Improvement Science Publications
Research papers published by our team
Authors - Alice Dunning, Gemma Louch, Angela Grange, Karen Spilsbury, Judith Johnson
Values are of high importance to the nursing profession. Value congruence is the extent to which an individual’s values align with the values of their organisation. Value congruence has important implications for job satisfaction.
This study explored nurse values, value congruence and potential implications for individual nurses and organisations in terms of wellbeing and patient care and safety.
Fifteen nurses who worked in acute hospital settings within the UK participated in semi-structured telephone interviews. Thematic analysis was utilised to analyse the data.
Four themes were identified: organisational values incongruent with the work environment; personal and professional value alignment; nurse and supervisor values in conflict; nurses’ values at odds with the work environment. Perceived value incongruence was related to poorer wellbeing, increased burnout and poorer perceived patient care and safety. The barriers identified for nurses being able to work in line with their values are described.
Value congruence is important for nurse wellbeing and patient care and safety. Improving the alignment between the values that organisations state they hold, and the values implied by the work environment may help improve patient care and safety and support nurses in practice.
Authors - Raabia Sattar, Rebecca Lawton, Maria Panagioti & Judith Johnson
Qualitative synthesis approaches are increasingly used in healthcare research. One of the most commonly utilised approaches is meta-ethnography. This is a systematic approach which synthesises data from multiple studies to enable new insights into patients’ and healthcare professionals’ experiences and perspectives. Meta-ethnographies can provide important theoretical and conceptual contributions and generate evidence for healthcare practice and policy. However, there is currently a lack of clarity and guidance surrounding the data synthesis stages and process.
This paper aimed to outline a step-by-step method for conducting a meta-ethnography with illustrative examples.
A practical step-by-step guide for conducting meta-ethnography based on the original seven steps as developed by Noblit & Hare (Meta-ethnography: Synthesizing qualitative studies.,1998) is presented. The stages include getting started, deciding what is relevant to the initial interest, reading the studies, determining how the studies are related, translating the studies into one another, synthesising the translations and expressing the synthesis.
We have incorporated adaptations and developments from recent publications. Annotations based on a previous meta-ethnography are provided. These are particularly detailed for stages 4–6, as these are often described as being the most challenging to conduct, but with the most limited amount of guidance available.
Meta-ethnographic synthesis is an important and increasingly used tool in healthcare research, which can be used to inform policy and practice. The guide presented clarifies how the stages and processes involved in conducting a meta-synthesis can be operationalised.
Authors - Claire Marsh, Rosemary Peacock, Laura Sheard, Rebecca Lawton
Listening and responding to patients is essential but healthcare organisations struggle to do this effectively. This article describes a project to create the six-step Yorkshire Patient Experience Toolkit, which supports teams to collect and use patients’ feedback to improve care. Six wards trialled the toolkit and found that, while it addressed complex patient needs, the teams needed skilled support and collaborative processes.
Citation: Marsh C et al (2021) Testing a toolkit that uses patient experience feedback to improve care. Nursing Times [online]; 117: 1, 39-43.
Authors: Claire Marsh is senior research fellow, Bradford Institute for Health Research; Rosemary Peacock is research fellow, School of Medicine, University of Leeds; Laura Sheard is associate professor, York Trials Unit; Rebecca Lawton is professor, Bradford Institute for Health Research; at the time of the research, all were at Bradford Institute for Health Research.
Authors - Judith Johnson, Ruth Simms-Ellis, Gillian Janes, Thomas Mills, Luke Budworth, Lauren Atkinson & Reema Harrison
Healthcare professionals are experiencing unprecedented levels of occupational stress and burnout. Higher stress and burnout in health professionals is linked with the delivery of poorer quality, less safe patient care across healthcare settings. In order to understand how we can better support healthcare professionals in the workplace, this study evaluated a tailored resilience coaching intervention comprising a workshop and one-to-one coaching session addressing the intrinsic challenges of healthcare work in health professionals and students.
The evaluation used an uncontrolled before-and-after design with four data-collection time points: baseline (T1); after the workshop (T2); after the coaching session (T3) and four-to-six weeks post-baseline (T4). Quantitative outcome measures were Confidence in Coping with Adverse Events (‘Confidence’), a Knowledge assessment (‘Knowledge’) and Resilience. At T4, qualitative interviews were also conducted with a subset of participants exploring participant experiences and perceptions of the intervention.
We recruited 66 participants, retaining 62 (93.9%) at T2, 47 (71.2%) at T3, and 33 (50%) at T4. Compared with baseline, Confidence was significantly higher post-intervention: T2 (unadj. β = 2.43, 95% CI 2.08–2.79, d = 1.55, p < .001), T3 (unadj. β = 2.81, 95% CI 2.42–3.21, d = 1.71, p < .001) and T4 (unadj. β = 2.75, 95% CI 2.31–3.19, d = 1.52, p < .001). Knowledge increased significantly post-intervention (T2 unadj. β = 1.14, 95% CI 0.82–1.46, d = 0.86, p < .001). Compared with baseline, resilience was also higher post-intervention (T3 unadj. β = 2.77, 95% CI 1.82–3.73, d = 0.90, p < .001 and T4 unadj. β = 2.54, 95% CI 1.45–3.62, d = 0.65, p < .001). The qualitative findings identified four themes. The first addressed the ‘tension between mandatory and voluntary delivery’, suggesting that resilience is a mandatory skillset but it may not be effective to make the training a mandatory requirement. The second, the ‘importance of experience and reference points for learning’, suggested the intervention was more appropriate for qualified staff than students. The third suggested participants valued the ‘peer learning and engagement’ they gained in the interactive group workshop. The fourth, ‘opportunities to tailor learning’, suggested the coaching session was an opportunity to personalise the workshop material.
Authors - Judith Johnson, Jane Arezina, Liz Tomlin, Siobhan Alt*, Jon Arnold, Sarah Bailey, Hannah Beety, Ruth Bender-Atik, Louise Bryant, Jen Coates, Sam Collinge, Jo Fishburn, Jane Fisher, Jan Fowler, Tracey Glanville, Julian Hallett, Ailith Harley-Roberts, Ailith Harley-Roberts, Gill Harrison, Karen Horwood, Catriona Hynes, Lindsay Kimm, Alison McGuinness, Lucy Potter, Liane Powell, Janelle Ramsay, Pieta Shakes, Roxanne Sicklen, Alexander Sims, Tomasina Stacey, Anushka Sumra, Samantha Thomas, Karen Todd, Jacquie Torrington, Rebecca Trueman, Lorraine Walsh, Katherine Watkins, Gill Yaz, Natasha K Hardicre
Studies indicate there is a need to improve the delivery of unexpected news via obstetric ultrasound, but there have been few advances in this area. One factor preventing improvement has been a lack of consensus regarding the appropriate phrases and behaviours which sonographers and ultrasound practitioners should use in these situations.
To develop consensus guidelines for unexpected news delivery in Early Pregnancy Unit and Fetal Anomaly Screening Programme NHS settings.
A workshop was conducted to identify priorities and reach consensus on areas of contention. Contributors included interdisciplinary healthcare professionals, policy experts, representatives from third-sector organisations, lay experts and academic researchers (n = 28). Written and verbal feedback was used to draft initial guidance which was then circulated amongst the wider writing group (n = 39). Revisions were undertaken until consensus was reached.
Consensus guidelines were developed outlining the behaviours and phrases which should be used during scans where unexpected findings are identified. Specific recommendations included that: honest and clear communication should be prioritised, even with uncertain findings; technical terms should be used, but these should be written down together with their lay interpretations; unless expectant parents use other terminology (e.g. ‘foetus’), the term ‘baby’ should be used as a default, even in early pregnancy; at the initial news disclosure, communication should focus on information provision. Expectant parents should not be asked to make decisions during the scan.
These recommendations can be used to develop and improve news delivery interventions in obstetric ultrasound settings. The full guidelines can be accessed online as supplemental material and at https://doi.org/10.5518/100/24.
Authors - Kristian G. Hudson, Rebecca Lawton & Siobhan Hugh-Jones
Preventing the onset of poor mental health in adolescence is an international public health priority. Universal, whole school preventative approaches are valued for their reach, and anti-stigmatising and resilience building principles. Mindfulness approaches to well-being have the potential to be effective when delivered as a whole school approach for both young people and staff. However, despite growing demand, there is little understanding of possible and optimal ways to implement a mindfulness, whole school approach (M-WSA) to well-being. This study aimed to identify the determinants of early implementation success of a M-WSA. We tested the capacity of the Consolidated Framework for Implementation Research (CFIR), to capture the determinants of the implementation of a mental health intervention in a school setting.
Key members of school staff (n = 15) from five UK secondary schools attempting to implement a M-WSA were interviewed at two-time points, 6 months apart, generating a total of 30 interviews. Interviews explored participants’ attitudes, beliefs and experiences around implementing a M-WSA. Interview data were coded as CFIR constructs or other (non CFIR) factors affecting implementation. We also mapped school-reported implementation activity and perceived success over 30 months.
The CFIR captured the implementation activities and challenges well, with 74% of CFIR constructs identifiable in the dataset. Of the 38 CFIR constructs, 11 appeared to distinguish between high and low implementation schools. The most essential construct was school leadership. It strongly distinguished between high and low implementation schools and appeared inter-related with many other distinguishing constructs. Other strongly distinguishing constructs included relative priority, networks and communications, formally appointed implementation leaders, knowledge and beliefs about the intervention, and executing.
Our findings suggest key implementation constructs that schools, commissioners and policy makers should focus on to promote successful early implementation of mental health programs. School leadership is a key construct to target at the outset. The CFIR appears useful for assessing the implementation of mental health programs in UK secondary schools.
Authors - Raabia Sattar, Judith Johnson, Clin, Rebecca Lawton PhD
To synthesize the literature on the views and experiences of patients/family members and health-care professionals (HCPs) on the disclosure of adverse events.
Systematic review of qualitative studies. Searches were conducted in MEDLINE, Embase, PubMed, CINAHL and PsycINFO. Study quality was evaluated using the Critical Appraisal Skills Programme tool. Qualitative data were analysed using a meta-ethnographic approach, comprising reciprocal syntheses of ‘patient’ and ‘health-care professional’ studies, combined to form a lines-of-argument synthesis embodying both perspectives.
Fifteen studies were included in the final syntheses. The results highlighted that there is a difference in attitudes and expectations between patients and HCPs regarding the disclosure conversation. Patients/family members expressed a need for information, the importance of sincere regret and a promise of improvement. However, HCPs faced several barriers, which hindered appropriate disclosure practices. These included difficulty of disclosure in a blame culture, avoidance of litigation, lack of skills on how to conduct disclosure and inconsistent guidance. A lines-of-argument synthesis is presented that identified both the key elements of an ideal disclosure desired by patients and the facilitators for HCPs, which can increase the likelihood of this taking place.
Although patients/family members and HCPs both advocate disclosure, several barriers prevent HCPs from conducting disclosure effectively. Both groups have different needs for disclosure. To meet patients’ requirements, training on disclosure for HCPs and the development of an open, transparent culture within organizations are potential areas for intervention.
Authors - Siobhan Kathleen McHugh, Rebecca Lawton, Jane Kathryn O'Hara, Laura Sheard
Background Teamwork and communication are recognised as key contributors to safe and high-quality patient care. Interventions targeting process and relational aspects of care may therefore provide patient safety solutions that reflect the complex nature of healthcare. Team reflexivity is one such approach with the potential to support improvements in communication and teamwork, where reflexivity is defined as the ability to pay critical attention to individual and team practices with reference to social and contextual information.
To systematically review articles that describe the use of team reflexivity in interprofessional hospital-based healthcare teams.
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six electronic databases were searched to identify literature investigating the use of team reflexivity in interprofessional hospital-based healthcare teams.
includes articles investigating the use of team reflexivity to improve teamwork and communication in any naturally occurring hospital-based healthcare teams. Articles’ eligibility was validated by two second reviewers (5%).
Fifteen empirical articles were included in the review. Simulation training and video-reflexive ethnography (VRE) were the most commonly used forms of team reflexivity. Included articles focused on the use of reflexive interventions to improve teamwork and communication within interprofessional healthcare teams. Communication during interprofessional teamworking was the most prominent focus of improvement methods. The nature of this review only allows assessment of team reflexivity as an activity embedded within specific methods. Poorly defined methodological information relating to reflexivity in the reviewed studies made it difficult to draw conclusive evidence about the impact of reflexivity alone.
The reviewed literature suggests that VRE is well placed to provide more locally appropriate solutions to contributory patient safety factors, ranging from individual and social learning to improvements in practices and systems.
Authors - Judith Johnson, Tmam Abdulaziz Al-Ghunaim, Chandra Shekhar Biyani, Anthony Montgomery, Roland Morley & Daryl B. O’Connor
Surgical disciplines are popular and training places are competitive to obtain, but trainees report higher levels of burnout than either their non-surgical peers or attending or consultant surgeons. In this review, we critically summarise evidence on trends and changes in burnout over the past decade, contributors to surgical trainee burnout, the personal and professional consequences of burnout and consider the evidence for interventions. There is no evidence for a linear increase in burnout levels in surgeons over the past decade but the impact of the COVID-19 pandemic has yet to be established and is likely to be significant. Working long hours and experiencing stressful interpersonal interactions at work are associated with higher burnout in trainees but feeling more supported by training programmes and receiving workplace supervision are associated with reduced burnout. Burnout is associated with poorer overall mental and physical well-being in surgical trainees and has also been linked with the delivery of less safe patient care in this group. Useful interventions could include mentorship and improving work conditions, but there is a need for more and higher quality studies.
Authors - Gemma Louch, Caroline Reynolds, Sally Moore, Claire Marsh, Jane Heyhoe, Abigail Albutt, Rebecca Lawton
Objectives There is growing evidence that patients can provide feedback on the safety of their care. The 44-item Patient Measure of Safety (PMOS) was developed for this purpose. While valid and reliable, the length of this questionnaire makes it potentially challenging for routine use. Our study aimed to produce revised, shortened versions of PMOS (PMOS-30 and PMOS-10), which retained the psychometric properties of the longer version.
To produce a shortened diagnostic measure, we analysed data from 2002 patients who completed PMOS-44, and examined the reliability of the revised measure (PMOS-30) in a sample of 751 patients. To produce a brief standalone measure, we again analysed data from 2002 patients who completed PMOS-44, and tested the reliability and validity of the brief standalone measure (PMOS-10) in a sample of 165 patients.
The process of shortening the questionnaire involved a combination of secondary data analysis (eg, Standard Deviation and inter-item correlations) and a consensus group exercise to produce PMOS-30 and examine face validity. Analysis of PMOS-30 data examined reliability (eg, Cronbach’s alpha). Further secondary data analysis (ie, corrected item-total correlations) produced PMOS-10, and primary data collection assessed its reliability and validity (eg, Cronbach’s alpha, analysis of variance).
Fourteen items were removed to produce PMOS-30 and the percentage of negatively worded items was reduced from 57% to 33%. PMOS-30 demonstrated good internal reliability (α=0.89). The 10 items with the highest corrected item-total correlations across both PMOS-44 and PMOS-30 composed PMOS-10. PMOS-10 had good internal reliability (α=0.79), demonstrated convergent validity; however, discriminant validity was not established.
Two revised, shortened versions of the original PMOS-44 (PMOS-30 and PMOS-10) were produced to capture patient feedback about safety in hospital. The measures demonstrated good reliability and validity, and preserved the psychometric properties of the original measure.
Authors - Lesley Hughes, Laura Sheard, Lisa Pinkney, Rebecca L Lawton
Implicit racial bias is a persistent and pervasive challenge within healthcare education and training settings. A recent systematic review reported that 84% of included studies (31 out of 37) showed evidence of slight to strong pro-white or light skin tone bias amongst healthcare students and professionals. However, there remains a need to improve understanding about its impact on healthcare students and how they can be better supported. This narrative review provides an overview of current evidence regarding the role of implicit racial bias within healthcare education, considering trends, factors that contribute to bias, and possible interventions. Current evidence suggests that biases held by students remain consistent and may increase during healthcare education. Sources that contribute to the formation and maintenance of implicit racial bias include peers, educators, the curriculum, and placements within healthcare settings. Experiences of implicit racial bias can lead to psychosomatic symptoms, high attrition rates, and reduced diversity within the healthcare workforce. Interventions to address implicit racial bias include an organizational commitment to reducing bias in hiring, retention, and promotion processes, and by addressing misrepresentation of race in the curriculum. We conclude that future research should identify, discuss, and critically reflect on how implicit racial biases are enacted and sustained through the hidden curriculum and can have detrimental consequences for racial and ethnic minority healthcare students.