BackgroundLogic models are commonly used in evaluations to represent the causal processes through which interventions produce outcomes, yet significant debate is currently taking place over whether they can describe complex interventions which adapt to context. This paper assesses the logic models used in healthcare research from a complexity perspective. A typology of existing logic models is proposed, as well as a formal methodology for deriving more flexible and dynamic logic models.AnalysisVarious logic model types were tested as part of an evaluation of a complex Patient Experience Toolkit (PET) intervention, developed and implemented through action research across six hospital wards/departments in the English NHS. Three dominant types of logic model were identified, each with certain strengths but ultimately unable to accurately capture the dynamics of PET. Hence, a fourth logic model type was developed to express how success hinges on the adaption of PET to its delivery settings. Aspects of the Promoting Action on Research Implementation in Health Services (PARIHS) model were incorporated into a traditional logic model structure to create a dynamic “type 4” logic model that can accommodate complex interventions taking on a different form in different settings.ConclusionLogic models can be used to model complex interventions that adapt to context but more flexible and dynamic models are required. An implication of this is that how logic models are used in healthcare research may have to change. Using logic models to forge consensus among stakeholders and/or provide precise guidance across different settings will be inappropriate in the case of complex interventions that adapt to context. Instead, logic models for complex interventions may be targeted at facilitators to enable them to prospectively assess the settings they will be working in and to develop context-sensitive facilitation strategies. Researchers should be clear as to why they are using a logic model and experiment with different models to ensure they have the correct type.Electronic supplementary materialThe online version of this article (10.1186/s12874-019-0701-4) contains supplementary material, which is available to authorized users.
Background 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. Methods 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. Results 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. Conclusions We found preliminary evidence that the intervention was well received and effective, but further research using a randomised controlled design will be necessary to confirm this.
Objectives: Despite decades of research, improving health care safety remains a global priority. Individual studies have demonstrated links between staff engagement and care quality, but until now, any relationship between engagement and patient safety outcomes has been more speculative. This systematic review and meta-analysis therefore assessed this relationship and explored if the way these variables were defined and measured had any differential effect. Methods: After systematic searches of Medline, CINAHL, PsycInfo, Embase, Cochrane Library, and National Institute for Health Research Journals databases, narrative and random-effects meta-analyses were completed, with pooled effect sizes expressed as Pearson r. Results: Fourteen studies met the inclusion criteria, 11 of which were suitable for meta-analysis. Meta-analyses indicated a small but consistent, statistically significant relationship between staff engagement and patient safety (all outcomes; 11 studies; r = 0.22; 95% confidence interval [CI], 0.07 to 0.36; n = 30,490) and 2 patient safety outcome categories: patient safety culture (7 studies; r = 0.22; 95% CI, 0.01 to 0.41; n = 27,857) and errors/adverse events (4 studies; r = −0.20; 95% CI, −0.26 to −0.13; n = 2633). The specific approach to conceptualizing engagement did not affect the strength of the findings. Conclusions: This is the first review to demonstrate a significant relationship between engagement and both safety culture scores and errors/ adverse events. Despite a limited and evolving evidence base, we cautiously conclude that increasing staff engagement could be an effective means of enhancing patient safety. Further research is needed to determine causality and clarify the nature of the staff engagement/patient safety relationship at individual and unit/workgroup levels.
Background Patients are increasingly being asked to provide feedback about their experience of health-care services. Within the NHS, a significant level of resource is now allocated to the collection of this feedback. However, it is not well understood whether or not, or how, health-care staff are able to use these data to make improvements to future care delivery. Objective To understand and enhance how hospital staff learn from and act on patient experience (PE) feedback in order to co-design, test, refine and evaluate a Patient Experience Toolkit (PET). Design A predominantly qualitative study with four interlinking work packages. Setting Three NHS trusts in the north of England, focusing on six ward-based clinical teams (two at each trust). Methods A scoping review and qualitative exploratory study were conducted between November 2015 and August 2016. The findings of this work fed into a participatory co-design process with ward staff and patient representatives, which led to the production of the PET. This was primarily based on activities undertaken in three workshops (over the winter of 2016/17). Then, the facilitated use of the PET took place across the six wards over a 12-month period (February 2017 to February 2018). This involved testing and refinement through an action research (AR) methodology. A large, mixed-methods, independent process evaluation was conducted over the same 12-month period. Findings The testing and refinement of the PET during the AR phase, with the mixed-methods evaluation running alongside it, produced noteworthy findings. The idea that current PE data can be effectively triangulated for the purpose of improvement is largely a fallacy. Rather, additional but more relational feedback had to be collected by patient representatives, an unanticipated element of the study, to provide health-care staff with data that they could work with more easily. Multidisciplinary involvement in PE initiatives is difficult to establish unless teams already work in this way. Regardless, there is merit in involving different levels of the nursing hierarchy. Consideration of patient feedback by health-care staff can be an emotive process that may be difficult initially and that needs dedicated time and sensitive management. The six ward teams engaged variably with the AR process over a 12-month period. Some teams implemented far-reaching plans, whereas other teams focused on time-minimising ‘quick wins’. The evaluation found that facilitation of the toolkit was central to its implementation. The most important factors here were the development of relationships between people and the facilitator’s ability to navigate organisational complexity. Limitations The settings in which the PET was tested were extremely diverse, so the influence of variable context limits hard conclusions about its success. Conclusions The current manner in which PE feedback is collected and used is generally not fit for the purpose of enabling health-care staff to make meaningful local improvements. The PET was co-designed with health-care staff and patient representatives but it requires skilled facilitation to achieve successful outcomes. Funding The National Institute for Health Research Health Services and Delivery Research programme.
Background: The National Health Service in England (NHSE) has introduced a new Structured Medication Review (SMR) service within forming Primary Care Networks (PCNs) during the COVID-19 pandemic. Policy drivers are addressing problematic polypharmacy, reducing avoidable hospitalisations and delivering better value from medicines spending. This paper explores early implementation of the SMR from the perspective of the primary care clinical pharmacist workforce. Aim: To identify factors affecting the early implementation of the SMR service. Design and setting: Qualitative interview study in general practice September 2020 to June 2021. Method: Two semi-structured interviews were carried out with 10 newly appointed pharmacists in 10 PCNs in Northern England; and one with 10 pharmacists already established in GP practices in 10 other PCNs across England. Audio-recordings were transcribed verbatim and a modified framework method supported a constructionist thematic analysis. Results: SMRs were not yet a PCN priority and SMR implementation was largely delegated to individual pharmacists, with those already in general practice appearing more ready for this. New pharmacists were on the primary care education pathway and drew on pre-existing practice frames, habits and heuristics. Those lacking in patient-facing expertise sought template driven, institution-centred, practice. Consequently, SMR practices reverted to prior medication review practices, compromising the distinct purposes of the new service. Conclusion: Early SMR implementation did not match the vision for patients presented in policy of an invited, holistic, shared-decision-making opportunity offered by well-trained pharmacists. There is an important opportunity cost of SMR implementation without prior adequate skills development, testing and refining.
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