existing and new factor models were similar in terms of fit. The correlations between the new PEECH factors and the PPE-15 were all in the expected direction, but two of the new factors (personal interactions and feeling valued) were more strongly associated with the PPE-15 than the remaining two factors (feeling informed and treated as an individual).

CONCLUSIONS

PEECH can help to build an understanding of complex interpersonal aspects of quality of care, alongside the more transactional and functional aspects typically captured by PPE-15. Further testing of the combined instrument should be undertaken in a wider range of healthcare settings.

Guided reflection as a tool to deal with the theory– practice gap in critical care nursing students

Critical care nursing students experience inconsistencies between the theoretical content they have learnt and what is expected from them in practice, which retards the learning process. This has been described as the theory–practice gap. There seems to be no single solution to address the integration of theory and practice. In an attempt to bridge this gap, a study was done to establish the influence of guided reflection on critical care nursing students in dealing with their theoretical and practical experiences. A qualitative, explorative, descriptive and contextual design was followed. An instrument for guided reflection was designed which was used during semi-structured interviews during the data collection process. Field notes and narrative descriptions were also used as means to collect data. Themes that emerged from the data included a description of incidents experienced, critical analysis of knowledge, critical analysis of feelings and changed perspective experienced. Theory–practice integration occurred to an extent in some of the categories; conversely, the inability to apply theory to practice evoked responses such as feelings of guilt and incompetence. Guided reflection appeared to have assisted the participants in clarifying theoretical and practical experiences, and in reaching a changed perspective by understanding the link between theory and practice. Guided reflection ought to be incorporated in the education of nurses from their basic training in theory and practice so that student nurses will be aware of their own competencies in order to provide optimal patient care.OpsommingKritiekesorgverpleegstudente ervaar teenstrydighede ten opsigte van dit wat hul geleer word en wat van hul in die praktyk verwag word wat weer die leerproses vertraag. Dit word as die teorie–praktykgaping beskryf. Daar blyk geen enkelvoudige oplossing te wees vir die integrasie van teorie en praktyk nie. In ’n poging om die gaping te oorbrug, is ’n studie oor die invloed van begeleide refleksie op kritiekesorgverpleegkundige studente se teoretiese en praktiese ervaringe gedoen. ’n Kwalitatiewe, verkennende, beskrywende en kontekstuele navorsingsontwerp is gevolg. ‘n Instrument vir begeleide refleksie is ontwerp wat gebruik is tydens semi-gestruktureerde onderhoude in die data-insamelingsproses. Veldnotas en narratiewe beskrywings was ook middele ten einde data in te samel. Tema’s wat uit die data na vore gekom het was ‘n beskrywing van ervaringe, kritiese analise van data, kritiese analise van gevoelens en ‘n veranderde perspektief met betrekking tot ervaringe. Teorie–praktyk integrasie het tot ‘n mate in sommige kategorieë plaasgevind het. Daarinteen het die onvermoë om die teorie in die praktyk toe te pas response tot gevolg gehad, soos skuldgevoelens en gevoelens van onbevoegdheid. Dit wil voorkom asof begeleide refleksie die deelnemers gehelp het om duidelikheid en ’n veranderde perspektief ten opsigte van hul teoretiese en praktiese ervaringe te verkry. Begeleide refleksie behoort reeds vanaf basiese opleiding in verpleegkundiges se teoretiese en praktiese opleiding geïnkorporeer te word sodat verpleegkundiges bewus sal wees van hulle eie vaardighede om sodoende optimale pasiëntsorg te kan lewer.

Further psychometric testing of an instrument to measure emotional care in hospital

AIMS AND OBJECTIVES

This paper describes further testing of the instrument Patient Evaluation of Emotional Care during Hospitalisation.

BACKGROUND

In 2005, a questionnaire was developed that could be completed by patients to evaluate the quality of emotional care received during their time in hospital. This questionnaire was tested at an acute care private hospital in Perth, Western Australia, with encouraging estimates of reliability and validity. The purpose of this study was to further test this questionnaire in a larger sample of inpatients at a public hospital in the same state.

DESIGN

Psychometric evaluation.

METHOD

A hospital-wide survey of 13 wards of a public hospital was conducted. Two hundred and fifty-one patients completed the questionnaire.

RESULTS

Psychometric testing of the Patient Evaluation of Emotional Care during Hospitalisation demonstrated acceptable internal consistency reliability. Confirmatory factor analysis substantiated the four sub-scales as follows: Level of Security, Level of Knowing, Level of Personal Value and Level of Connection. The Level of Connection sub-scale was assessed for the first time in this study. This sub-scale had the lowest mean score of all the sub-scales across the hospital as well as in each of the wards surveyed. Qualitative data substantiated, from the patients’ perspective, a lack of connection with hospital staff.

CONCLUSIONS

Further psychometric testing of the Patient Evaluation of Emotional Care during Hospitalisation instrument has confirmed its psychometric properties and usefulness as an instrument to measure emotional care during hospitalisation.

RELEVANCE TO CLINICAL PRACTICE

The Patient Evaluation of Emotional Care during Hospitalisation is a reliable and valid tool with which the emotional care of patients in hospital can be measured and the effectiveness of interventions assessed.

An evaluation of aged-care workers' knowledge of and attitudes toward the palliative approach

This study, a cross-sectional survey, evaluated the knowledge of the palliative approach to care of an entire care workforce in an Australian residential aged-care organization (n = 116, 30% response rate). Knowledge deficits were found at all staff levels: RNs lacked a full comprehension of pain and symptom management, and personal care attendants' knowledge scores were not statistically different from those of ancillary staff. RN division 1 reported a more positive attitude toward caring for dying patients than other staff groups. Increasing experience in the field was found to be the main determinant of knowledge of, and attitudes toward, the palliative approach, while increasing hours of palliative care education and higher post-school educational level conferred some benefit. Study findings provide strong impetus for education in the palliative approach to care for the entire interdisciplinary team. With targeted education and support, older residents' needs for a palliative approach to care can be identified by all members of the care team, and appropriate response and/or referral can be achieved.