Implementing the 4D cycle of appreciative inquiry in health care: a methodological review

Rescuing the profession we love: general practice training sector recommendations for improving the attractiveness of general practice training. A qualitative analysis

OBJECTIVES

To investigate the views of the general practice training sector about responding to recruitment challenges, with the aim of identifying effective initiatives and other solutions.

STUDY DESIGN

Qualitative study; focus group discussion of recommendations from a medical educator workshop.

SETTING, PARTICIPANTS

An initial online appreciative enquiry workshop for medical educators followed by focus group discussions by a broader selection of people involved in general practitioner training (Royal Australian College of General Practitioners fellows, supervisors, practice managers, medical educators, registrars).

MAIN OUTCOME MEASURES

Key overarching themes and major recommendations for increasing recruitment derived from focus group responses to workshop recommendations, based on qualitative descriptive analysis.

RESULTS

The 26 medical educators at the workshop made four major recommendations: increase the number of student and junior doctor clinical placements in general practice; increase exposure of students and junior doctors to general practitioner teachers and educators; improve general practitioner trainee pay and entitlements; and improve the integration of general practice and hospital patient care and professional relationships. Thirty-four semi-structured focus group participants broadly supported the recommendations, provided that supervisors and training practices were adequately compensated for the effects on workloads, income, and patient care. Two overarching themes infused participant responses: "rescuing the profession we love" (reflecting participants' passion for general practice and their sense of threat), and "no idea what general practitioners do" (perceptions of being misunderstood and misrepresented by hospital-based practitioners).

CONCLUSIONS

Clinicians, educators, and policy makers should work together to increase the number of high quality, adequately supported student and junior doctor placements in general practice, improve intra-professional relationships, and trial new models of general practitioner trainee payment and conditions.

Characteristics of strong midwifery leaders and enablers of strong midwifery leadership: An international appreciative inquiry

OBJECTIVES

This research aimed to identify the characteristics of strong midwifery leaders and explore how strong midwifery leadership may be enabled from the perspective of midwives and nurse-midwives globally.

DESIGN

In this appreciative inquiry, we collected qualitative and demographic data using a cross-sectional online survey between February and July 2022.

SETTING

Responses were received from many countries (n = 76), predominantly the United Kingdom (UK), Australia, the United States of America (USA), Canada, Uganda, Saudi Arabia, Tanzania, Rwanda, India, and Kenya.

PARTICIPANTS

An international population (n = 429) of English-speaking, and ethnically diverse midwives (n = 211) and nurse-midwives (n = 218).

MEASUREMENTS

Reflexive thematic analysis was used to make sense of the qualitative data collected. Identified characteristics of strong midwifery leadership were subsequently deductively mapped to established leadership styles and leadership theories. Demographic data were analysed using descriptive statistics.

FINDINGS

Participants identified strong midwifery leaders as being mediators, dedicated to the profession, evidence-based practitioners, effective decision makers, role models, advocates, visionaries, resilient, empathetic, and compassionate. These characteristics mapped to compassionate, transformational, servant, authentic, and situational leadership styles. To enable strong midwifery leadership, participants identified a need for investment in midwives' clear professional identity, increased societal value placed upon the midwifery profession, ongoing research, professional development in leadership, interprofessional collaborations, succession planning and increased self-efficacy.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study contributes to understandings of trait, behavioural, situational, transformational and servant leadership theory in the context of midwifery. Investing in the development of strong midwifery leadership is essential as it has the potential to elevate the profession and improve perinatal outcomes worldwide. Findings may inform the development of both existing and new leadership models, frameworks, and validated measurement tools.

Virtual interprofessional (VIP) education, a family medicine-occupational therapy-physiotherapy collaborative experience: the perspectives of patients, learners and providers on the opportunities and challenges

This study examined the experiences of patients, Occupational Therapy (OT), Physiotherapy (PT) and Medicine learners, Providers, and Faculty, in implementing a Virtual Interprofessional (VIP) education initiative in two academic Family Medicine (FM) collaborative clinics. A qualitative descriptive study drew on a strength-based approach as part of the evaluation of the interfaculty VIP initiative. Participants involved in VIP care were conveniently sampled. Interviews were conducted with four patients, and focus groups were held with a total of 16 providers, preceptors and learners in OT, PT and FM. Data were analyzed using content analysis and managed using NVivo12. Four main categories emerged: 1) Challenges in implementing VIP care in FM; 2) Operational challenges, 3) Facilitators of VIP care in FM; and 4) Experiential learning outcomes and benefits of VIP care. This innovation supported knowledge and insights on interprofessional competencies acquired during practice, provided inclusive and comprehensive access to care for patients, and identified opportunities to enhance medical, OT and PT education in VIP care in FM. A collaborative approach with faculty from different disciplines (FM, School of Health Professions: OT and PT) can provide ongoing opportunities for VIP care for patients, and foster IP learning and acquisition of competencies for FM, OT and PT learners and providers.

A divided community: A descriptive qualitative study of the impact of the COVID-19 pandemic on nurses and their relationships

AIMS

To identify the personal and professional impact of the COVID-19 pandemic on clinical nurses with regard to personal and workplace safety, personal and professional relationships and perceptions of their team, organization and community, and to understand lessons learned to inform future responses to pandemics or global emergencies.

DESIGN

Qualitative, descriptive free-text surveys, informed by appreciative inquiry.

METHODS

Nurses working in adult COVID- and non-COVID cohort medical-surgical and intensive care units, outpatient cancer and general surgery centres were invited to participate. Data were collected between April and October 2021 and analysed using summative content analysis.

RESULTS

In total, 77 participants completed free-text surveys. Five themes were identified: (1) Constraints on nursing: barriers in communication and diminished patient safety and quality of care; (2) Navigating uncertainty: the emotional toll of the pandemic; (3) Team solidarity, renewed appreciation and reaffirming purpose in nursing work; (4) Enhanced trust versus feeling expendable; and (5) Increased isolation and polarization within communities. Nurses described a perceived negative impact on a number of their relationships, including with patients, employer and community. They described a huge emotional toll that included feelings of isolation and polarization. While some nurses described feeling supported by their team and employer, others described feeling expendable.

CONCLUSION

Nurses' responses provided insights into negative emotional experiences during the pandemic due to heightened uncertainty and fear, and also the importance of support received from peers, colleagues and their employer. Nurses experienced feelings of isolation and polarization within their communities. The varied responses reflect the importance of societal solidarity when faced with global emergencies, and the need for nurses to feel valued by their patients and employer.

IMPACT

Effective responses to public health emergencies require individuals and communities to work together to achieve collective goals. Efforts to retain nurses are critical during global emergencies.

PATIENT OR PUBLIC CONTRIBUTION

No patient and public involvement.

The INSIGHT project: reflections on the co-production of a quality recognition programme to showcase excellence in public involvement in health and care research

BACKGROUND

The quality of Patient and Public Involvement (PPI) in healthcare research varies considerably and is frequently tokenistic. We aimed to co-produce the Insight | Public Involvement Quality Recognition and Awards programme, based on the UK Standards for Public Involvement (UKSPI) alongside an incremental scale designed by Expert Citizens (a lived experience-led community group), to incentivise and celebrate continuous improvement in PPI.

METHODS

We used Task and Finish Groups (19/44 [43%] public contributor membership) to co-produce the programme which we piloted in three organisations with different healthcare research models. We used surveys and review sessions to capture learning and reflections.

RESULTS

We co-created: (1) A Quality descriptor matrix comprising four incremental quality levels (Welcoming, Listening, Learning, Leading) for each UKSPI standard. (2) An assessment framework including guidance materials, self-assessment form and final report template. (3) An assessor training package. (4) The quality awards event format and nomination form. These materials were modified based on pilot-site feedback. Of survey respondents: 94.4% felt they had made at least 'Some' personal contribution (half said 'Quite a lot'/'A great deal'), 88.9% said they were 'Always'/'Often' able to express their views freely and, 100% stated the programme would have 'A lot of impact'/'Quite a bit of impact'. During the project, we identified the importance of taking time to explain project aims and contributor roles, adapting to the needs of individual contributors and, using smaller bespoke sessions outside the main Task and Finish Groups.

CONCLUSIONS

We co-produced and piloted a quality recognition programme to incentivise and celebrate continuous quality improvement in PPI. One public contributor stated, "I feel strongly that the Insight framework and awards will raise awareness of the [public involvement] work going on in many community settings. [It] is likely to result in better sharing of positive practice, incentivising research groups of any size to start work or to improve the quality of [PPI] could be one of the main benefits. I'm excited that if this initiative takes off, regionally and then in the longer term nationally, it could be a significant step in advancing the [public] voice."

Midwife-led birthing centres in four countries: a case study

BACKGROUND

Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC.

METHODS

A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff.

RESULTS

Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels.

CONCLUSION

The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

'What does good look like'-exploring access to healthcare for the homeless population in Gateshead, England

BACKGROUND

individuals who are homeless encounter extreme health inequalities and as a result often suffer poor health. This study aims to explore ways in which access to healthcare could be improved for individuals who are homeless in Gateshead, UK.

METHODS

twelve semi-structured interviews were conducted with people working with the homeless community in a non-clinical setting. Transcripts were analysed using thematic analysis.

RESULTS

six themes were identified under the broad category of 'what does good look like', in terms of improving access to healthcare. These were: facilitating GP registration; training to reduce stigma and to provide more holistic care; joined-up working in which existing services communicate rather than work in isolation; utilising the voluntary sector as support workers could actively support access to healthcare and provide advocacy; specialised roles such as specialised clinicians, mental health workers or link workers; and specialised bespoke services for the homeless community.

CONCLUSIONS

the study revealed issues locally for the homeless community accessing healthcare. Many of the proposed actions to facilitate access to healthcare involved building upon good practice and enhancing existing services. The feasibility and cost-effectiveness of interventions suggested requires further assessment.

A Qualitative Study of Occupational Therapists' Understanding of Spirituality in South Africa

Occupational therapy is a holistic profession that assists clients to restore meaning to their lives-a vital spiritual task. Spirituality is a multifaceted and multidimensional construct that occupational therapists need to integrate into everyday practice. In this study, Occupational Therapy educators' and clinicians' understanding of spirituality in their practice was qualitatively explored by purposively selecting 24 participants who attended a workshop based on an appreciative approach, in Gauteng, South Africa. Data were collected through self-report interview schedules and focus group inquiries and were analysed using the creative hermeneutic method. Participants expressed spirituality in occupational therapy as connectedness, meaning of life and client-centred practice.

What does 'good' palliative care look like for children and young people? A qualitative study of parents' experiences and perspectives

BACKGROUND

Worldwide, around 21 million children would benefit from palliative care and over 7 million babies and children die each year. Whilst provision of paediatric palliative care is advancing, there major gaps between what should be done, and what is being done, in clinical practice. In 2017, the National Institute for Health and Care Excellence (NICE) introduced a quality standard, to standardise and improve children's palliative care in England. However, there is little evidence about what good experiences of palliative care for children are, and how they relate to the quality standard for end-of-life care.

AIM

This study explored how the NICE quality standard featured in parental experiences of palliative care for children to understand what 'good' palliative care is.

DESIGN

Qualitative study, employing in-depth, telephone and video-call, semi-structured interviews. Data were analysed using thematic analysis, informed by Appreciative Inquiry.

SETTING/PARTICIPANTS

Participants were parents of children and young people (aged 0-17 years) in England, who were receiving palliative care, and parents whose child had died.

RESULTS

Fourteen mothers and three fathers were interviewed. Seven were bereaved. Parents were recruited via four children's hospices, one hospital, and via social media. Good palliative care is co-led and co-planned with trusted professionals; is integrated, responsive and flexible; encompasses the whole family; and enables parents to not only care for, but also to parent their child to end of life.

CONCLUSIONS

Findings have implications for informing evidence based practice and clinical guidelines, overall improving experiences of care.

The 5D Cycle for Health Equity: Combining Black Feminism, Radical Imagination, and Appreciative Inquiry to Transform Perinatal Quality Improvement

Too often, quality improvement initiatives are rooted in the health care system's oppressive structures and hierarchies. Transformative quality improvement models that embody the wisdom and liberatory potential of oppressed groups areneeded to address the alarming inequities within perinatal health. Inspired by experiences with Appreciative Inquiry, a possibility-focused change model, and frustrated by the limits of traditional quality improvement, the author sought new approaches to perinatal quality improvement. Inquiry into Black feminist recommendations for perinatal quality improvement and the principles of radical imagination led to the creation of the 5D Cycle for Health Equity, which grounds Appreciative Inquiry's 5D cycle (define, discover, dream, design, deliver/destiny) in Black feminism and radical imagination. The 5D Cycle for Health Equity is an innovative approach to address health inequities by challenging oppressive quality improvement methods and health care structures. The cycle guides quality improvement collectives through a process that redefines harm and health equity; discovers new understandings of wellness across the past, present, and future; dreams of equitable care with the principles of antioppression and collectivity; designs solutions that embody the liberatory practices of oppressed groups; delivers solutions that strive to free everyone by freeing the most oppressed; and forges a new destiny. Midwives are well poised to use the 5D Cycle for Health Equity to disrupt structures of inequity and foster a health care system that supports the health and wellness of oppressed groups.

RESPONDER: A Qualitative Study of Ethical Issues Faced by Critical Care Nurses during the COVID-19 Pandemic

AIMS

To identify and understand ethical challenges arising during COVID-19 in intensive care; nurses' perceptions of how they made 'good' decisions and provided 'good' care when faced with ethical challenges, and use of moral resilience.

BACKGROUND

Little is known about the ethical challenges that nurses faced during the COVID-19 pandemic and ways they responded. Design Qualitative, descriptive free-text surveys and semi-structured interviews, underpinned by appreciative inquiry.

METHODS

Nurses working in intensive care in one academic quaternary care center and three community hospitals in Midwest United States were invited to participate. In total, 49 participants completed free-text surveys and 7 participants completed interviews. Data were analyzed using content analysis.

RESULTS

Five themes captured ethical challenges: implementation of the visitation policy; patients dying alone; surrogate decision-making; diminished safety and quality of care; and imbalance and injustice between professionals. Four themes captured nurses' responses: personal strength and values, problem-solving, teamwork and peer support, and resources.

CONCLUSIONS

Ethical challenges were not novel but were amplified due to repeated occurrence and duration. Some nurses' demonstrated capacities for moral resilience, but none described drawing on all four capacities.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers would benefit from greater ethics training to support their nursing teams.

Defining existing practices to support the sleep of hospitalized patients: A mixed-methods study of top-ranked hospitals

The objective of this study was to understand the existing practices and attitudes regarding inpatient sleep at the 2020 US News and World Report (USNWR) Honor Roll pediatric (n = 10) and adult (n = 20) hospitals. Section chiefs of Hospital Medicine from these institutions were surveyed and interviewed between June and August 2021. Among 23 of 30 surveyed physician leaders (response rate = 77%), 96% (n = 22) rated patient sleep as important, but only 43% (n = 10) were satisfied with their institutions' efforts. A total of 96% (n = 22) of institutions lack sleep equity practices. Fewer than half (48%) of top hospitals have sleep-friendly practices, with the most common practices including reducing overnight vital sign monitoring (43%), decreasing ambient light in the wards (43%), adjusting lab and medication schedules (35%), and implementing quiet hours (30%). Major themes from qualitative interviews included: importance of universal sleep-friendly cultures, environmental changes, and external incentives to improve patient sleep.

Why use Appreciative Inquiry? Lessons learned during COVID-19 in a UK maternity service

Choosing the ‘right’ research method is always an important decision. It affects the type of study questions that can be answered. In addition, the research method will have an impact on the participants – how much of their time it takes, whether the questions seem important to them and whether there is any benefit in taking part. This is especially important when conducting research with staff in health services. This article is a reflection on the process of using Appreciative Inquiry (AI) in a study that explored staff wellbeing in a UK maternity unit. We share our key learnings to help others decide if AI will fit their research aims, as well as highlight issues in its design and conduct. We discuss our experience of using AI,the strengths and limitations of this approach, and conclude with points to consider if you are thinking about using AI. Although a study team was actively involved in decisions, this paper is largely based on reflections by the first author, the researcher conducting the field work in the maternity services.

Early Mobility for Critically Ill Patients: Building Staff Commitment Through Appreciative Inquiry

BACKGROUND

Immobility contributes to many adverse effects in critically ill patients. Early progressive mobility can mitigate these negative sequelae but is not widely implemented. Appreciative inquiry is a quality improvement method/change philosophy that builds on what works well in an organization.

OBJECTIVES

To explore whether appreciative inquiry would reinvigorate an early progressive mobility initiative in a medical intensive care unit and improve and sustain staff commitment to providing regular mobility therapy at the bedside. Secondary goals were to add to the literature about appreciative inquiry in health care and to determine whether it can be adapted to critical care.

METHODS

Staff participated in appreciative inquiry workshops, which were conducted by a trained facilitator and structured with the appreciative inquiry 4-D cycle. Staff members' attitudes toward and knowledge of early progressive mobility were evaluated before and after the workshops. Performance of early progressive mobility activities was recorded before and 3 and 10 months after the workshops.

RESULTS

Sixty-seven participants completed the program. They rated the workshops as successfully helping them to understand the importance of early progressive mobility (98%), explain their responsibility to improve patient outcomes (98%), and engender a greater commitment to patients and the organization (96%). Regarding mobility treatments, at 3 months orders had improved from 62% to 88%; documentation, from 52% to 89%; and observation, from 39% to 87%. These improvements were maintained at 10 months.

CONCLUSION

Participation in the workshops improved the staff's attitude toward and performance of mobility treatments. Appreciative inquiry may provide an adjunct to problem-based quality improvement techniques.

Creating a Pathway for Psychosocial Support in Siblings of Youth with a Chronic Illness: Findings from an International Summit

OBJECTIVE

Serious childhood illnesses such as cancer affect all family members. Siblings experience strong emotions and disruptions to their routines as families reorganize to confront the disease and manage treatment. Addressing siblings' psychosocial needs is a standard of care in pediatric oncology, but siblings' needs are rarely met because of systematic barriers in our health care system. Thus, we aimed to re-envision sibling care. We used an appreciative inquiry approach to inform systematic screening of siblings' psychosocial risk and unmet needs as a first step toward providing appropriate support.

METHOD

Sibling-focused researchers, clinicians, policymakers, advocates, and families of youth with cancer (N = 29) convened for a 2-day community stakeholder-centered international summit to create a vision for standardizing and optimizing sibling-focused psychosocial screening and assessment as a pathway to care, including crafting a research agenda and articulating best clinical practices.

RESULTS

Summit attendees created a detailed framework for best practices in universal sibling psychosocial screening and pathways to support. The framework emphasizes links between hospital- and community-based care. It highlights the need to prepare systems to feasibly and effectively attend to siblings' needs and recommends incorporating siblings into family-based psychosocial screening at cancer diagnosis, systematically conducting sibling-focused psychosocial screening during and after cancer treatment, and connecting siblings with community-based resources.

CONCLUSION

A systematic approach to sibling psychosocial services expands the idea of family-centered care to include siblings and ensures that siblings' needs are adequately recognized and met. This framework was created in the context of cancer but is applicable across illness groups.

Women's lived experience of compassionate midwifery: Human and professional

OBJECTIVE

To develop an understanding of women's lived experience of compassionate midwifery DESIGN: A qualitative study using the principles of Interpretive Phenomenological Analysis (IPA). Data was collected during interviews with 17 women who identified themselves as having received compassionate midwifery care.

FINDINGS

Women participants' experience of compassionate care from midwives was experienced through a sense of a midwife Being With them, Being in Relationship with them and Empowerment. Women were also aware of the way midwives were able to Balance potentially conflicting aspects of their work, in order to provide compassionate care. Two other themes which emerged through extensive analysis of the data related to how women set their experience of compassion in the context of their personal suffering and that compassion made a difference. These themes will be reported separately.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The unique contribution of this study was to provide a window into the nature of women's lived experiences of compassionate midwifery and thus building, understanding around the qualities of compassionate midwifery and its impact on women. The findings are important because they challenge assumptions that compassion is ill-defined and therefore difficult to teach. On the contrary, compassionate midwifery was easily identified by women participants and had the features of an effective intervention for relieving their suffering. A dynamic model of Compassionate Midwifery in Balance has been proposed, providing a much-needed tool to inform practice, education and policy. Further research will build on this work by focussing on women in varied circumstances, environments and cultures and on understanding the lived experience of compassionate midwifery from the midwife's perspective.

Making the Random the Usual: Appreciative Inquiry/Boot Camp Translation-Developing Community-Oriented Evidence That Matters

Background: The evidence underlying clinical guidelines arising from typical scientific inquiry may not always match the needs and concerns of local communities. Our High Plains Research Network Community Advisory Council (HPRN CAC) identified a need for evidence regarding how to assist members of their community suffering from mental health issues to recognize their need for help and then obtain access to mental health care. The lack of evidence led our academic team to pursue linking Appreciative Inquiry with Boot Camp Translation (AI/BCT). This article describes the development and testing of this linked method. Method: We worked with the HPRN CAC and other communities affiliated with the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP) practice-based research networks to identify 5 topics for testing of AI/BCT. For each topic, we developed AI interview recruitment strategies and guides with our community partners, conducted interviews, and analyzed the interview data. Resulting themes for each topic were then utilized by 5 groups with the BCT method to develop community relevant messages and materials to communicate the evidence generated in each AI set of interviews. At each stage for each topic, notes on adaptations, barriers, and successes were recorded by the project team. Results: Each topic successfully led to generation of community specific evidence, messages, and materials for dissemination using the AI/BCT method. Beyond this, 5 important lessons emerged regarding the AI/BCT method: Researchers must (1) first ensure whether the topic is a good fit for AI, (2) maintain a focus on "what works" throughout all stages, (3) recruit one or more experienced qualitative analysts, (4) ensure adequate time and resources for the extensive AI/BCT process, and (5) present AI findings to BCT participants in the context of existing evidence and the local community and allow time for community partners to ask questions and request additional data analyses to be done. Conclusions: AI/BCT represents an effective way of responding to a community's need for evidence around a specific topic where standard evidence and/or guidelines do not exist. AI/BCT is a method for turning the "random" successes of individuals into "usual" practice at a community level.

Pilot Test of an Appreciative Inquiry Intervention in Hypertension Self-management

We implemented an Appreciative Inquiry (AI) intervention to assist people with hypertension improve diet, physical activity, and blood pressure. In a two-group randomized controlled trial conducted over 12 weeks, 50 participants were recruited at an urban outpatient health care clinic. The intervention used participants' high peak positive experiences to promote behavior change, during two face-to-face individual sessions and three coaching telephone calls. Data were analyzed using test of differences between groups and analysis of covariance controlling for confounding variables. The intervention group had significantly higher levels of ideal self, positive emotions, and self-efficacy for chronic disease management than the control group. No significant group differences in physical activity, diet, or blood pressure. Findings provide empirical evidence about the underlying processes by which AI may promote health behavior change. Future research should examine the effectiveness of this AI intervention in a larger sample of patients and over a longer intervention period.

Appreciative inquiry in a Norwegian nursing home: a unifying and maturing process to forward new knowledge and new practice

PURPOSE

Appreciative inquiry (AI) studies have proven to be useful in developing nursing knowledge and changing nursing practice. However, few AI studies have examined the meaning of participation over time among collaborating healthcare providers. Our aim was to explore and illuminate healthcare providers' participation over time in a Norwegian nursing home to develop new knowledge and practice, focusing on sensory gardens.

METHOD

Twenty healthcare providers participated in the 3 year AI study. Data were collected in fieldwork, interviews, and interventions. Saldañas' longitudinal analysis was applied.

RESULTS

The collaboration between the researcher and participants created insight of a relational room, which was named "the room of closeness". Participants' search for new arenas to apply the meaning of the room of closeness was found when focusing on the sensory garden. Their desire for joint development created a bottom-up perspective, the hallmark of successful AI.

CONCLUSION

Knowledge of participants' experiences may contribute to developing AI as a useful and transferable method, especially regarding co-creating participation, and may have implications for research and society. AI's strength-based approach may, however, lead to the neglect of data that are associated with problems, and complicate the assessment of success. Further research is therefore needed to develop AI.

Appreciative Inquiry in Psychiatry Peer Groups

OBJECTIVE

The purpose of the study was to explore the feasibility of using appreciative inquiry in a peer group of psychiatry residents.

METHODS

A peer coaching exercise using appreciative inquiry was modeled to a group of psychiatry residents who practised the approach. The topics discussed in separate sessions 1 month apart were values and identity as a psychiatrist, dealing with conflict and working within the psychiatric system. Following each session, the residents participated in focus group interviews. Transcripts were thematically analyzed and independently coded.

RESULTS

Four themes were identified: (i) connectedness, (ii) a structure for dialogue, (iii) reflection, and (iv) generative conversations.

CONCLUSION

Appreciative inquiry is a feasible method to facilitate focused and meaningful encounters and develop connection between members of a peer group.

Place of sanctuary: an appreciative inquiry approach to discovering how communities support breastfeeding and parenting

Background

Significant efforts by governments at a global and national level have not resulted in a significant increase in the duration of breastfeeding to six months. The views of family and social networks, and community attitudes particularly around breastfeeding in public, influence infant feeding decisions. Yet many interventions designed to increase breastfeeding focus on the individual woman and have not been developed from the 'ground up' in consultation with women and communities. This study aimed to identify the key components of Mother Infant Caring Communities that promote and support breastfeeding and early parenting.

Methods

Appreciative Inquiry was used to facilitate a 'Community Conversation' workshop in two local councils in Australia. Thirty-five participants attended the community conversation workshops including new parents, grandparents, children's services, local government, and representatives from maternity and child health services. In addition, one focus group discussion was conducted with six retail business owners or managers. Qualitative content analysis was used to analyse data. This paper presents the findings of the first phase (the Discovery phase) of the study.

Results

Four major themes emerged: "PLACE - A community for everyone"; "A PLACE for children and families"; "Sometimes a PLACE to breastfeed" and "The parent room: a hidden and unsafe PLACE to breastfeed". Participants described the characteristics of communities that provided a sanctuary and fostered well-being for parents and infants including, open green spaces, safe playgrounds, walking tracks and community hubs. Shopping centres were described as having the potential to be the 'village'. Community-based services to support breastfeeding and parenting were highly valued. Yet in both sites, participants stated that breastfeeding was rarely observed in public and bottle feeding was more evident.

Conclusion

Breastfeeding and parenting are embedded in the places where women and families live. Community spaces including shopping centres, should be designed to include infants and young children and offer appropriate facilities such as safe and clean parenting rooms. Health services must work with local government, businesses, and diverse community members to identify what parents' value about their community and design and implement innovative local strategies to support breastfeeding.

Evaluation of matron ward rounds to enhance patient experience and improve staff morale

Intentional rounding was introduced in the UK in 2012 to improve direct nursing care. Liverpool Women's NHS Foundation Trust (LWFT) introduced intentional nursing rounds, called comfort rounds, in 2013. These are carried out and documented by nursing staff who check the patients in their care every two hours, particularly in relation to pain management, nutritional needs, hygiene and toilet needs, and overall comfort. In September 2015, LWFT introduced daily matron ward rounds (MWRs) following a directive from the trust's chief executive to provide assurance that comfort rounds were completed and that patient feedback was acted on in a timely manner. This article presents findings from an evaluation of the initiative and describes how daily MWRs improve patient experience and staff morale but are resource intensive. Further qualitative research of their effect on staff morale and well-being, as well as patient experience, is recommended.

Does appreciative inquiry decrease false positive diagnosis during leprosy case detection campaigns in Bihar, India? An operational research study

BACKGROUND

India contributes ~60% to the global leprosy burden. The country implements 14-day community-based leprosy case detection campaigns (LCDC) periodically in all high endemic states. Paramedical staff screen the population and medical officers of primary health centres (PHCs) diagnose and treat leprosy cases. Several new cases were detected during the two LCDCs held in September-2016 and February-2018. Following these LCDCs, a validation exercise was conducted in 8 Primary health centres (PHCs) of 4 districts in Bihar State by an independent expert group, to assess the correctness of case diagnosis. Just before the February 2018 LCDC campaign, we conducted an "appreciative inquiry" (AI) involving the health care staff of these 8 PHCs using the 4-D framework (Discovery-Dream-Design-Destiny).

OBJECTIVES

To assess whether the incorrect case diagnosis (false positive diagnosis) reduced as a result of AI in the 8 PHCs between the two LCDC conducted in September-2016 and February-2018.

METHODOLOGY/PRINCIPAL FINDINGS

A three-phase quantitative-qualitative-quantitative mixed methods research (embedded design) with the two validation exercises conducted following September-2016 and February-2018 LCDCs as quantitative phases and AI as qualitative phase. In September-2016 LCDC, 303 new leprosy cases were detected, of which 196 cases were validated and 58 (29.6%) were false positive diagnosis. In February-2018 LCDC, 118 new leprosy cases were detected of which 96 cases were validated and 22 cases (23.4%) were false positive diagnosis. After adjusting for the age, gender, type of cases and individual PHCs fixed effects, the proportion of false positive diagnosis reduced by -9% [95% confidence intervals (95%CI): -20.2% to 1.7%, p = 0.068].

CONCLUSION

False positive diagnosis is a major issue during LCDCs. Though the decline in false positive diagnosis is not statistically significant, the findings are encouraging and indicates that appreciative inquiry can be used to address this deficiency in programme implementation.

Self-assessment of Goal Achievements Within a Gynecological Cancer Rehabilitation Counseling

BACKGROUND

There is an increasing focus on patient involvement in cancer rehabilitation. Goal assessment may improve the patient's self-management of life after cancer.

OBJECTIVE

The aim of this study was to evaluate whether (1) nurse-led supported goal setting and assessment of goal achievement were feasible in a clinical setting and (2) there was a positive association between women's goal achievement and their self-assessed global health status (GHS).

METHODS

Women surgically treated for gynecological cancer were offered rehabilitation counseling consisting of 2 face-to-face sessions and 2 phone calls carried out by a nurse. The Goal Attainment Scale evaluated goal achievement, whereas GHS was assessed with a quality-of-life questionnaire (European Organization of Research and Treatment of Cancer Quality of Life Questionnaire Core 30).

RESULTS

One hundred fifty-one women consented to participate; 70% of the women at the first phone call and 72% at the second phone call achieved their goals as "expected" or "more or much more than expected." Endometrial cancer patients more often achieved their goals than ovarian or cervical cancer patients. Approximately 32% of ovarian and 40% of cervical cancer patients scored their goal achievement "below expected." The patients' GHS was not associated with goal attainment measured at each phone call.

CONCLUSION

Goal measurement is feasible in cancer rehabilitation, in both goal setting and goal achievement. Goal achievement less than expected levels in women recovering from ovarian or cervical cancer suggests a need for additional support.

IMPLICATIONS FOR PRACTICE

This study supports goal setting and goal achievement as a feasible approach to improve cancer rehabilitation and that nursing professionals can facilitate individualized rehabilitation efforts.

Práticas exitosas dos preceptores de uma residência multiprofissional: interface com a interprofissionalidade

Resumo Nosso artigo, fundamentado na Pesquisa Apreciativa, apresenta e discute as melhores práticas de um grupo de preceptores de um programa de residência multiprofissional em Saúde. As melhores práticas identificadas são: a consulta multiprofissional, o acolhimento dos residentes e as ações integradas entre as diferentes ênfases da residência. Além dessas, identificaram-se as estratégias para desenvolver as práticas nos cenários de saúde que seguem os pressupostos da educação interprofissional, já que promovem a reflexão de diferentes atores do processo na construção de práticas que buscam maior atenção à saúde dos usuários do Sistema Único de Saúde (SUS).

Positive emotion in workplace impact

Purpose

The purpose of this paper is to highlight the role of positive emotions in generating workplace impacts and examine it through the application of an adapted appreciative inquiry process in the context of a work-based project aimed at promoting integrated working under challenging organisational circumstances.

Design/methodology/approach

The paper adopts a case study methodology which highlights how an organisation facing difficult circumstances (such as austerity measures, siloed cultures, constant threats of reorganisation, and requirement to work across occupational boundaries) adapted an appreciative inquiry intervention/method.

Findings

This paper found, first, that the utilisation of appreciative inquiry in the context of an adapted work-based project in difficult organisational circumstances generated positive emotions manifest through a compelling vision and action plans, second, that the impacts (such as a vision) can become entangled and therefore part of the wider ecological context which promotes pathways to such impact, but that, third, there are a various cultural and climate features which may limit the implementation of actions or the continuation of psychological states beyond the time-bound nature of the work-based project.

Practical implications

The paper illustrates how an organisation adapted a form of appreciative inquiry to facilitate organisational change and generated outcomes which were meaningful to the various occupational groupings involved.

Originality/value

This paper offers new evidence and insight into the adaptation of appreciative inquiry under challenging circumstances in the context of a work-based learning project. It also provides a richer picture of how positive emotion can manifest in ways which are meaningful to a localised context.

Interprofessional Collaboration between General Physicians and Emergency Department Teams in Belgium: A Qualitative Study

This study aimed to assess interprofessional collaboration between general physicians and emergency departments in the French speaking regions of Belgium. Eight group interviews were conducted both in rural and urban areas, including in Brussels. Findings showed that the relational components of collaboration, which are highly valued by individuals involved, comprise mutual acquaintanceship and trust, shared power and objectives. The organizational components of collaboration included out-of-hours services, role clarification, leadership and overall environment. Communication and patient's role were also found to be key elements in enhancing or hindering collaboration across these two levels of care. Relationships between general physicians and emergency departments' teams were tightly linked to organizational factors and the general macro-environment. Health system regulation did not appear to play a significant role in promoting collaboration between actors. A better role clarification is needed in order to foster multidisciplinary team coordination for a more efficient patient management. Finally, economic power and private practice impeded interprofessional collaboration between the care teams. In conclusion, many challenges need to be addressed for achievement of a better collaboration and more efficient integration. Not only should integration policies aim at reinforcing the role of general physicians as gatekeepers, also they should target patients' awareness and empowerment.

Future Dietitian 2025: informing the development of a workforce strategy for dietetics

BACKGROUND

Healthcare is changing and the professions that deliver it need to adapt and change too. The aim of this research was to inform the development of a workforce strategy for Dietetics for 2020-2030. This included an understanding of the drivers for change, the views of stakeholders and recommendations to prepare the profession for the future.

METHODS

The research included three phases: (i) establishing the context which included a literature and document review (environmental scan); (ii) discovering the profession and professional issues using crowd-sourcing technology; and (iii) articulating the vision for the future using appreciative inquiry.

RESULTS

The environmental scan described the current status of the dietetic profession, the changing healthcare environment, the context in which dietitians work and what future opportunities exist for the profession. The online conversation facilitated by crowd-sourcing technology asked the question: 'How can dietitians strengthen their future role, influence and impact?' Dietitians and interested stakeholders (726 and 109, respectively) made 6130 contributions. Seven priorities were identified and fed into the appreciative inquiry event. The event bought together 54 dietitians and analysis of the discussions generated five themes: (i) professional identity; (ii) strong foundations-creating structure and direction for the profession; (iii) amplifying visibility and influence; (iv) embracing advances in science and technology; and (v) career advancement and emerging opportunities.

CONCLUSIONS

A series of recommendations were made for the next steps in moving the workforce to a new future. The future for dietetics looks bright, embracing technology, as well as exploring different ways of working and new opportunities, as this dynamic profession continues to evolve.

A tailored intervention to improving the quality of intrahospital nursing handover

INTRODUCTION

Nursing handover is a process central to the delivery of high-quality and safe care. We aimed to improve the quality of nursing handover from the emergency department to ward and intensive care unit (ICU).

METHODS

A quasi-experimental non-equivalent control group pre-test - post-test design was applied. Handover quality was measured using the Handover Evaluation Scale (HES). A tailored intervention, inspired by appreciative inquiry, was designed to improve the implementation of an existing handover form and procedure.

RESULTS

In total 130 nurses participated, 66 before and 64 after the intervention. Initial structure of the HES showed no good fit to our data; the questions were reshaped into 3 dimensions: Quality of information, Interaction and support, and Relevance of information. Following the intervention, mean changes in HES factor scores ranged from -3.99 to +15.9. No significant difference in factor scoring by ward and ICU nurses was found. Emergency department nurses, however, perceived Interaction and support to be improved following the intervention.

CONCLUSION

The intervention did not result in an improved perception of handover quality by ward and ICU nurses. There was improvement in the perception of Interaction and support among emergency department nurses. The intervention positively effected teamwork and mutual understanding concerning nursing handover practice amongst emergency nurses. In order to improve intrahospital nursing handover, hospital-wide interventions are suggested. These interventions should be aimed at creating a generative story, improving mutual understanding, and establishing a supportive attitude regarding standardised procedures to reduce human error.

A Study Protocol for Applying User Participation and Co-Learning-Lessons Learned from the eBalance Project

The eBalance project is based on the idea that serious exergames-i.e., computer gaming systems with an interface that requires physical exertion to play-that are well adapted to users, can become a substantial part of a solution to recognized problems of insufficient engagement in fall-prevention exercise and the high levels of fall-related injuries among older people. This project is carried out as a collaboration between eight older people who have an interest in balance training and met the inclusion criteria of independence in personal activities of daily living, access to and basic knowledge of a computer, four staff working with the rehabilitation of older adults, and an interdisciplinary group of six research coordinators covering the areas of geriatric care and rehabilitation, as well as information technology and computer science. This paper describes the study protocol of the project's initial phase which aims to develop a working partnership with potential users of fall-prevention exergames, including its conceptual underpinnings. The qualitative methodology was inspired by an ethnographical approach implying combining methods that allowed the design to evolve through the study based on the participants' reflections. A participatory and appreciative action and reflection (PAAR) approach, accompanied by inquiries inspired by the Normalization Process Theory (NPT) was used in interactive workshops, including exergame testing, and between workshop activities. Data were collected through audio recordings, photos, and different types of written documentation. The findings provide a description of the methodology thus developed and applied. They display a methodology that can be useful for the design and development of care service and innovations for older persons where user participation is in focus.

SOARing Into Strategic Planning: Engaging Nurses to Achieve Significant Outcomes

In 2013, a new system chief nursing officer engaged the nursing leaders and staff in an Appreciative Inquiry process utilizing strengths, opportunities, aspirations, and results (SOAR), and a Journey of Excellence to assess and understand the current environment. The ultimate goal was to engage all nurses in strategic planning and goal setting to connect their patient care to the system strategic initiatives. This work led to the creation of a nursing vision, a revised professional practice model and greater council alignment, resulting in significant positive change and ongoing advancement throughout the system. The shared decision-making structure was key to the process with a direct connection of each council's goals, leading to the successful achievement of 34 of the 36 goals in 2 years. This article outlines the process, tools, and staff engagement strategies used to achieve system-wide success. This methodology has improved the outcomes across the organization in both small and system-wide work groups. This work can easily be replicated and adapted to help disparate staffs brought together through mergers or acquisitions to become aligned as a new team. This process, model, and framework, provides structure and results in significant outcomes that recognizes and celebrates the work of individual entities while aligning future strategies and goals.

Co-constructing Appreciative Inquiry across disciplines: A duo-ethnography

Orientation: Appreciative Inquiry (AI) has become increasingly popular as a tool for change management in the world of business and is spilling over into a range of contexts, linking a diversity of disciplines. However, instances where management has used AI in consultation with education for collaborative purposes could not be traced as yet.Research purpose: The aim of this study was for two AI practitioners, one in the field of Industrial and Organisational Psychology and one in Education, to partake in a collaborative study proceeding from reflection on the said researchers’ experiences with facilitating AI in different contexts.Motivation for the study: With social constructionism as a core principle underlying AI, it is argued that sharing experiences across disciplines could enrich the literature and the application of AI in different contexts.Research design, approach and method: The research is based on a qualitative, empirical, duo-ethnography using self-reflective narratives of the experiences of facilitating AI in cross-disciplinary contexts.Main findings: Reflecting on experiences in various disciplines lead to the co-construction of new knowledge. Not only were similar experiences supported, validated and extended, thus affirming the strength-based principle of AI, but it also provided the opportunity for disciplinary cross-fertilisation by combining different perspectives regarding the formality of the AI process and the extent of the facilitator’s and participants readiness to work with AI methodology.Practical/managerial implications: The formality of the AI process and hence the extent of the facilitator’s involvement (signalling his or her readiness to participate actively and take the lead in co-creating a new reality) must be tempered by due allowance for the participant’s readiness to work with AI methodology. Furthermore, participants should be accommodated within the psychological space where they find themselves at the moment when the intended intervention is initiated.Contribution/value-add: Duo-ethnography provided the researchers with the opportunity to challenge the ‘other’ to reflect on their own discipline-related AI experiences, in a deeper, more relational and authentic way. The voices and ideas identified and presented counter narratives, also blended in unique ways to augment the definition of AI as a multidisciplinary force to co-create a better society. More specifically, the ‘readiness’ of the facilitator for an AI encounter was conceptualised and applied to the psychological and behavioural readiness of not only the participants, but also the facilitators of AI workshops.

Embedding compassionate care in local NHS practice: developing a conceptual model through realistic evaluation

The aim of this study was to critically analyse the impact of the ‘Leadership in Compassionate Care Programme’ and offer a conceptual model of factors that can embed compassionate care in contemporary health care environments. This three-year initiative (2008–2011) was designed to embed compassionate care in both practice and pre-registration education. Using a realistic evaluation approach this longitudinal qualitative study involved data collection in eight participating wards. The ‘level of adoption’ of the Programme varied across the wards, which pointed to key context and mechanisms that were influential in embedding compassionate care. Contextual factors that promoted adoption of the Programme were stability, support and leadership. The most important mechanisms were appreciative inquiry coupled with skilled facilitation. Powerful practice development techniques focused on articulating and demonstrating values; giving patients, relatives and staff a voice to express their experiences and emotions; and instituting effective feedback mechanisms. In the high adopting wards the main outcomes included personalisation of patient care, an increased sense of involvement for relatives and ‘caring conversations’ becoming an accepted part of working practice. Embedding and sustaining compassionate care demands strategic vision and investment in a local infrastructure that supports relationship-centred care, practice development and effective leadership at all levels.

Using appreciative inquiry to implement person-centred dementia care in hospital wards

The quality of care of persons with dementia in hospitals is not optimal and can be challenging. Moreover, staff may find difficulty in translating what they have learned during training into practice. This paper report the development and evaluation of a set of workshops using an appreciative inquiry approach to implement person-centred dementia care in two hospital wards. Staff worked collaboratively to develop a ward vision and to implement a number of action plans. Using appreciative inquiry approach, staff attitudes towards persons with dementia improved, inter-professional collaboration was enhanced and small changes in staff practices were noted. Dementia care in hospitals can be enhanced by empowering staff to take small but concrete actions after they engage in appreciative inquiry workshops, during which they are listened to and appreciated for what they can contribute.

Evaluation of an Organisational Intervention to Promote Integrated Working between Health Services and Care Homes in the Delivery of End-of-Life Care for People with Dementia: Understanding the Change Process Using a Social Identity Approach

In the United Kingdom, approximately a third of people with dementia live in long-term care facilities for adults, the majority of whom are in the last years of life. Working arrangements between health services and care homes in England are largely ad hoc and often inequitable, yet quality end-of-life care for people with dementia in these settings requires a partnership approach to care that builds on existing practice. This paper reports on the qualitative component of a mixed method study aimed at evaluating an organisational intervention shaped by Appreciative Inquiry to promote integrated working between visiting health care practitioners (i.e. General Practitioners and District Nurses) and care home staff. The evaluation uses a social identity approach to elucidate the mechanisms of action that underlie the intervention, and understand how organisational change can be achieved. We uncovered evidence of both (i) identity mobilisation and (ii) context change, defined in theory as mechanisms to overcome divisions in healthcare. Specifically, the intervention supported integrated working across health and social care settings by (i) the development of a common group identity built on shared views and goals, but also recognition of knowledge and expertise specific to each service group which served common goals in the delivery of end-of-life care, and (ii) development of context specific practice innovations and the introduction of existing end-of-life care tools and frameworks, which could consequently be implemented as part of a meaningful bottom-up rather than top-down process. Interventions structured around a Social Identity Approach can be used to gauge the congruence of values and goals between service groups without which efforts to achieve greater integration between different health services may prove ineffectual. The strength of the approach is its ability to accommodate the diversity of service groups involved in a given area of care, by valuing their respective contributions and building on existing ways of working within which practice changes can be meaningfully integrated.

Does online learning click with rural nurses? A qualitative study

OBJECTIVE

To explore the factors that influence rural nurses engagement with online learning within a rural health district in New Sound Wales (NSW), Australia.

DESIGN

This qualitative study based on appreciative inquiry methodology used semi-structured interviews with managers and nurses. Purposive sampling methods were used to recruit facility managers, whereas convenience sampling was used to recruit nurses in 2012-2013.

SETTING

Three public health facilities in rural NSW.

PARTICIPANTS

Fourteen nurses were involved in the study, including Health Service Managers (n = 3), Nurse Unit Manager (n = 1), Clinical Nurse Specialists (n = 3), Registered Nurses (n = 2), Enrolled Nurses (n = 2) and Assistant in Nursing (n = 3).

MAIN OUTCOME MEASURE

The research found that online learning works well when there is accountability for education being undertaken by linking to organisational goals and protected time. Nurses in this study valued the ability to access and revisit online learning at any time. However, systems that are hard to access or navigate and module design that did not provide a mechanism for users to seek feedback negatively affected their use and engagement.

CONCLUSION

This study demonstrates that rural nurses' engagement with online learning would be enhanced by a whole of system redesign in order to deliver a learning environment that will increase satisfaction, engagement and learning outcomes.

Goal setting in cancer rehabilitation and relation to quality of life among women with gynaecological cancer

BACKGROUND

Rehabilitation should be integrated in the routine cancer care of women treated for gynaecological cancers. Goal setting is expected to facilitate the process through patient involvement and motivation. Our knowledge about goal setting in cancer rehabilitation is, however, sparse.

OBJECTIVES

This study aimed to: 1) analyse rehabilitation goals defined during hospital-based rehabilitation in patients with gynaecological cancer, with regard to number, category, changes over time, and differences between cancer diagnosis, and 2) analyse the association between health-related quality of life and goals defined for rehabilitation.

MATERIAL AND METHODS

Consecutively, all patients treated surgically for endometrial, ovarian, and cervical cancer were invited for hospital-based rehabilitation at Odense University Hospital, Denmark, including two sessions at the hospital one and three months following surgery and two phone calls for follow-up. Questionnaires from the EORTC were used to prepare patients and facilitate individual goal setting with definitions of up to three goals. All goals were grouped into six categories.

RESULTS

A total of 151 (63%) patients accepted the invitation including 50 endometrial, 65 ovarian, and 36 cervical cancers patients. All patients defined goals at the first session, 76.4% defined three goals, 21.9% two, and 1.6% had one goal. Physical goals decreased over time but were the most frequent at both sessions (98% and 89%). At both sessions, the social and emotional categories were the second and third most frequent among patients with endometrial and ovarian cancer. Sexual issues were dominant among the cervical cancer patients. Regression analysis showed significant association between quality of life scores and goal setting within the social and emotional domains.

CONCLUSION

Goal setting seemed feasible in all problem areas. The EORTC questionnaires were helpful during the process although expectations of the sub-scores being predictive of which areas to address were not convincing.

Using 'appreciative inquiry' in India to improve infection control practices in maternity care: a qualitative study

BACKGROUND

Infections acquired during childbirth are a common cause of maternal and perinatal mortality and morbidity. Changing provider behaviour and organisational settings within the health system is key to reducing the spread of infection.

OBJECTIVE

To explore the opinions of health personnel on health system factors related to infection control and their perceptions of change in a sample of hospital maternity units.

DESIGN

An organisational change process called 'appreciative inquiry' (AI) was introduced in three maternity units of hospitals in Gujarat, India. AI is a change process that builds on recognition of positive actions, behaviours, and attitudes. In-depth interviews were conducted with health personnel to elicit information on the environment within which they work, including physical and organisational factors, motivation, awareness, practices, perceptions of their role, and other health system factors related to infection control activities. Data were obtained from three hospitals which implemented AI and another three not involved in the intervention.

RESULTS

Challenges which emerged included management processes (e.g. decision-making and problem-solving modalities), human resource shortages, and physical infrastructure (e.g. space, water, and electricity supplies). AI was perceived as having a positive influence on infection control practices. Respondents also said that management processes improved although some hospitals had already undergone an accreditation process which could have influenced the changes described. Participants reported that team relationships had been strengthened due to AI.

CONCLUSION

Technical knowledge is often emphasised in health care settings and less attention is paid to factors such as team relationships, leadership, and problem solving. AI can contribute to improving infection control by catalysing and creating forums for team building, shared decision making and problem solving in an enabling environment.