Using FRAM to explore sources of performance variability in intravenous infusion administration in ICU: A non-normative approach to systems contradictions

Furniss, Dominic; Nelson, David; Habli, Ibrahim; White, Sarahlouise; Elliott, Matthew; Reynolds, Nick; Sujan, Mark

doi:10.1016/j.apergo.2020.103113

Cited by 26 publications

(52 citation statements)

References 24 publications

(34 reference statements)

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“…They also appreciated the importance of context-dependent adaptations (Safety-II) as a strategy for dealing with unexpected situations to ensure patient safety. This finding broadly supports the work of other studies demonstrating how adaptations are required in everyday work to provide safety improvements and resilience in the system [ 27 – 29 ]. It is imperative to highlight that the RHC concept has often been misconstrued, as adaptations have been regarded as being opposite to control, the implication being that the two cannot coexist [ 30 , 31 ].…”

Section: Discussionsupporting

confidence: 89%

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

Iflaifel

Lim

Crowley

et al. 2022

BMC Health Serv Res

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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.

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Section: Discussionsupporting

confidence: 89%

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

Iflaifel

Lim

Crowley

et al. 2022

BMC Health Serv Res

View full text Add to dashboard Cite

show abstract

“…The use of VRE allowed healthcare practitioners to recognise their personal roles and to appreciate the importance of context-dependent adaptations as a strategy for dealing with unexpected situations in ways ensuring patient safety. This nding broadly supports the work of other studies demonstrating how adaptations are required in everyday work to provide safety improvements and resilience in the system [35][36][37].…”

Section: Exploring the Use Of Vriiis Using Vre And Quantitative Datasupporting

confidence: 88%

Video Reflexive Ethnography Methodology to Explore the Use of Variable Rate Intravenous Insulin Infusions

Iflaifel

Lim

Crowley

et al. 2021

Preprint

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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, reflect on and thereby improve these. This study set out to explore the use of VRIII with VRE, a secondary aim being to describe VRE’s feasibility and acceptability. Methods: This study was conducted in a Vascular Surgery Unit. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records. Qualitative data were collected using VRE methodology. The latter involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting video-clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis and the quantitative data used to judge the outcomes of the video-observed tasks. Feasibility in relation to recruitment and data collection, as well as the acceptability of using VRE, were assessed based on participant responses during the study.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 (lack of knowledge of the appropriate medications to be prescribed with VRIII) and encouraged participants to suggest solutions (face-to-face, VRIII-focused training). The use of VRE was judged acceptable, based on the researcher’s interpretation of participants’ willingness to participate, and feasible, since all patients and 83% of the healthcare practitioners who were approached to participate agreed to do so. Conclusions: VRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. The use of VRE to explore VRIII in a single unit was judged feasible and acceptable. However, future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs.

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“…The method has been widely applied in many work fields (eg, aviation, railway and airway traffic management, and construction), but its implementation in healthcare research remains more limited. [36][37][38][39][40][41][42][43][44][45][46] Hence, this study aims to provide an overview of how ECS therapy is organised and to define suggestions for improvement using FRAM. It is the first step in developing a general cross-domain protocol to improve ECS therapy for patients with either DVT or CVI, matching daily practice, and in adherence to guidelines and scientific evidence.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Using the Functional Resonance Analysis Method to explore how elastic compression therapy is organised and could be improved from a multistakeholder perspective

et al. 2021

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ObjectivesElastic compression stocking (ECS) therapy is an important treatment for patients with deep venous thrombosis (DVT) and chronic venous insufficiency (CVI). This study aimed to provide insight into the structure and variability of the ECS therapy process, its effects on outcomes, and to elicit improvement themes from a multiple stakeholder perspective.DesignThirty semi-structured interviews with professionals and patients were performed. The essential functions for the process of ECS therapy were extracted to create two work-as-done models using the Functional Resonance Analysis Method (FRAM). These findings were used to guide discussion between stakeholders to identify improvement themes.SettingTwo regions in the Netherlands, region Limburg and region North-Holland, including an academic hospital and a general hospital and their catchment region.ParticipantsThe interviewees were purposely recruited and included 25 healthcare professionals (ie, general practitioners, internists, dermatologists, nurses, doctor’s assistants, occupational therapists, home care nurses and medical stocking suppliers) and 5 patients with DVT or CVI.ResultsTwo FRAM models were created (one for each region). The variability of the functions and their effect on outcomes, as well as interdependencies between functions, were identified. These were presented in stakeholder meetings to identify the structure of the process and designated variable and uniform parts of the process and its outcomes. Ultimately, six improvement themes were identified: dissemination of knowledge of the entire process; optimising and standardising initial compression therapy; optimising timing to contact the medical stocking supplier (when oedema has disappeared); improving the implementation of assistive devices; harmonising follow-up duration for patients with CVI; personalising follow-up and treatment duration in patients with DVT.ConclusionsThis study provided a detailed understanding of how ECS therapy is delivered in daily practice by describing major functions and variability in performances and elicited six improvement themes from a multistakeholder perspective.

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Using FRAM to explore sources of performance variability in intravenous infusion administration in ICU: A non-normative approach to systems contradictions

Cited by 26 publications

References 24 publications

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

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

Video Reflexive Ethnography Methodology to Explore the Use of Variable Rate Intravenous Insulin Infusions

Using the Functional Resonance Analysis Method to explore how elastic compression therapy is organised and could be improved from a multistakeholder perspective

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