Using Video-Reflexive Ethnography to Engage Hospital Staff to Improve Dementia Care

Understanding Team Dynamics and Culture of Safety Using Video Reflexive Ethnography during Real-Time Emergent Intubation

Rationale: Endotracheal intubation is the third most common bedside procedure in U.S. hospitals. In over 40% of intubations, preventable complications attributable to human factors occur. A better understanding of team dynamics during intubation may improve patient safety. Objectives: To explore team dynamics and safety-related actions during emergent endotracheal intubations in the emergency department and intensive care unit and to engage members of the care team in reflection for process improvement through a novel video-based team debriefing technique. Methods: Video-reflexive ethnography involves in situ video recording and reflexive discussions with practitioners to scrutinize behaviors and to identify opportunities for improvement. In this study, real-time intubations were recorded in the emergency department and intensive care unit at Mayo Clinic Rochester, and facilitated video-reflexive sessions were conducted with the multidisciplinary procedural teams. Themes about team dynamics and safety-related action were identified inductively from transcriptions of recorded sessions. Results: Between December 2022 and January 2023, eight video-reflexive sessions were conducted with a total of 78 participants. Multidisciplinary members included nurses (n = 23), respiratory therapists (n = 16), pharmacists (n = 7), advanced practitioners (n = 5), and physicians (n = 26). In video-reflexive discussions, major safety gaps were identified and several solutions were proposed related to the use of a multidisciplinary intubation checklist, standardized communication and team positioning, developing a culture of safety, and routinely debriefing after the procedure. Conclusions: The findings of this study may inform the development of a team supervision model for emergent endotracheal intubations. This approach could integrate key components such as a multidisciplinary intubation checklist, standardized communication and team positioning, a culture of safety, and debriefing as part of the procedure itself.

Raising patient voices in medical education: an assessment of patient perceived effect of social determinants of health conversations and the patient-physician relationship on quality of obstetric care, to inform the development of patient driven medical education curricula

Background

Conventional medical education lacks the lived experiences of patients which may authentically convey the social determinants of health (SDOH) and resulting health disparities. Videos of first-person patient narratives may prove a valuable education tool in this regard. The objective of this study is to investigate how patient demographics, satisfaction with care, and patient-physician relationships influence obstetric patient interest and willingness to contribute to a SDOH video curriculum by sharing their lived experiences through first-person narratives.

Methods

Study design included an anonymous, cross-sectional survey and an optional semi-structured telephone interview. Participants were 18 years old with a live-birth delivery <8 weeks prior to recruitment and received care during their pregnancy at Los Angeles General Medical Center (LAGMC). Variables surveyed included demographics, satisfaction with care, aspects of the patient-physician relationship, perceived utility, and personal interest in contributing to an educational SDOH video. A bivariate analysis was conducted to compare participants' characteristics and responses on interest in contributing and perceived helpfulness of first-person patient SDOH videos.

Results

72.43% of participants (N = 70) believed a patient's first-person video on SDOH would be "Helpful" in preparing physicians to provide competent medical care; however, 71.43% responded "No" to "Interest" in sharing with physicians their experiences with SDOH. English preference and being U.S. born were factors significantly associated with viewing first-person SDOH video as "Helpful" (P > 0.001). Major themes from telephone interviews reflected enthusiasm for first-person patient narratives and perceived benefits of using patient experiences to educate physicians on SDOH. However, participants cited barriers to disclosing SDOH including brief and strictly clinical interactions with physicians, lack of continuity of care, and fear of being judged by physicians.

Conclusion

While most participants recognized the utility of addressing social needs in medical education and reported satisfaction with their obstetricians and care, these factors did not uniformly translate into willingness to contribute first-person patient narratives. To improve the representation of patients from racial, ethnic, gender, linguistic, and sexual minorities into medical curricula, further research and strategies are needed to overcome the barriers discouraging patient disclosure of social needs to physicians.

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Co-design of a digital app "WhatMatters" to support person-centred care: A critical reflection

BACKGROUND

People with dementia often do not receive optimal person-centred care (PCC) in care settings. Family members can play a vital role as care partners to support the person with dementia with their psychosocial needs. Participatory research that includes the perspectives of those with lived experience is essential for developing high-quality dementia care and practices.

OBJECTIVE

Throughout 2021-2022, a mobile app, called WhatMatters, was co-developed to provide easy-to-access and personalised support for people with dementia in hospitals and long-term care homes, with input from patients/residents, family partners and healthcare staff. This article discusses and critically reflects on the experiences of patients/residents, family partners, and healthcare staff involved in the co-design process.

METHODS

For the app development, we applied a participatory co-design approach, guided by a User Experience (UX) model. The process involved co-design workshops and user testing sessions with users (patients/residents, family partners, healthcare staff) to co-develop the WhatMatters prototype. We also conducted focus groups and one on one interviews with staff and caregiver participants to explore their experiences. Our research team, which also included patient partners, took part in regular team meetings during the app's development, where we discussed and reflected on the co-design process. Reflexive thematic analysis was performed to identify themes that represent the challenges and rewarding experiences of the users involved in the co-design process, which guided our overall reflective process.

FINDINGS

Our reflective analysis identified five themes (1) clarifying the co-design process, (2) ensuring inclusive collaborations of various users, and (3) supporting expression of emotion in a virtual environment, (4) feeling a sense of achievement and (5) feeling valued.

IMPLICATIONS

WhatMatters offers potential for providing personally relevant and engaging resources in dementia care. Including the voices of relevant users is crucial to ensure meaningful benefits for patients/residents. We offer insights and lessons learned about the co-design process, and explore the challenges of involving people with lived experiences of dementia in co-design work, particularly during the pandemic.

Patient safety for people experiencing advanced dementia in hospital: A video reflexive ethnography

BACKGROUND

Patient safety for people experiencing dementia in acute hospitals is a global priority. Despite national strategies as well as safety and quality guidelines, how safety practices are enacted within the complexities of everyday work are poorly understood and articulated.

METHODS

Using video reflexive ethnography, this 18-month study was conducted within an inpatient geriatric evaluation and management unit for people experiencing dementia and/or delirium in Australia. Patients, family members, and staff members participated by: allowing researchers to document fieldwork notes and video-record their practices and/or accounts thereof; and/or interpreting video-recordings with researchers to co-analyse and make sense of the data.

RESULTS

Safe care for people experiencing advanced dementia involved: negotiating risk via leadership, teamwork, and transparency; practice-based learning through situated adaptation; managing personhood versus protocols by doing the 'right' thing; joyful and meaningful work; as well as incorporating patient and family voices to do safety together.

CONCLUSION

Patient safety for people experiencing dementia requires continuous responsiveness and prioritising in the context of multiple risks by a staff collective with a shared purpose. Ongoing research to better understand how the nuances of patient safety unfold in everyday complex clinical realities in diverse contexts and with key stakeholders is required.

Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

Background

The use of variable rate intravenous insulin infusion (VRIII) is a complex process that has consistently been implicated in reports of error and consequent harm. Investment in patient safety has focused mainly on learning from errors, though this has yet to be proved to reduce error rates. The Resilient Health Care approach advocates learning from everyday practices. Video reflexive ethnography (VRE) is an innovative methodology used to capture everyday practices, reflect on and thereby improve these. This study set out to explore the use of VRIIIs by utilising the VRE methodology.

Methods

This study was conducted in a Vascular Surgery Unit. VRE methodology was used to collect qualitative data that involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records in order to contextualise the outcomes of the video-observed tasks.

Results

The use of VRE in conjunction with quantitative data revealed that context-dependent adaptations (seeking verbal orders to treat hypoglycaemia) and standardised practices (using VRIII guidelines) were strategies used in everyday work. Reflexive meetings highlighted the challenges faced while using VRIII, which were mainly related to lack of clinical knowledge, e.g. prescribing/continuing long-acting insulin analogues alongside the VRIII, and problems with organisational infrastructure, i.e. the wireless blood glucose meter results sometimes not updating on the electronic system. Reflexive meetings also enabled participants to share the meanings of the reality surrounding them and encouraged them to suggest solutions tailored to their work, for example face-to-face, VRIII-focused training.

Conclusions

VRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. Future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07883-w.

VIPCare: Understanding the support needed to create affective interactions between new caregivers and residents with dementia

Introduction

In this paper, we study the support needed by professional caregivers of those with dementia, and present a first step toward development of VIPCare, a novel application with the goal of assisting new caregivers at care-centres in interacting with residents with dementia.

Methods

A mixed-methods study including two questionnaires, two focus groups, and seven co-design sessions with 17 professional caregivers was conducted to (a) understand caregivers’ challenges/approaches used to reduce negative interactions with persons with dementia, (b) identify the existing gaps in supporting information for improving such interactions, and (c) co-design the user interface of an application that aims to help improve interactions between a new professional caregiver and persons with dementia. A pre-questionnaire assessed knowledge of smartphones and attitude toward technology. A post-questionnaire provided an initial evaluation of the designed user interface.

Results

Focus groups emphasized the importance of role-playing learned through trial and error. The layout/content of the application was then designed in four iterative paper-prototyping sessions with professional caregivers. An iOS/Android-based application was developed accordingly and was modified/improved in three iterative sessions. The initial results supported efficiency of VIPCare and suggested a low task load index.

Conclusions

We presented a first step toward understanding caregiver needs and developing an application that can help reduce negative interactions between professional caregivers and those with dementia.

Mixing qualitative methods versus methodologies: A critical reflection on communication and power in inpatient care

This paper offers an illustrative example to demonstrate one way of combining qualitative methods. The context for the study was a UK inpatient psychiatric hospital. Data set one was collected from weekly ward rounds where inpatient staff met with autistic patients to review medication, listen to patient concerns and make plans or adjustments in light of this. Data set two was reflective discursive interviews with patients and staff. The research objective was to critically consider the potential reasons for discrepancies in dissatisfaction reports from patients in the interviews, compared to relative compliance exhibited by patients in the ward rounds. Utilising a video-reflexive design and critical discursive psychology approach, both data sets were analysed together. It is possible to simultaneously analyse two different data sets, one naturally occurring and one researcher generated because of the epistemological congruence in the overall design. We have presented an argument for the benefits of mixing two qualitative methods, thereby extending the mixed-methods evidence base beyond the traditional discussions of quantitative and qualitative paradigms.

Implementing Silent Disco Headphones in a Hospital Unit: A Qualitative Study of Feasibility, Acceptance, and Experience Among Patients and Staff

INTRODUCTION

Music is so widely available and inexpensive in the modern world; it is a common option for stress reduction, comfort and enjoyment. Silent disco headphones are used among young people; however, no study has yet investigated whether it is feasible to use these headphones to support mental health and well-being among older people with dementia in hospital settings.

OBJECTIVE

The study's main objective is to explore whether music delivered by silent disco headphones was feasible and acceptable to a sample of inpatients staying in an older adult mental health unit of a large urban hospital.

METHODS

We employed a video-ethnographic design in data collection, including conversational interviews and observations with video recording among ten patient participants in a hospital unit. A focus group was conducted with ten hospital staff on the unit.

RESULTS

Our analysis identified three themes that represented experiences of patients and staff: (1) perceived usefulness, (2) perceived ease of use, and (3) attitude. Patient participants reported the music delivered by the headphones brought positive benefits. Witnessing the positive effects on patients influenced the staff's view of how music could be used in the clinical setting to support patients' well-being.

CONCLUSIONS

The music delivered by the silent disco headphones in an older adult mental health unit was found to be an acceptable and feasible intervention for patients. Leadership support is identified as an enabling factor in supporting technology adoption in the clinical setting. The findings can be used to inform practice development and future research.

Creating a toolkit with stakeholders for leveraging tablet computers to support person-centred dementia care in hospitals

Introduction

People with dementia may refuse care because they feel overwhelmed by an unfamiliar environment. Everyday technology such as tablets have the potential to support person-centred dementia care in hospitals.

Aims

We aimed to identify barriers and enabling factors in order to develop a toolkit to support the use of tablets in engaging individual and group activities, especially to play family videos, for hospitalized older people with dementia.

Methods

A participatory action research approach was employed. We facilitated staff focus groups and conducted interviews with stakeholders. A toolkit was developed based on participants’ perspectives on how to support successful adoption.

Results

Our analysis identified two enabling factors: users’ engagement in developing a toolkit for support and adapting implementation to meet local needs. Barriers included staff and family inexperience, mechanical instability of hardware, issues around privacy and data access, technology use and personalization of messages. The toolkit includes short videos, a brochure for family caregivers, and a pocket card for staff.

Discussion and implications: Staff, family and patients start with varying levels of experience with the use of tablets, making education and support vitally important to implementation. Health organizations should involve staff, patients, and families to find practical solutions.

The experiences of hospital staff who provide care for people living with dementia: A systematic review and synthesis of qualitative studies

AIMS AND OBJECTIVES

To systematically review and synthesise qualitative data from studies exploring the experiences of hospital staff who care for people living with dementia (Plwd).

BACKGROUND

In hospital, the number of Plwd continues to rise; however, their experiences of care remain problematic. Negative experiences of care are likely to contribute to poorer mental and physical health outcomes for Plwd while in hospital and after discharge. Experiences of the hospital staff who care for Plwd can also be poor or unrewarding. It is important to understand the experiences of staff in order to improve staff well-being and ultimately the experience of care for Plwd while in hospital.

DESIGN

Systematic review and evidence synthesis of qualitative research.

DATA SOURCES

We searched 16 electronic databases in March 2018 and completed forward and backward citation chasing.

METHODS

Eligible studies explored the experiences of paid and unpaid staff providing care in hospital for Plwd. Study selection was undertaken independently by two reviewers, and quality appraisal was conducted. We prioritised included studies according to richness of text, methodological rigour and conceptual contribution. We adopted approaches of meta-ethnography to analyse study findings, creating a conceptual model to represent the line of argument.

FINDINGS

Forty-five studies reported in 58 papers met the inclusion criteria, and of these, we prioritised 19 studies reported in 24 papers. The line of argument was that Institutions can improve staff experiences of care for Plwd by fostering person-centred care (PCC). PCC aligned with staff perceptions of 'good care'; however, staff often felt prevented from providing PCC because of care cultures that prioritised tasks, routines and physical health. Staff experienced conflict over the care they wanted to give versus the care they were able to give, and this caused moral distress. When staff were able to provide PCC, this increased experiences of job satisfaction and emotional well-being.

CONCLUSIONS

Person-centred care not only has the potential to improve the experience of care for Plwd and their carers, but can also improve the experiences of hospital staff caring for Plwd. However, without institutional-level changes, hospital staff are often unable to provide PCC even when they have the experience and knowledge to do so.

IMPLICATIONS FOR PRACTICE

Institutional-level areas for change include the following: training; performance indicators and ward cultures that prioritise psychological needs alongside physical needs; adequate staffing levels; inclusive approaches to carers; physical environments that promote familiarisation, social interaction and occupation; systems of documentation about individual needs of Plwd; and cultures of sharing knowledge across hierarchies.

"Even Though I Have Dementia, I Prefer That They Are Personable": A Qualitative Focused Ethnography Study in a Danish General Hospital Setting

Patients with dementia often face challenges in hospital settings due to cognitive impairment. The aim of this study is to explore the encounter between patients with dementia and hospital staff, from the patient perspective. Focused ethnography guided the method for data collection and the analytical approach was abductive. The findings, based on 10 observations of patients with dementia and their encounter with hospital staff in a variety of hospital settings, reveal that staff often seem to not see the person beyond the dementia diagnosis. The findings also show, however, that significant moments are constantly negotiated during encounters between patients with dementia and hospital staff, moments which occasionally allow staff to see the patients to be seen as the person they are. A rethinking of the current dementia discourse is discussed, recommending attention to the two-way interaction between patients with dementia and hospital staff, and within this an awareness of a personable approach.

Fundamental care for people with cognitive impairment in the hospital setting: A study combining positive organisational scholarship and video-reflexive ethnography

AIMS AND OBJECTIVES

To clarify how high-quality fundamentals of care for people with dementia and/or delirium were practised in a specialist geriatric evaluation and management unit.

BACKGROUND

Older people with cognitive impairment represent a significant number of people who are admitted to hospital. They are at increased risk of dying, readmission and long hospital stays, relative to those without cognitive impairment. There is an urgent need to elucidate the conditions that underpin safe and high-quality fundamental care for these patients and their families.

METHODS

Using the innovative methodologies of positive organisational scholarship in healthcare and video-reflexive ethnography, this 18-month study was conducted within an inpatient geriatric evaluation and management unit for people with dementia and/or delirium in South Australia. Patients, family members and staff members (managerial, clinical and nonclinical) participated by allowing researchers to document ethnographic fieldwork notes and film their practices and/or accounts thereof; and/or interpreting digital recordings with researchers in order to make sense of data in a process of co-analysis. This study is reported using Standards for Reporting Qualitative Research reporting guidelines.

RESULTS

High-quality fundamental care for people with dementia and/or delirium in hospital and their families was associated with the special space of the hospital unit; an aptitude for people with dementia; a capacity to translate person-centred fundamentals of care from rhetoric to reality; and an appreciation for teamwork.

CONCLUSION

This study clarified how teams working in hospital can practise high-quality fundamentals of care for older people with dementia and/or delirium. Delivery of high-quality fundamental care in this setting was dependent, not only on nurses, but the entire ward team working cohesively in a "weave of commitment."

RELEVANCE TO CLINICAL PRACTICE

Efforts to improve fundamental care for people with cognitive impairment need to encompass values and philosophy of person-centred care, including the contributions by all staff to care delivery.

The experience of hospital staff in applying the Gentle Persuasive Approaches to dementia care

WHAT IS KNOWN ON THE SUBJECT?: Although the seminal work of McCormack et al. (International Practice Development Journal, 2015, 5, 1) and Nolan, Davies, Brown, Keady, and Nolan () provides useful conceptual frameworks in person-centred care, research is needed to understand how theoretical concepts can be applied into practice to support dementia care. Also, evidence is needed to demonstrate the impacts of implementing person-centred care and staff experiences. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper adds to the emerging work that is providing a greater understanding of how team education in practice can make a difference in building capacity to improve dementia care. We offer timely evidence and useful insights into how an education programme, Gentle Persuasive Approaches (GPA), was implemented ("what worked" and "how") in a large Canadian hospital to improve knowledge and skills among staff in dementia care. The GPA education helped hospital staff enact person-centred care by cultivating shared values and a learning environment to change attitudes, practices and conditions for continuous practice development. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses in advance practice are well positioned to lead dementia education and advocate for person-centred care in hospitals. Hospital leaders are responsible for providing resources to cultivate a supportive environment for continuous learning to ensure the workforce gains the capacity to meet the changing demands and needs of the ageing population. System support is essential for creating conditions to enable person-centred care. ABSTRACT: Introduction Hospital staff lacks knowledge and skills in dementia care. There is a need to understand how person-centred care theory can be operationalized in staff's practices to improve dementia care. Aims To describe the staff's experiences of learning and applying the Gentle Persuasive Approaches (GPA) to enact person-centred care in a hospital. Methods Mixed methods, including posteducation survey and focus groups, were used. Thematic analysis was conducted to identify themes that describe participants' experiences. Results Three hundred and ten staff and leaders in a hospital participated in the GPA education and completed a posteducation survey (n = 297). After 1 year, two follow-up focus groups were conducted with interdisciplinary staff (n = 24) across medicine and mental health programmes. Our analysis identified three themes to enable person-centred care: (a) changing attitudes, (b) changing practices and (c) changing conditions. Discussion This study contributes to the literature by providing evidence of how an education programme was implemented in a large Canadian hospital to build capacity for dementia care. Joint education for interprofessional staff offers value in enabling person-centred care. Implication Mental health nurses are in position to lead dementia education and advocate for person-centred care in hospitals. Staff need structural support to engage in team learning for practice improvement.