Assessing the Impact of a Transforming Care Initiative in the Australian Context
Sarah Elizabeth Ann Burston
RN, BSc(Hons), MSc
School of Nursing and Midwifery,
Griffith Health
Griffith University
A thesis submitted for the award of the degree of
Doctor of Philosophy
January 2015
i
Abstract
Hospitalised patients experience harm as a consequence of adverse events,
including inpatient falls and hospital-acquired pressure ulcers. Nurses are
attempting to address this situation with the development of international
initiatives aimed at improving the safety and quality of nursing care. Evidence to
support the implementation of these initiatives is limited, yet widespread
implementation continues.
The aim of this study was to understand the implementation, impact and
sustainment of an initiative to transform nursing care in four acute medical-
surgical units. The focus of the initiative was to provide a patient centred
framework to improve the safety and quality of nursing care. A number of
interventions were implemented such as clinical bedside handover and rounding.
This study was conducted in two phases. Phase One used a non-equivalent
control group design with historical controls and an uncontrolled interrupted time
series. More than 10,000 patients discharged between July 2008 and December
2010 were included. Patients discharged during the initial three months of
implementation, were excluded. Two nurse-sensitive indicators were used as
outcome measures; inpatient falls and hospital-acquired pressure ulcers. Coded
administrative data were analysed using statistical process control to identify
changes in the nurse-sensitive indicators over time. Phase Two used an
interpretive approach to explore the implementation and sustainability of the
initiative as perceived by nurses involved in the implementation and still working
at the study site. Interviews were conducted with eight Registered Nurses. The
ii
interviews were transcribed and analysed using an inductive content analysis
approach.
Phase One findings demonstrated improvement in the proportion of
patients experiencing an inpatient fall in one surgical and one medical unit. No
improvement was noted in the remaining two units for inpatient falls or in the
proportion of patients acquiring pressure ulcers in any of the four study units.
Improvement in the nurse-sensitive indicators was therefore not consistent across
all four study units.
Phase Two findings established that nurses perceived that the transforming
care initiative had been successfully implemented and sustained. Six main
categories were derived from participant responses, representing factors perceived
to have influenced the implementation and sustainability of the initiative. These
categories were; Engaging the whole team, Shifting culture, Rolling transforming
care out, Leading the change to transforming care, Seeing the change and
Entrenching new ways of working. The conceptualisation of these factors
generated the ‘4Ps Model of Sustained Implementation of a New Model of
Nursing Care’, within four domains; people, process, product and place.
Recommendations for nursing practice, education and research are
discussed. With regard to nursing practice, utilising a model such as the ‘4P’s’ to
guide implementation of new models of nursing care, is recommended. This
would aide nurses seeking to improve the safety and quality of patient care by
promoting consideration of salient factors prior to implementation. With regard to
education, opportunities that promote teamwork and interdisciplinary
iii
communication may be beneficial. In addition, nurses need the opportunity to
share their experience and learn from one another, and a ’Community of Practice’
may meet this need. Finally, high quality research remains limited in regard to the
effectiveness of transforming care initiatives and further research would help to
secure the benefits of such programmes and generate support. A prospective
cluster trial could be undertaken to assist in demonstrating effectiveness.
Additionally, conducting a comprehensive process evaluation may provide a more
detailed understanding of implementation and guide future initiatives. Empirical
testing and refinement of the conceptual model is also recommended to gain a
better understanding of four domains and their intra- and inter-relationships.
This study was set against a background of growing awareness of the
need to improve the safety and quality of nursing care. Despite an inconsistent
relationship between transforming care and nurse-sensitive indicators, nurses
perceived that there were benefits for patients and staff. Nurses should continue to
seek to improve the safety and quality of patient care and invest in initiatives such
as transforming nursing care.
iv
Statement of Originality
This work has not previously been submitted for a degree or diploma in any university.
To the best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made in the thesis
itself.
(Signed)_____________________________
Sarah Burston
v
Table of Contents
Abstract ................................................................................................................................ i
Statement of Originality ..................................................................................................... iv
List of Illustrations ........................................................................................................... viii
Acknowledgement of Papers included in this Thesis and Extent of Assistance ................ ix
Acknowledgement of Grants Awarded and Presentations ................................................. xi
Acknowledgements ........................................................................................................... xii
CHAPTER 1 ....................................................................................................................... 1
Introduction ......................................................................................................................... 1
1.1 Introduction ............................................................................................................... 1
1.2 Background ............................................................................................................... 2
1.3 Aim of the Study ....................................................................................................... 7
1.4 Significance............................................................................................................... 7
1.5 Overview of the Thesis Structure ............................................................................ 12
1.6 Summary ................................................................................................................. 14
CHAPTER 2 ..................................................................................................................... 15
Literature Review .............................................................................................................. 15
2.1 Statements of Contribution to Co-authored Papers ................................................. 15
2.2 Introduction ............................................................................................................. 17
2.3 Contemporary Approaches to Transforming Care .................................................. 17
2.4 Nurse-sensitive Indicators to Measure Nursing Care Quality ................................. 33
2.5 Implementing New Practices into Nursing ............................................................. 50
2.6 Summary ................................................................................................................. 58
CHAPTER 3 ..................................................................................................................... 59
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Method .............................................................................................................................. 59
3.1 Introduction ............................................................................................................. 59
3.2 Research Questions ................................................................................................. 59
3.3 Setting ..................................................................................................................... 60
3.4 Transforming Care Initiative ................................................................................... 60
3.5 Phase One: Relationship between Transforming Care and Nurse-sensitive
Indicators ...................................................................................................................... 65
3.6 Phase Two: Perceptions of the Impact and Sustainability of the Transforming Care
Initiative ........................................................................................................................ 76
3.7 Ethical Consideration .............................................................................................. 85
3.8 Summary ................................................................................................................. 87
CHAPTER 4 ..................................................................................................................... 89
Phase One Results ............................................................................................................. 89
4.1 Statement of Contribution to Co-authored Published Paper ................................... 89
4.2 Introduction ............................................................................................................. 90
4.3 The Relationship between the Transforming Care Initiative and Nurse-sensitive
Indicators in Two Surgical Units .................................................................................. 90
4.4 The Relationship between a Transforming Care Initiative and Nurse-sensitive
Indicators in Two Medical Units (Paper 4) ................................................................. 105
4.5 Summary ............................................................................................................... 126
CHAPTER 5 ................................................................................................................... 128
Phase Two Findings ........................................................................................................ 128
5.1 Introduction ........................................................................................................... 128
5.2 Implementation and Sustainment of a Local Transforming Care Initiative: People,
Process and Product (Paper 5) .................................................................................... 128
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5.3 Summary ............................................................................................................... 156
CHAPTER 6 ................................................................................................................... 159
Discussion ....................................................................................................................... 159
6.1 Introduction ........................................................................................................... 159
6.2 Summary of Findings ............................................................................................ 159
6.3 People .................................................................................................................... 161
6.4 Process .................................................................................................................. 165
6.5 Product .................................................................................................................. 174
6.6 Place ...................................................................................................................... 177
6.7 Limitations of the Study ........................................................................................ 179
6.8 Recommendations for Nursing Practice, Education and Research ....................... 182
6.9 Conclusion ............................................................................................................ 191
REFERENCES ............................................................................................................... 193
APPENDIX A ................................................................................................................. 238
Participant Information Sheet ......................................................................................... 238
APPENDIX B: ................................................................................................................ 239
Participant Consent Form ............................................................................................... 239
APPENDIX C ................................................................................................................. 241
Interview Schedule .......................................................................................................... 241
APPENDIX D ................................................................................................................. 242
Audit Trail-Subcategory Adapting Transforming Care to Context ................................ 242
viii
List of Illustrations
Tables
Table 1 Nursing Profile of Study Units ............................................................................ 60
Table 2 Interventions Implemented Initially in Each Unit ................................................ 64
Table 3 Coding Variables ................................................................................................. 71
Table 4 Summary of Improvement of NSIs .................................................................... 126
Figures
Figure 1. Time Series Data-points .................................................................................... 65
Figure 2 The 4P’s’ Model of Sustained Implementation of a New Model of Nursing Care
........................................................................................................................................ 178
ix
Acknowledgement of Papers included in this Thesis and Extent of
Assistance
ALL PAPERS INCLUDED ARE CO-AUTHORED
Included in this thesis are papers in Chapters 2, 4 and 5 which are co-
authored with other researchers. My contribution to each co-authored paper is
outlined at the front of the relevant chapter. The bibliographic details (if published
or accepted for publication) and status (if prepared or submitted for publication)
for these papers including all authors, are:
Chapter 2:
• Burston, S., Chaboyer, W., Wallis, M. & Stanfield, J. (2010). A discussion
of approaches to transforming care: Contemporary strategies to improve
patient safety. Journal of Advanced Nursing, 67(11), 2488-2495.
• Burston, S., Chaboyer, W. & Gillespie, B. (2014). Nurse-sensitive
indicators to reflect nursing care quality: A review and discussion of the
issues. Journal of Clinical Nursing, 23(13-14), 1785-1795.
Chapter 4:
• Burston, S., Chaboyer, W., Gillespie, B. & Carroll, R. (2014). The effect
of a transforming care initiative on patient outcomes in acute surgical
units: A time series study. Journal of Advanced Nursing, Advance online
publication doi:10.1111/jan.12508
• Burston, S., Gillespie, B. & Chaboyer, W. (2014). The relationship
between a transforming care initiative and nurse-sensitive indicators in
two medical units. International Journal of Nursing Practice, submitted
for review.
Chapter 5
• Burston, S., Gillespie, B. & Chaboyer, W. (2014). Implementation and
x
sustainment of a local transforming care initiative: People, process, product
and place. Prepared for submission.
Appropriate acknowledgements of those who contributed to the research but
did not qualify as authors are included in each paper.
(Signed) _________________________________ (Date) ______________
Sarah E A Burston
(Countersigned) ___________________________ (Date) ______________
Supervisor: Professor Wendy Chaboyer
xi
Acknowledgement of Grants Awarded and Presentations
Grants
2009 Queensland Health Research Grant awarded by Office of the Chief Nurse,
$9,588
2013 Joyce Wickham Memorial Grant awarded by Australian College of Nursing
$5,000
Presentation of study
Burston, S., Chaboyer, W., Gillespie, B. & Carroll, R. (2013). The effects of a
transforming care initiative on nurse-sensitive indicators in acute surgical units: a
time series study. RCN Annual International Nursing Research Conference, 20-
22 March Belfast, poster presentation.
xii
Acknowledgements
The completion of this thesis reflects the support and guidance I have been
fortunate to receive whilst on my PhD journey. I would like to acknowledge the
amazing support of my supervisors, Professor Wendy Chaboyer and Associate
Professor Brigid Gillespie. Their supervision and encouragement has been
instrumental in completing this study and their belief in my capability, kept me
going. I would also like to acknowledge the supervision of Professor Marianne
Wallis in the early stages of my degree. A special thanks is also owed to my
manager Lyn. The opportunity to be able to focus full time on the thesis in the
final few months was only possible due to her support. I am fortunate to have such
a wonderful mentor.
I also thank all my friends and colleagues who always showed interest in the study
and enquired how I was going, not a question it was always easy to respond to. I
also acknowledge the staff involved in the initiative and their support of this study
and willingness to participate.
Finally, I acknowledge the huge debt I owe my husband Ken for his patience,
support and endless cups of tea. His belief that I would complete the thesis and
constant encouragement kept me going and helped me maintain some perspective.
1
CHAPTER 1
Introduction
1.1 Introduction
Hospitalised patients are experiencing serious adverse events (D'Amour,
Dubois, Tchouket, Clarke, & Blais, 2014; de Vries, Ramrattan, Smorenburg,
Gouma, & Boermeester, 2008). Awareness of this situation was crystallised into
action over a decade ago following two key reports: ‘To Err is Human’ and
‘Crossing the Quality Chasm’ (Institute of Medicine, 1999, 2001). Yet, despite a
proliferation of international programs and partnerships, the safety and quality of
patient care continues to generate concern, requiring further investigation.
This two phase study examined the impact and sustainability of a local
transforming nursing care (transforming care) initiative that aimed to improve the
safety, quality and patient focus of inpatient nursing care. It was based on two
similar approaches: Transforming Care at the Bedside (TCAB) (Institute of
Healthcare Improvement, 2012a) and the Releasing Time to Care: The Productive
Ward™ (The Productive Ward) (National Health Service [NHS] Institute for
Innovation and Improvement, 2012). The impact of this initiative on nurse-
sensitive indicators (NSIs), and sustainment of the initiative in acute medical-
surgical units was studied using both quantitative and qualitative methods. This
study was undertaken because there was a lack of evidence regarding the
implementation and impact of transforming care initiatives in the Australian
context. Through understanding how this initiative was implemented and
sustained and its impact, there is the potential to inform new nursing strategies to
improve patient care and outcomes in the future.
2
1.2 Background
1.2.1 Hospitalised Patients Experience Adverse Events
Improving patient safety has been on the international and national agenda
for over a decade. An adverse event has been defined as an “unintentional injury
that resulted in temporary or permanent disability or death and that was
associated with healthcare management rather than the underlying disease
process” (Wilson et al., 2012). Drawing on the results of eight international key
studies published between 1991 and 2006 from the United States of America
(US), Australia, United Kingdom (UK), New Zealand and Canada, a systematic
review reported that 9.2% of patients experienced hospital adverse events (de
Vries et al., 2008). A more recent study of 11,379 patients in 58 acute care
hospitals across five Latin-American countries reported that 10.5% of patients
(adult and paediatric) experienced an adverse event (Aranaz-Andrés et al., 2011).
In addition, a study undertaken in Africa and the Middle East of 15,548 patient
medical records from 26 hospitals identified that 8.2% had experienced at least
one adverse event (Wilson et al., 2012). Most recently, a Canadian study
quantified the risk of medical patients experiencing at least one of six nursing-
related adverse events as one in seven (D'Amour et al., 2014). These studies
demonstrate that patients continue to experience adverse events. There are various
causes of these adverse events and the consequences for both patients and
organisations can be extremely serious.
The consequences of these adverse events for the patient can range from
no disability to permanent disability or death. Adverse events in healthcare have
been estimated to be responsible for 44,000 to 98,000 accidental deaths each year
in hospital in the US (Institute of Medicine, 1999). Further, adverse events have
3
been related to the death of a patient through a causal relationship in 5.8% to 30%
of cases (Aranaz-Andrés et al., 2011; de Vries et al., 2008; Wilson et al., 2012).
Alarmingly, it has been estimated that 43.5% to 83% (median percentage) of these
adverse events were potentially preventable (Aranaz-Andrés et al., 2011; de Vries
et al., 2008; Wilson et al., 2012). In a study of 1,000 adult deaths across 10 UK
hospitals, 5.2% were judged to have had a 50% chance or greater of being
prevented (Hogan et al., 2012). Although smaller than other estimates, the burden
of harm from preventable adverse events remains substantial (Hogan et al., 2012).
For healthcare providers and governments these adverse events can prove
costly. The associated cost of these adverse events to the Australian national
hospital expenditure has been estimated at $2 billion per year (Ehsani, Jackson, &
Duckett, 2006). An extrapolated cost of US $4.4 billion per year was calculated
for Medicare beneficiaries for 2009, in the US (Department of Health and Human
Services: Office of the Inspector General, 2010). Clearly, the estimates of costs
will depend on the methodology used to identify adverse events but they are
substantial.
1.2.2 Initiatives to Improve Patient Safety and Quality Implemented
A leading international organisation has identified six quality domains for
improvement of health care systems: safety, effectiveness, patient centredness,
timeliness, efficiency and equity (Institute of Medicine, 2001). To address these
domains, healthcare agencies are developing initiatives to drive the safety and
quality agenda in healthcare. Through collaborative partnerships these priorities
set the agenda, set standards, identify solutions and identify suitable consistent
measures.
4
The World Health Organisation (WHO), with two initiatives has helped to
prioritise the safety of patient care. The WHO ‘High 5’ program was focused on
reducing the frequency of five challenging patient safety problems (WHO, 2014).
Seven countries were involved, including US, Australia and Germany and aimed
to implement and evaluate standardised solutions to patient safety issues. Two
standardised operating protocols have been developed: medical accuracy at
transition of care and correct procedures at the correct body site. In 2005, a World
Alliance for Patient Safety comprising the WHO, The Joint Commission and Joint
Commission International, launched the ‘Nine Patient Safety Solutions’ project
(WHO, 2007). It was aimed at good process design being used to prevent
potential human error reaching the patient. Solutions were to promote an
environment and support system to minimise risk of harm. The nine solutions
were to address, among others, look-alike sound-alike medication names, patient
identification and communication during patient handover.
Nationally, healthcare standards are being used to drive the safety and
quality agenda. Ten National Quality and Safety Healthcare Standards (NQSHS),
have been developed by the Australian Commission on Safety and Quality in
Health Care (Australian Commission on Safety and Quality in Health Care),
2011). These reflect some of the themes of the WHO priorities such as medication
safety, patient identification and clinical handover. These standards have been
incorporated into the Australian hospital accreditation scheme.
To demonstrate performance against standards, measures are required.
The challenge is identifying comparable measures. In the US the National Quality
Forum (NQF) plays an important role in identifying measures for patient safety
5
nationally, and facilitates the development of measures to provide uniformity and
promote comparison for public reporting. The NQF developed reportable
measures, Serious Reportable Events (SRE) in Healthcare, which now total 29
(National Quality Forum (NQF), 2011). These SREs are serious, largely
preventable and of concern to the public and healthcare providers. Examples
include surgical events such as wrong body site, care management events such as
medication errors and patient death or severe disability due to a fall (NQF, 2011).
Again, these measures reflect some of the WHO priorities. Development of
international and national programs to improve the safety and quality of
healthcare provide evidence that concerns have been recognised and action is
being taken.
1.2.3 Nurses’ Efforts to Improve Patient Safety and Quality
Nurses are striving to improve the safety and quality of patient care by
implementing nurse-led initiatives, whilst working in challenging environments.
Two such initiatives reflecting international safety and quality priorities have been
implemented; Transforming Care at the Bedside (TCAB), in 2003 in the US
(Institute of Healthcare Improvement, 2012a) and Releasing Time to Care: The
Productive Ward™ (The Productive Ward), in 2007 in the UK (NHS Institute for
Innovation and Improvement, 2012). Additionally, the profession has been
identifying and using NSIs to measure the impact of nursing care on a global scale
(American Nurses Association (ANA), 2012; Collaborative Alliance for Nursing
Outcomes (CALNOC), 2014; VanDeVelde-Coke et al., 2012). Examples of NSIs
include hospital-acquired pressure ulcers (HAPU), falls and infection rates. The
development of indicators has been informed by studies exploring the
relationships between nursing structural, process and outcome variables (Aiken et
al., 2014; Hyang Yuol, Blegen, & Harrington, 2014; Van Bogaert, Kowalski,
6
Weeks, Van Heusden, & Clarke, 2013). The findings of these and similar studies
attempt to demonstrate the influence of nursing care on patient outcomes but have
not been consistent (Burston, Chaboyer, & Gillespie, 2014). These initiatives are
being introduced by a profession facing many challenges that reflects the context
in which nurses work.
Several challenges for the nursing profession have intensified in recent
years. These include the increased demands of caring for an ageing population,
burdensome documentation requirements, increasing acuity on medical-surgical
wards, high nursing turnover, developments in technology and meeting quality
improvement requirements (Duffield et al., 2007; Needleman, 2013; Rutherford,
Moen, & Taylor, 2009). This suggests that the nursing workforce itself is under
stress. In addition, the workforce is ageing with the number of nurses aged 50
years and older increasing from 35.1% in 2008 to 39.1 % in 2012, maintaining a
consistent trend (Australian Institute of Health and Welfare, 2013). The already
stressed workforce therefore faces the added burden of future shortages as these
older nurses retire. The negative consequences of a challenging work environment
and the resulting sub-optimal nursing care have been publicised in a report into
the failings of a UK public hospital (The Mid Staffordshire NHS Foundation Trust
Public Inquiry, 2013). The report demonstrated that nurses are assumed to
contribute to patient outcomes and explicated the cultural environment the nurses
were working in. This was exemplified by the poor communication between the
board and ward staff (Royal College of Nursing, 2013). Working in this complex
environment, nurses are still responding to the need to address safety and quality
of care concerns by supporting these new initiatives.
7
1.3 Aim of the Study
The aim of this study was to understand the implementation, impact and
sustainment of an initiative to transform nursing care in one institution. To
achieve this, the study was conducted in two phases. First, the impact of the
initiative on two NSIs were examined. This first phase was quantitative and used a
time series design with non-equivalent historical controls. Second, this study
explored the perceptions of nurses involved in implementing and sustaining the
initiative. The second phase used an interpretive design. Interviews were
conducted with nurses who had been involved in the implementation. Specifically
this study:
1. Assessed the relationship between transforming care and two nurse-
sensitive indicators in hospitalised medical-surgical patients: inpatient
falls and hospital-acquired pressure ulcers (HAPU), and
2. Explored and described the implementation and sustainability of the
transforming care initiative.
The results provide insight and assists healthcare leaders and clinical staff
striving to improve the safety and quality of patient care with regard to
implementing and sustaining improvement strategies.
1.4 Significance
This study is significant to nursing for three reasons. First, by gaining a
better understanding of the process of implementating a transforming care
initiative over a period of time, there is the potential to discover the factors that
influenced its sustainment to guide nurses in future improvement initiatives.
8
Second, by deepening the understanding of leadership activities undertaken to
implement quality improvement initiatives, this study can identify areas for the
professional development and education of nurses. This will assist nurses tasked
with leading or participating in implementing change. Lastly, by providing
evidence of the effectiveness of the implementation of a transforming care
initiative, this study can guide nurses when implementing similar initiatives to
improve patient outcomes. Each of these are expanded on in the following
sections.
1.4.1 The Process of Implementation
This study is significant as it will improve the safety and quality of nursing
care by promoting a better understanding of the process of implementing a
transforming care initiative and its sustainment. The study identifies factors that
influenced implementation and sustainability and will therefore be beneficial to
nurses seeking to implement similar initiatives. Initiatives to improve the safety
and quality of healthcare are constantly being introduced and promoted. It is
important to evaluate the impact of these initiatives to guide future quality
improvement activities.
An evaluation framework will assist in this endeavour by providing
guidance on what to examine and in what ways. Donabedian (1966, 1988)
proposed a framework to evaluate the quality of health service delivery. It
identifies three domains: structure, process and outcomes. This framework
provides guidance to this study examining the implementation and sustainment of
a transforming care initiative. The model has been criticised as being too linear,
lacking consideration for organisational attributes and the substitution of structure
and processes with resources and activities (Eggli & Halfon, 2003; Glickman,
9
Baggett, Krubert, Peterson, & Schulman, 2007; Mitchell, Ferketich, & Jennings,
1998). Yet its simplicity and ease of application ensures it remains an accepted
and commonly used model in nursing. Donabedian’s framework has helped to
elucidate the relationship between the attributes of nurses providing the care
(structure), the interventions of those nurses (process) and the outcomes for their
patients. Peak nursing bodies such as the American Nurses Association have
grounded their work in developing NSIs on this framework and it has been
consistently used to guide nursing research (Doran, 2011; Gallagher & Rowell,
2003).
This study reflects the three domains of Donabedian’s framework. The
process and outcome factors were explored in Phase One and were related to the
implementation of the transforming care initiative and two NSIs: inpatient falls
and HAPU. In Phase Two, structural and process factors were explored in relation
to the perceptions of nurses who implemented and sustained the initiative such as
the administration of the initiative including the leadership strategy and resources.
The use of this framework to review relevant factors can assist in identifying
whether further improvement is required. By identifying the challenges and
developing recommendations regarding the implementation of the initiative, this
study assists the sustainment of future initiatives to improve the safety and quality
of nursing care.
1.4.2 Leadership Activities to Implement Change
This research is significant because it provides a better understanding of
the leadership activities of nurses implementing initiatives to improve nursing
care safety and quality. Leadership has been identified as one of five factors that
influence the sustainability of health-related change programmes (Scheirer, 2005).
10
Access to further information on the leadership activities required of nurses
participating in quality improvement initiatives in the Australian context, may
assist future nurses tasked with this challenge.
The leadership requirements of implementing and sustaining change have
been highlighted in case reports and research studies of TCAB and The
Productive Ward undertaken in the US and UK (Armitage & Higham, 2011;
Parkerton et al., 2009). Requirements such as organising teams, engaging frontline
staff and developing staff skills for both nursing leaders and frontline staff were
recognised. In addition, the leadership style and the actions of leaders to spread
and sustain change were aspects of leadership concluded to be important in the
implementation and impact of The Productive Ward in the UK (Morrow, Robert,
& Maben, 2014). A strong link has also been identified between sustainability and
the leadership skills and qualities of the nurse leader at unit level (Clarke &
Marks-Maran, 2014). Nurse Managers who find themselves implementing
practice changes are not always educationally prepared to fulfil such a leadership
role with good leadership not a requirement for management (Salter, Green, Ree,
Carmody-Bubb, & Duncan, 2009). This study contributes to the understanding of
the leadership activities required of nurses participating in quality improvement
initiatives. The study takes an inductive approach to advancing knowledge of
clinical nursing leadership activities required to implement change.
1.4.3 Improving Patient Outcomes
Finally, this study is significant because it provides evidence of the
benefits of the implementation of a transforming care initiative for nurses seeking
to improve patient outcomes. The study identifies whether the approach has been
effective in the Australian context. This will assist in guiding further improvement
11
activities, informing nurses seeking to explore the relationship between
transforming care and patient outcomes.
Patients are experiencing adverse events in hospital and nurses are
therefore seeking ways to minimise these events and improve patient outcomes. A
challenge has been identifying the nurse-sensitivity of patient outcomes to inform
nursing interventions targeted at improving nursing care safety and quality. Many
patient outcomes have been examined for their nurse-sensitivity such as falls,
HAPU and medication errors (Blegen, Goode, Spetz, Vaughan, & Park, 2011;
Patrician et al., 2011).
A few studies have reported the impact of TCAB and The Productive
Ward on patient outcomes. First, an evaluation of TCAB in the US demonstrated
a significant reduction in falls resulting in harm and readmissions within 30 days
but no impact on other patient outcomes (Needleman et al., 2009). An Australian
study also reported that the proportion of patient falls resulting in harm decreased
significantly after implementation as did medication errors but did not
demonstrate significant improvement in the proportion of patients experiencing
HAPU (Chaboyer, Johnson, Hardy, Gehrke, & Panuwatwanich, 2010). Second,
following implementation of The Productive Ward in the UK a decrease in
Methicillin-resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile
rates have been reported (Shepherd, 2008; Smith & Rudd, 2010). The number of
patients falling and the prevalence of pressure ulcers have also demonstrated a
downward trend in a UK hospital following implementation (Bloodworth, 2011).
12
These limited reports suggest that these transforming care initiatives are
having some impact on patient outcomes. However, direct comparison is difficult
due to the disparity of measures used and whether specific activities were directed
at these measures, rather than their use as overarching measures of nursing care
quality. Challenges encountered in demonstrating benefits for patient outcomes
have included a lack of robust measures, differences in information technology
infrastructure and lack of staff training in measurement (NHS Scotland, 2013;
Robert, Morrow, Maben, Griffiths, & Callard, 2011; University of California Los
Angeles-RAND Evaluation Team, 2007). Lack of clarity regarding how to
demonstrate the impact of nursing care related to the implementation of a
transforming care initiative remains. This research, through the use of two NSIs,
may provide recommendations for nurses looking to evaluate the impact of
comparable nurse-led quality improvement initiatives.
In summary, the implementation, impact and sustainment of initiatives to
improve the safety and quality of nursing care requires further consideration. The
findings of this study provides information on how to implement nursing safety
and quality initiatives and identifies factors that will assist sustainment. It may
also provide guidance in the leadership activities to implement such quality
improvement initiatives. Further, the research provides evidence for nurses trying
to improve patient outcomes by examining whether the approach has had an
impact on NSIs.
1.5 Overview of the Thesis Structure
This study used a combination of methods, both quantitative and
qualitative, in two phases. This first chapter has described the background to this
13
study. The aims and significance for nursing have also been discussed. The
following chapters are summarised below.
The literature relating to ‘Transforming care’ and NSIs were reviewed and
are presented as two published papers in Chapter Two. An introduction to each
paper is provided and after each paper an update considering research made
available since publication is presented. The first paper is a critical review of
nurse-led approaches to transforming care. The second paper provides a review
and discussion of the issues of selecting NSIs to reflect nursing care quality. A
third section of the chapter provides an overview of relevant theories and a review
of implementing change in nursing practice.
Following this an outline of the methodology for both phases of the study
is provided in Chapter Three. Phase One was a retrospective study using a time
series design to explore the relationship between the transforming care initiative
and NSIs. Phase Two was interpretive in design to explore the perceptions of
those involved in the implementation and sustainment of the transforming care
initiative. An overview of the design, sample, data collection, data analysis and
ethical considerations for both phases of the study are provided.
The findings of the study are presented in Chapters Four and Five. Chapter
Four presents the results of Phase One for the four study units; two surgical and
two medical. A published paper provides the outcomes for the two surgical units
including background, method, the results and discussion. This identified
inconsistent improvement across the two units for the NSIs measured. A ‘paper in
draft’ presents the results of the two medical units. It also includes a background
14
to the study, method, results and discussion. The results for the two medical units
were congruent with those of the two surgical units.
Chapter Five, presents the findings of Phase Two. Interviews were held
with eight Registered Nurses and the six major categories that emerged from the
interviews are described. The main categories included; Engaging the whole team,
Shifting culture, Rolling transforming care out, Leading the change to
transforming care, Seeing the change and Entrenching new ways of working. The
findings are again presented as a ‘paper in draft’ which incorporates a background
to the study, the study design, the findings and a discussion of the findings.
Finally, Chapter Six discusses the findings of the overall study. The
findings from both Chapters Four and Five are synthesised. Implications and
recommendations for nursing practice, education and research are identified. The
limitations and conclusions drawn from the study are also discussed.
1.6 Summary
Following the publication of reports raising awareness of patient safety
risks, the safety and quality of patient care has become a priority for healthcare
professionals. Transforming care initiatives offer the potential for nurses to make
improvements and their impact can be explored using Donabedian’s conceptual
framework for evaluating the quality of care. The next chapter critically examines
the literature relating to transforming care, NSIs and implementing change into
practice.
17
2.2 Introduction
Concerns regarding the safety and quality of patient care have led to the
development of various approaches to transform nursing care. This chapter first
critically reviews the literature in relation to two contemporary approaches,
TCAB and The Productive Ward. After an overview of these approaches is
provided, a published review paper is presented, followed by an update of the
literature since its publication. Second, a critical review of NSIs is undertaken,
using the same approach of overview, published paper and update. Finally a
review of evidence regarding implementation of change in nursing practice is
provided.
2.3 Contemporary Approaches to Transforming Care
Nurses are challenged to change the way they are working to address
quality and patient safety concerns. ‘Transformation’ is defined as ‘a marked
change in nature, form or appearance’ (Oxford Online Dictionary, 2010).
Transformational change has been described as widespread change in an
organisation, affecting power relations, processes, culture and organisational
perspectives (Doebbeling & Flanagan, 2011). Elements such as leadership
commitment and initiatives that engage staff have been proposed as critical to
successful transformation of patient care by affecting components including
culture, operational functions and processes (Lukas et al., 2007). Approaches to
transforming care have offered nurses the frameworks to explore some of these
elements and adopt practice changes.
Many initiatives and programs have been implemented over the past 30
years internationally to improve nursing care safety and quality and the work
18
environment of nurses. These include the US based Magnet Recognition
Program® (American Nurses Credentialing Center, 2014) and the Essence of Care
2010 program in the UK (Department of Health, 2010). In the past decade, two
approaches primarily aimed at nurses caring for patients in acute medical-surgical
units have been initiated; TCAB in the US (Institute of Healthcare Improvement,
2008; Rutherford et al., 2009), and The Productive Ward in the UK (NHS Institute
of Innovation and Improvement, 2009). These approaches provided frameworks
for change in medical-surgical units where the largest volume of inpatient care is
delivered. Adoption of these two approaches has continued internationally, yet the
impact of these approaches remains unclear.
2.3.1 Transforming Care at the Bedside
TCAB was launched in 2003 as a partnership of two American
organisations, the Institute of Healthcare Improvement (IHI) and the Robert Wood
Johnson Foundation (RWJF) in the US (Institute of Healthcare Improvement,
2012a). Following the initial pilot with participating hospitals from across the US,
the American Organisation of Nurse Executives (AONE) partnered with RWJF to
continue to expand the initiative (Dearmon et al., 2013). This nurse-led approach
initially aimed to achieve improvements in healthcare delivery to medical-surgical
patients but expanded to other areas (Martin et al., 2007).
TCAB encourages nurses to identify areas for improvement in their units
and use a rapid change cycle, PDSA (Plan-Do-Study-Act), to adopt, adapt or
abandon interventions to transform care delivery (Rutherford et al., 2009).
Engagement of nurses is promoted to transform their clinical processes, work
environment and quality of care and can be the key to success (Needleman et al.,
19
2009). This engagement of front-line staff and managers has been considered to
be its point of difference with previous improving care processes (Rutherford et
al., 2009). It fosters a ‘bottoms-up’ approach to improvement. Specific goals are
framed around the safety and reliability of care, patient-centred care, value-
adding, teamwork and vitality (Rutherford, Lee, & Greiner, 2004). Examples of
interventions implemented by the pilot hospitals have included staff names at the
bedside (Martin et al., 2007), patient controlled liberalised diets (Scott-Smith &
Greenhouse, 2007), nurses participating in presenting patients in morning rounds
(Stefancyk, 2008a), nurse-status boards (Viney, Batcheller, Houston, & Belcik,
2006) and the introduction of rapid response teams (Rutherford et al., 2004).
2.3.2 Releasing Time to Care: The Productive Ward™
The UK NHS Institute of Innovation and Improvement formally launched
The Productive Ward in 2007 (National Nursing Research Unit [NNRU] and the
NHS Institute for Innovation and Improvement, 2011; White, Wells, &
Butterworth, 2013). A pilot was expanded from four to 10 partner hospitals and
then other hospitals followed. The aims of The Productive Ward program are to
increase the time nurses spend in direct patient care, improve patient and staff
experience and empower frontline staff to improve ward based systems and
processes (NHS Institute for Innovation and Improvement & NNRU, 2010). The
program is founded on the principles of ‘lean thinking’ (NNRU and the NHS
Institute for Innovation and Improvement, 2011). Lean thinking principles centre
on reducing activities that do not add value (Womack & Jones, 1996). By
reducing activities that do not add value, nurses could potentially spend more time
providing direct patient care.
20
The Productive Ward program contains three foundation modules
followed by modules focused on specific processes such as meals, ward round,
nursing procedures, medication safety and patient observations. These modules
contain self-directed activities and techniques enabling ward staff to make
improvements at a pace that suits each ward and organisation (NHS Institute of
Innovation and Improvement, 2009). There have been several positive reports of
the implementation in acute hospitals (Lennard, 2012; Shepherd, 2009; Smith &
Rudd, 2010).
A paper has been published on these approaches to transforming care
(Burston, Chaboyer, Wallis, & Stanfield, 2011). The critical review of these
contemporary approaches to transforming care identified that they appear to share
some commonalities with regard to their aims, interventions and outcome
measures. However, differences were apparent in regard to their implementation,
and sustainability.
2.3.3 Discussion of Approaches to Transforming Care: Contemporary Strategies to
Improve Patient Safety (Paper 1)
Citation: Burston, S., Chaboyer. W., Wallis, M. & Stanfield, J. (2011). A
discussion of approaches to transforming care: Contemporary strategies to
improve patient safety. Journal of Advanced Nursing, 67(11), 2488-2495.
29
2.3.4 Supporting Evidence for Transforming Care Initiatives
Following the publication of Paper 1, there have been further contributions
to the evidence regarding the contemporary approaches, TCAB and The
Productive Ward. A search of CINAHL and MEDLINE® using the initial review
search terms, was undertaken for the period 2010 to September 2014. The
evidence has been categorised as experiential reports, literature reviews and
research and evaluation. These three areas are reviewed.
Experiential reports of implementing transforming care initiatives
detailing the experience of implementation continue to be published in acute care
in the UK (Bloodworth, 2011; Smith & Rudd, 2010), perioperative (Bloodworth,
2011) and mental health settings (Dyer, 2014; Lennard, 2014; Mumvari &
Pithouse, 2010) associated with the implementation of The Productive Ward.
Some reports include the outcomes used to measure the impact such as unplanned
absence, time spent in direct patient care, staff satisfaction and infection rates
although methodological details and statistical analysis is often not clarified
(Mumvari & Pithouse, 2010; Smith & Rudd, 2010). Reflection on preparation for
implementation of TCAB has also been considered suggesting that adequate and
appropriate system structuring and pre-planning will aid success (Osman &
Nolan, 2013).
Literature reviews explicating the lessons to be learned from
implementation, have also added to the body of literature (White & Waldron,
2014; White et al., 2013; Wright & McSherry, 2013a). Significant benefits were
identified following implementation of The Productive Ward such as the
increased amount of time spent in direct patient care and a reduction in healthcare
30
associated infections such as Clostridium Difficile (Wright & McSherry, 2013a).
Key enabling factors have also been identified including the importance of having
a dedicated improvement resource to facilitate units introducing The Productive
Ward (White et al., 2013). Three key areas of leadership have also been identified
as contributors to success to The Productive Ward initiative, executive
sponsorship, role of nurse leadership and the leadership development potential of
implementing such initiatives (White & Waldron, 2014). However, a review of
the implementation of The Productive Ward recognised that the patient’s
experience and public involvement in the development, roll out and evaluation of
the programme has not been discussed in the literature (Wright & McSherry,
2013a). Following this review, one study explored the perceived impact of The
Productive Ward from eight patients’ perspective and reported the patients’
positive feedback (Wright & McSherry, 2013b).
Large scale evaluations and further research of implementation have been
conducted. Reports have been published of The Productive Ward in the UK which
included case studies from 11 hospitals and of ten implementation sites in New
Zealand (Moore & Blick, 2013; NNRU and the NHS Institute for Innovation and
Improvement, 2011; NHS Scotland, 2013). A further overall report of TCAB in
the US summarised earlier reported findings from the three phased national pilot
conducted in thirteen hospitals between 2004 and 2008 (Robert Wood Johnson
Foundation, 2011). These reports identify the perceived benefits of these
initiatives such as reduction in falls, more time to provide direct patient care and
better team-working, following large scale implementation of The Productive
Ward in the UK. A reduction in falls, particularly those resulting in harm, was the
most consistent benefit reported for patients across these multi-site evaluations
31
(NNRU and the NHS Institute for Innovation and Improvement, 2011; Robert
Wood Johnson Foundation, 2011).
Several studies have explored implementation of these contemporary
initiatives from the participants’ perspectives (Davis & Adams, 2012; Morrow,
Robert, & Maben, 2012; Robert et al., 2011; Roussel et al., 2012). These studies
provide evidence for the enablers and barriers to implementation such as the
importance of dedicated leadership and lack of staff time and the benefits such as
developing nursing leadership capacity. The nature and impact of leadership on
local implementation has also been explored (Morrow et al., 2014). Insight is
provided into the multiple levels of leadership, actions of those leaders, the
leadership styles and frontline staff having permission to lead. A framework of
leadership processes was developed to assist organisations implementing quality
improvement interventions.
A few smaller scale studies conducted at single sites involving one or
more medical-surgical units have also reported the impact of transforming care
initiatives on staff and patient outcomes. Direct care and value-added care
activities such as bedside procedures and administering medications were found to
be enhanced in a US study examining the effectiveness of a TCAB initiative in a
35-bed medical-surgical unit that had 30 full and part-time registered nurses
(Dearmon et al., 2013). A significant reduction in falls with harm was also
demonstrated in this study using data derived from institutional monthly reports.
A downward trend in falls was also reported in a study of The Productive Ward in
one hospital trust in the UK (Bloodworth, 2011). A decreasing trend in the
prevalence of HAPU was also noted although the statistical significance of either
32
of these trends was not reported. The effect of the implementation of TCAB on
the nurses’ work environment has also been recently explored and was
demonstrated to be inconsistent in a Canadian study conducted in four medical-
surgical units (Lavoie-Tremblay et al., 2014). A significant improvement in the
communication of specific information and a post-test reduction in social support
from colleagues were evident, suggesting that a focus on improving
communication and ensuring the support of all team members is required (Lavoie-
Tremblay et al., 2014). However, the benefits of these initiatives for medical-
surgical patients remains unclear due to the limited number and small scale of
these studies.
Although contributions to the supporting evidence for transforming care
continue to be made, the number of publications on The Productive Ward have
reduced since 2009, which may indicate that interest has dwindled (White, Wells,
& Butterworth, 2014; Wright & McSherry, 2013a). However, there remains a
need for further research demonstrating the benefits of transforming care for
patients for medical-surgical patients. This may reflect the challenges of
insufficient data, competing interests (White et al., 2014) and methodology.
Finally, the main drivers for some of these initiatives have been disbanded as a
result of changing priorities and funding. Consequently, the ability to undertake
future evaluations may be limited, for example by impacting on the availability of
resources, Nevertheless, only limited research demonstrating the benefits of
transforming care for patients is available. Efforts to fill this gap may help to
determine if these initiatives are worth pursuing in other countries.
33
2.4 Nurse-sensitive Indicators to Measure Nursing Care Quality
Evaluation of new models of care helps to determine if they are effective.
NSIs, can be used to assist this. The structure, process and outcomes framework
guides potential measures for nursing (Irvine, Sidhani, & Hall, 1998). Structural
indicators for nursing could be the Registered Nurse skill mix and experience.
Process indicators could include the activities the nurses performed and potential
outcome indicators are inpatient falls and HAPU. Canadian researchers proposed
that the structural variables influence the process and outcome variables and
process variables affect the outcomes (Irvine et al., 1998). The challenge for
Nurse Managers is identifying outcomes that are influenced by nursing structural
and process variables to use as measures of nursing quality to support the
implementation of quality improvement initiatives (Burston, Chaboyer, &
Gillespie, 2014).
Effective measures are required to demonstrate the impact of introducing
change to nursing practice. Nurse-sensitive quality indicators have been described
as ‘those in which the quality and quantity of nursing interventions influence a
patient’s outcome’ (Boltz, Capezuti, Wagner, Rosenberg, & Secic, 2013). Other
surrogate terms used to describe NSIs are outcome indicators/measurements,
nursing performance quality indicators and patient safety indicators (Heslop &
Lu, 2014). The terms nurse-sensitive patient outcomes and NSIs are often used
interchangeably. To differentiate between them, nurse-sensitive patient outcomes
can be viewed as what is to be measured and the indicator identifies how the
outcome is calculated. NSIs is the term that will be used in this study. NSIs have
been developed at organisational, professional and government levels. Several
healthcare professional groups have identified a series of NSIs for reporting in the
34
US and Europe (American Nurses Association (ANA), 2012; Butler et al., 2006;
Collaborative Alliance for Nursing Outcomes (CALNOC), 2014; Institute of
Healthcare Improvement, 2012b). These reporting systems can offer a means to
standardise measurement, creating the opportunity to benchmark the standard of
nursing practice and provide consistent measures for quality improvement and
research purposes.
2.4.1 Nurse-sensitive Indicators to Reflect Nursing Care Quality: A Review and
Discussion of the Issues (Paper 2)
Citation: Burston, S., Chaboyer, W., & Gillespie, B. (2014). Nurse-
sensitive indicators to reflect nursing care quality: A review and discussion of the
issues. Journal of Clinical Nursing, 23(13-14), 1785-1795.
46
2.4.2 Further Evidence Regarding Nurse-sensitive Indicators
Following the publication of Paper 2, the literature regarding the use of
NSIs to measure nursing care quality has been extended. The original search
terms were mirrored for the period 2012 to September 2014. Ongoing
contributions have been made to the understanding of the impact of nursing
structural and process variables on patient outcomes and attempts to seek
consensus on suitable indicators to reflect nursing care quality.
A range of NSIs continue to be explored such as hospital-acquired
pressure ulcers, falls and hospital-acquired infections. These continue to be
examined in relation to a range of nursing structural and process variables.
Nursing structural variables explored include skill mix (Twigg, Duffield,
Bremner, Rapley, & Finn, 2012; Yang, Hung, Chen, & Shieh, 2012), education
(Aiken et al., 2014; Boltz et al., 2013; Weinberg, Cooney-Miner, & Perloff,
2012), workload (ratios) (Aiken et al., 2012; Hinno, Partanen, & Vehviläinen-
Julkunen, 2012) and supplemental nurses (Aiken, Shang, Xue, & Sloane, 2013;
Xue, Aiken, Freund, & Noyes, 2012). These studies largely demonstrate the
influence nursing has on patient outcomes with some inconsistency.
The association between nursing structural variables and NSIs have
continued to be explored with conflicting findings. For example, two studies
demonstrated variability in outcomes impacted by skill mix. A single site study
conducted in an acute respiratory care centre in Taiwan, concluded that skill mix
did not affect the development of pressure ulcers (Yang et al., 2012). In contrast,
an Australian multi-site study undertaken in three tertiary hospitals, noted
decreases in eight of fourteen outcomes explored including pressure ulcers with a
47
higher RN skill mix (Twigg et al., 2012). Similarly, with regard to nurse
education level, conflicting results have been reported. A relationship between the
percentage of Bachelor of Science in Nursing degree (BSN) prepared nurses and
patient outcomes was not demonstrated in a study of nurses on 45 units across
nine hospitals (Weinberg et al., 2012). This result is not congruent with a larger
US study undertaken in 665 hospitals that concluded that a 10% increase in BSN
degree nurses decrease the odds on patient outcomes by approximately 4% (Aiken
et al., 2012). A further multi-site US study explored post-registration specialty
certification, a gerontological certification, in 44 units, but did not report a
positive impact on patient outcomes (Boltz et al., 2013). Finally, with respect to
temporary nurse staffing, a single site study in US reported no significant
relationships with patient outcomes (Xue et al., 2012). In contrast, two studies,
conducted in US and New Zealand, demonstrated a greater risk of adverse patient
outcomes when temporary staffing was used (Aiken et al., 2013; North et al.,
2013). However, when the work environment was taken into account in one of the
US studies, the significant association between the use of agency-employed
supplemental nurses and mortality in large scale multi-site studies was not
supported, reflecting the complexity of confounding factors (Aiken et al., 2013).
Overall, while there is variation in the findings, the larger scale studies indicate
that nursing structural variables may have an association with patient outcomes
and the sophistication of the methodology and risk adjustment might account for
the disparity in findings. Particularly the combined work of an international
collaborative now involving 30 countries continues to verify the association
between nursing structural variables and patient outcomes in different healthcare
systems providing evidenced based NSIs (Aiken et al., 2014).
48
Further, nursing process variables continue to be examined in relation to
their association with patient outcomes. The literature is both vast and variable in
relation to the specific nursing interventions that are explored. There has been
some exploration of interventions related to falls and HAPU in acute medical-
surgical units. A US study of 28 units in four hospitals reported that a faster call
response time was associated with lower falls and falls resulting in harm,
suggesting that if nurses respond faster to call lights it may contribute to lower
falls rates (Tzeng, Titler, Ronis, & Yin, 2012). An hourly rounding intervention
was also implemented in two orthopaedic units in one US hospital and
demonstrated an initial improvement, although falls rates had moved back
towards the baseline at 12 months post implementation (Tucker, Bieber, Attlesey-
Pries, Olson, & Dierkhising, 2012). The study demonstrated the potential of
rounding as a strategy but the fidelity of the intervention by the nurses was
questioned. With regard to HAPU, a single-site Australian study of the
implementation of recommendations of a best practice guideline for pressure ulcer
prevention in medical-surgical patients, was conducted (Barker et al., 2013). The
interventions included improving nurse compliance with risk assessment,
accuracy of risk assessment and use of pressure ulcer prevention strategies. A
decrease in the prevalence of HAPU was reported over a nine year period.
The use of more positive process outcome measures in place of adverse
patient events have also continued to be explored. A small scale US study
demonstrated an improvement in cancer patients maintaining or improving their
muscle strength while hospitalised following a nurse-led exercise program
intervention although the improvement was not significant (McLaughlin,
Wittstein, White, Czaplinski, & Gerard, 2012). Also, a Canadian study of nurse-
49
practitioner-managed cardiac surgery follow up examined symptoms, patient
satisfaction and quality of life as outcome measures (Sawatzky, Christie, &
Singal, 2013). The patients randomised to the nurse practitioner follow up
demonstrated significantly fewer symptoms and higher physical functioning status
at two weeks post discharge, compared to the control group. Measures of
functional status were also used as an outcome measure of skilled nursing
facilities that used activities of daily living to quantify productivity of nursing care
received by patients who had experienced a stroke (Shah et al., 2013). This US
multi-site study demonstrated an improvement in patients’ functional status.
Furthermore, the search for ‘sets’ of NSIs to quantify the quality of
nursing and midwifery care or specialty practice continues to be explored. These
often reflect process variables such as time spent in direct patient care and
education provided to the patient. An Australian study described the use of a
Delphi approach to select indicators for paediatric hospitals (Wilson, Hauck,
Bremner, & Finn, 2012). Initially, 42 potential indicators were identified by
consensus and were reduced in further rounds. The development of indicators for
the specific practices of Nurse Practitioners has also been attempted to identify
their impact in hospitals and ambulatory care settings (Kapu & Klienpell, 2013).
A Finnish study reported the applicability of an American Perioperative Nursing
Data Set to the Finnish context (Lamberg, Salanterä, & Juntilla, 2013). The
original data set included three groups of outcomes; safety, physiological
responses and behavioural responses relating to knowledge and rights/ethics. Most
of the indicators were validated but a few were rejected, refining the data set. For
example, radiation safety was rejected as it was considered difficult to assess
radiation injuries intra-operatively or immediately afterwards. This reflects a
50
limitation of these data sets in that often some indicators chosen in one context are
not transferable. The challenge of generating consensus is a further issue for
defining sets of indicators. The variance among the experts used was noted in the
studies that used expert panels and the associated difficulties identifying how
many and who to include. However, the drive to develop data sets may assist in
identifying optimal nurse staffing and what those nurses do in practice. Further
effort is required to develop and validate data sets and clearly identify the
indicator measure to be used.
Considering these studies in conjunction with the previously explored
literature regarding NSIs, provides considerable support for their use to reflect
nursing care quality. Debate continues regarding the inconsistency of some
findings which may be more reflective of the variations in methodology. This is
particularly relevant with regard to patient outcomes that are rare events, and can
be documented in several places with no assurance that documentation occurs.
There is also a lack of consensus on the definition of measures. Application of
NSIs is growing, such as through the development of data sets, but remains
limited in the reflection of the impact of transforming care initiatives on the
associated safety and quality of nursing care.
2.5 Implementing New Practices into Nursing
Despite the implementation of multiple patient safety programs, progress
toward improvement has been slow (Leape et al., 2009). Added to this, the
majority of improvement efforts in healthcare often fail to result in sustained
change (Essén & Lindblad, 2013; Hovlid, Bukve, Haug, Aslaksen, & von Plessen,
2012). It has been asserted that there is a failure to translate research into practice
51
and policy (Grimshaw, Eccles, Hill, & Squires, 2012). This may be due to how
new practices are introduced rather than the new strategies or goals of the strategy
being inappropriate (Caldwell, Chatman, O'Reilly III, Ormiston, & Lapiz, 2008).
As health care systems are considered to be complex adaptive systems,
(Glouberman & Zimmerman, 2002; Greenhalgh, Robert, Macfarlane, Bate, &
Kyriakidou, 2004), it is likely that simple, sequential change models will not
suffice with more complicated change processes required to address the multiple
influential factors. A review of theories and models to assist in implementing
practice change is provided. The importance of leadership to introducing new
ways of working is also reviewed.
Several theories for introducing change have been applied in healthcare to
assist in informing the development of interventions to affect change. These
theories have developed from a variety of disciplines, such as social science,
research utilisation in nursing, health promotion and organisational management
(Estabrooks, Thampson, Lovely, & Hofmeyer, 2006). These theories can be
categorised in regard to their level of impact; individual, group or organisational
(Rycroft-Malone & Bucknall, 2010). Alternatively, theories have also been
grouped as ‘impact’ and ‘process’ theories (Grol, Basch, Hulscher, Eccles, &
Wensing, 2007). Impact theories are considered as those that describe how a
specific intervention will facilitate change as opposed to process theories which
identify the preferred implementation activities (Grol et al., 2007).
Impact theories include those with a cognitive, educational, leadership or
teamwork focus associated with various aspects, beliefs and assumptions
regarding behavioural change. Many theories focus on changing individual
52
behaviour to affect change. An example is the ‘The Theory of Planned Behaviour’
which considers antecedents such as attitude toward behavior, subjective norms
and perceived behavioral control that predict an individual's behavioral intentions
and behaviours (Ajzen, 1991). Alternatively, ‘Adult Learning Theory’ considers
the concepts of adult learning being self-directed and self-controlled (Knowles,
1980), and the ‘Transtheoretical Model of Behaviour Change’ was based on the
therapy literature and studies of ‘self-changers’ (Prochaska & DiClemente, 1983).
These theories have been applied in practice. The Theory of Planned Behaviour
has been applied to immunisation practice to try to understand the attitudes,
beliefs, behavioural intentions and self-reported behaviour of nurses and
physicians, to inform development of interventions to target immunisation
provider behaviour (Pielak et al., 2010). ‘Adult Learning Theory’ has been
applied in nursing to improve the transfer of patients from an intensive care unit to
a ward through the development of a brochure for families and ‘The
Transtheoretical Model’ has been applied to self-change of smoking behaviour
(Mitchell & Courtney, 2004; Prochaska & DiClemente, 1983). Although these
theories assist in identifying appropriate individual behavioural interventions they
provide limited guidance regarding steps and strategies to effectively implement
the change.
In contrast, process theories and models are often staged processes with
implementation activities associated with each stage. These include Lewin’s
(1951) three stage model, Kotter’s (1996) eight stage process and Rogers’ (1995)
five stage ‘Diffusion of Innovation Model’. Lewin offered a linear model of
change proposing three stages; unfreezing, moving and refreezing (Lewin, 1951).
This model has been argued to be too simplistic in today’s healthcare as it does
53
not account for organisational politics, is top down in approach and management
driven (Burnes, 2004). Similarly, Kotter’s eight stage model of change is also
sequential and includes steps aimed at generating the urgency for the change,
creating a guiding coalition, developing and communicating the vision,
empowering action, generating short term wins, never letting up and incorporating
change into the culture (Kotter, 1996). These steps also require contextualising
and tools to assist this are not provided (Applebaum, Habashy, Malo, & Hisham,
2012). Rogers described five stages in exploring the diffusion of innovations:
knowledge, persuasion, decision, implementation and confirmation (Rogers,
2003). This model identified significant characteristics that can influence the
spread of an innovation. These included the willingness of people to adopt
change, the degree to which the innovation is seen to be better than current
practice and the ability to test an innovation prior to widespread adoption (Rogers,
2003). These models have been used in nursing for the implementation of nursing
bedside handover (Chaboyer et al., 2009; McMurray, Chaboyer, Wallis, &
Fetherston, 2010), preoperative fasting guidelines (Anderson & Comrie, 2009)
and electronic medical records (Neumeier, 2013).
These impact and process theories can be viewed as focused on specific
aspects of individual or group behaviours or process orientated. However,
multiple influential factors have been identified including leadership, relevancy of
the innovation, teamwork, facilitation and executive support, contextual issues,
engagement or ownership and resource deficits that need to be considered when
implementing change (Bradley, Sclesinger, Webster, Baker, & Inoseye, 2004;
Dogherty, Harrison, Graham, Vandyk, & Keeping-Burke, 2013; Irwin, Bergman,
& Richards, 2013; Solomans & Spross, 2011). Therefore it has been asserted that
54
understanding and applying frameworks that incorporate elements of both impact
and process theories provide an ideal change model (Grol et al., 2007). The
contemporary ‘Behaviour Change Wheel’ (Michie, van Stralen, & West, 2011),
has attempted to draw together aspects of several constructs of these theories
(Brehaut & Eva, 2012). This model supports the analysis of the extent to which
capability, motivation and opportunity need to change, for behavioural change to
occur and attempts to account for a wide range of factors that affect adherence and
identify appropriate interventions to affect behaviour change (Michie et al., 2013;
Michie et al., 2011).
Following implementation of change, effective sustainment is important.
Sustaining the benefits of improvement presents challenges to nurses in complex
acute care environments. Sustainability has been described as “a point at which
new ways of working become the norm and the underlying systems and ways of
working become transformed in support” (Greenhalgh, Bate, Kyriakidou,
Macfarlane, & Peacock, 2004, p. 32). This suggests the new practice has been
integrated into practice and desired outcomes continue to be delivered (Doyle et
al., 2013; NHS Institute for Innovation and Improvement, 2007). However, after a
perceived successful implementation, the innovation may not continue as
originally intended (Stirman et al., 2012) or there may be an ‘improvement
evaporation’ (NHS Institute for Innovation and Improvement, 2007). Models have
been developed to increase the potential for sustainability such as a self-
assessment tool; the ‘Sustainability Model’ (Maher, Gustafson, & Evans, 2010).
This model identified 10 factors that promote sustainability including credibility
of the benefits, adaptability of the process, staff attitudes and leadership
engagement. The model has been applied in the support of multidisciplinary teams
55
undertaking projects to implement evidence-based practice such as care bundles
and care pathways (Doyle et al., 2013). Application was however found to be
difficult with seven out of 19 projects indicating challenges to understanding and
applying the tool. There remains a need to understand what and how improvement
interventions in health care are sustained to assist future improvement initiatives.
In attempting to understand the implementation of transforming care
initiatives to change nursing practice, some evidence has been forthcoming. Two
large scale evaluations have been undertaken. The TCAB initiative in the US has
been studied from inception at the initial pilot sites (Rutherford et al., 2004;
University of California Los Angeles-RAND Evaluation Team, 2007). An
examination of the introduction of The Productive Ward in the UK has been
similarly undertaken (NHS Institute for Innovation and Improvement & NNRU,
2010; Robert et al., 2011). Both of these studies have reported the complexity of
implementing and sustaining the initiatives and the challenges encountered,
echoing factors known to influence change such as the organisational context and
time constraints. A study conducted in 11 units in one facility in the UK explored
the sustainability of The Productive Ward over a 44 week period (Clarke &
Marks-Maran, 2014). Sustainability was measured by module progression and
staff engagement and the results were variable. Recommendations included
planning for sustainability and for those implementing the initiatives to
understand factors related to sustainability. Currently, there appear to have been
no contributions to the literature regarding the process of implementing and
sustaining a transforming care initiative in the Australian context.
56
The large scale evaluations that have been undertaken also highlighted the
importance of leadership to implementation and sustainability of transforming
care initiatives. The importance of leadership to the implementation of change has
been discussed in the literature. Leaders are considered essential to all change
models as they provide inspiration, vision and support (Schifalacqua, Costello, &
Denman, 2009). The Institute of Healthcare Improvement recognised the
importance of leadership to the implementation of TCAB and introduced a fifth
pillar, ‘transformational leadership’, to its TCAB framework (Rutherford et al.,
2009). This reflects the viewpoint that a transformational leadership style is
conducive to implementing change.
Several theories of leadership have been adopted over the years including
situational, transactional and transformational (Giltinane, 2013). Nurses leading or
participating in a transforming care initiative need a leadership style that will
facilitate the new practice. The adoption of a transformational leadership style is
believed to be most beneficial perhaps because transformational leaders are able
to develop followers through creating a vision that provides meaning and
motivation (Bass & Steidlmeier, 1999; Porter-O'Grady, 2003). The
transformational leader inspires and motivates their followers to accept innovation
(Aarons, 2006). The findings of a US study of 278 nurses across four hospitals are
congruent with these attributes, concluding that a transformational leadership style
was associated with the ability to influence followers, meet their needs through
communication and other strategies and create a positive work environment
(Casida & Parker, 2011). The effectiveness of a transformational leadership style
to encourage staff safety participation has also been demonstrated by the results of
a meta-analysis testing of a theoretical model of safety leadership (Clarke, 2013).
57
In addition, another approach to leadership has been considered, the
authenticity of leaders. This refers to transformational leaders building credibility,
respect and trust through leading employees in a way that is seen as authentic
(Avolio, Gardner, Walumba, Luthens, & May, 2004). Leaders who are authentic
know who they are and believe and act in accordance with those values and
beliefs (Avolio et al., 2004). Two Canadian studies that used secondary analysis
of data, reported that registered nurses perceived greater work engagement for
nurses and decreased adverse patient outcomes were benefits of managers who
portrayed higher levels of authentic leadership (Bamford, Wong, & Laschinger,
2013; Wong & Giallonardo, 2013). Therefore it appears that an authentic
transformational leadership style would be beneficial for those implementing
changes in nursing practice such as transforming care initiatives, through
alignment with the aims of encouraging a focus on patient safety and engaging
staff. The activities of the leaders in relation to implementing the transforming
care initiative remains to be explored in the Australian context and will be
explored in this study.
Implementing change is a complex process and requires a framework that
focuses on not just working through a series of steps but on how the behaviour
change will be facilitated. Although, the use of a guiding framework can simplify
the process for those implementing change, there is still vulnerability to failure at
any stage (Mitchell, 2013). A lack of fidelity to these frameworks during
implementation suggests that the framework applied needs to be able to respond
to unpredictable interactions between ‘various forces at multiple-levels’ (Essén &
Lindblad, 2013). These issues underscore an identified gap in the literature
concerning the processes by which changes in practice are sustained in particular
58
settings and how they can be enhanced (Greenhalgh, et al., 2004). Notably, there
has been limited evidence regarding the change process associated with the
implementation and sustainment of transforming care initiatives internationally
and none appear available within the Australian context.
2.6 Summary
This chapter has critically reviewed the relevant literature relating to two
contemporary approaches to transforming care, NSIs and a review of the
introduction of new practices into nursing. NSIs are required to measure the
impact of these initiatives. Many patient outcomes have been explored including
falls and HAPU to demonstrate sensitivity to nursing structural and process
variables. To implement these transforming care approaches, theories and models
of change can offer guidance for implemention and sustainment. The model for
change needs to be able to respond to contextual issues and unpredictable events
that occur in complex healthcare settings. This study addresses the identified gaps
in the literature regarding the implementation of transforming care initiatives.
Although further evidence is slowly emerging, the benefits remain unclear. In
phase one the study examined the impact of the transforming care initiative on
NSIs. An understanding of how these initiatives are implemented and sustained in
the Australian context was examined in phase two.
In the following chapter, an overview of the methodology for both phases
of this study is provided. The research questions are clarified and the study setting
and intervention are described. Subsequently the methodology for the study
phases are presented including discussion of the methods of data collection and
analyses and ethical considerations are considered.
59
CHAPTER 3
Method
3.1 Introduction
The overall aim of this study was to understand the implementation,
impact and sustainment of an initiative to transform nursing care in one
institution. The study was conducted in two phases. This chapter provides an
overview of the research questions and the method used in each phase of the
study. The first phase used a non-equivalent control group design with historical
controls and an uncontrolled interrupted time series and the second phase was an
interpretive study.
3.2 Research Questions
The research question that guided Phase One was
‘What is the relationship between transforming care and two NSIs,
inpatient falls and hospital-acquired pressure ulcers (HAPU), in
hospitalised medical-surgical patients?’
The research question that guided Phase Two was
‘What are the perceptions of nurses involved in the implementation of a
transforming care initiative with regard to its implementation and
sustainability?’
60
3.3 Setting
The setting for this study was a 450 bed regional general teaching hospital
in Australia serving a resident population of approximately 500,000. The facility
provided a range of services including critical and acute care, mental health,
maternity and paediatrics. However, major burn or cardiac surgery services were
not provided. Four 28-bed acute care units piloted the local transforming care
initiative; two medical and two surgical. The nursing profile of the four units is
described in Table 1.
Table 1 Nursing Profile of Study Units
Unit S1 S2 M1 M2
Type of unit Surgical Surgical Medical Medical
Number of beds 28 28 28 28
Nursing establishment
(FTE)
29.6 31.6 36.2 39.7
Registered Nurse (FTE) 20.2 19.3 22.8 23.6
Note. S = surgical, M = medical, FTE = Full Time Equivalent.
3.4 Transforming Care Initiative
The local transforming care initiative had its foundations primarily in
TCAB (Rutherford et al., 2009) and the ‘Releasing Time to Care: Productive
Ward’ (NHS Institute for Innovation and Improvement, 2012). The intent to
improve the safety and quality of nursing care was congruent with these
approaches as were some of the interventions implemented and the use of the
TCAB pillars to group the interventions implemented in the four units. The
initiative introduced interventions creating a new ‘model of care’. The increasing
61
focus on patient participation in care and safety and quality provided a patient
centred framework to improve care.
The ‘model of care’ implemented through this initiative, is not to be
confused with terms such as theoretical models of nursing, or models of care
delivery. Theroretical models of nursing aim to provide a definition of nursing,
based on assumptions about human nature and the wider socio-environmental
context (McCrae, 2011). They are more specific to a particular aspect or setting
than a conceptual model (Alligood, 2010). A number of theoretical models have
been developed, particularly in the 1980’s and 1990’s, including Roy’s
Adaptation Model and Orem’s Self-care Theory (Orem, 1991; Roy, 1980). In
contrast, models of nursing care delivery describe the organisation of daily work;
patient allocation, task allocation and team nursing (Fairbrother, Jones, & Rivas,
2010). The term ‘model of care’ is used in this study to refer to “an operational
model for redesigning nursing practice for the provision of patient care in an
organisational setting, specifically at a clinical services unit level (ward)”
(Fowler, Hardy, & Howarth, 2006, p. 40). It provides governance for the way
nurses not only organise their care, but communicate within their own team and
with other health care professionals, make decisions, and specify communication
and coordination strategies to support patient care (Fowler et al., 2006). This
conceptualisation reflects some of the goals of the interventions introduced as part
of the transforming care initiative at the study site and therefore it is appropriate to
consider it a ‘model of care’. In addition, this model of care focuses strongly on
the patient and family which is deemed as being essential to the safety and quality
of patient care (Institute of Medicine, 2001).
62
At the study site, a multidisciplinary executive team was established to
facilitate and support the initiative and also assisted in dealing with any challenges
that arose. A project team was also created, led by a manager, to assist in
engaging staff and maintaining motivation. Three project officers were appointed,
two of which had a nursing background and one an allied health background.
An integral part of the initiative was the introduction of of a model of care
comprised of numerous individual interventions. Nursing interventions have been
described as therapies, treatments, procedures or actions designed to improve a
client’s health condition towards desired health outcomes and may be
implemented by providers to and with clients (Sidhani & Braden, 1998). No
attempt was made by the researchers to manipulate this initiative or the individual
interventions. The lack of control over which and how many interventions each
study unit implemented meant that more than one intervention could be
implemented concurrently, creating a ‘bundle’ of interventions (Conn, Rantz,
Wipke- Tevis, & Maas, 2001). Patient safety is a complex problem and ‘bundled’
interventions are considered appropriate in response to a multi-dimensional
problem that is located in a conceptual framework that suggests combining
multiple interventions (Conn et al., 2001). The implication of this is in the
interpretation of the effects of an individual intervention (Sidhani & Braden,
1998). In recognition of this there was no attempt to link any one specific
intervention to the NSIs.
Each unit coordinated a meeting to introduce the program and engage the
staff with the aim of building an impetus for change. In parallel, issues were
identified by the unit staff that they considered impacted on their ability to deliver
63
optimal care to patients. Issues regarding communication and teamwork and
processes such as referrals and patient flow were identified. The units were then
introduced to a range of interventions they could adopt by the project team or
sourced or created their own. These inteventions were evidence based where
possible. Nursing interventions introduced as part of the initiative have been
categorised by the TCAB pillar they potentially influenced (Table 2). Between 10
to 12 interventions were introduced by each unit. While Table 2 shows that the
same seven interventions were introduced by all four units, other interventions
such as ‘Staff resource traffic lights’ were only adopted in one unit. In reality,
interventions may influence more than one pillar and were therefore allocated to
the pillar deemed most appropriate. Implementation of some interventions was
through a rapid improvement cycle, reminiscent of the ‘plan, do, study, act’cycle
(Langley, Nolan, Nolan, Norman, & Provost, 2009).
.
Clear records of which specific interventions were adopted by each study
unit were maintained to note implementing interventions was not standardised
with local unit adaptations occuring. Interventions included introducing ‘5S’(sort,
set, shine, standardise, sustain), a lean strategy, aimed at maintaining a clean and
efficient working environment and to reduce time spent searching for clinical
supplies (Bloodworth 2011), utilising patient whiteboards at the bedside to make
key information visible including current patient status and nursing handover at
the patient’s bedside. The interventions were mainly implemented in the study
units over an initial three month period from September to November 2009.
Further interventions or adaptations occurred over time.
64
Tab
le 2
Inte
rven
tions
Impl
emen
ted
Initi
ally
in E
ach
Uni
t
Pi
llar
D
escr
iptio
n S1
S2
M
1 M
2 Sa
fe a
nd
Rel
iabl
e
Car
e
Beh
ind
the
bed
whi
tebo
ards
Sa
me
colo
ur c
odes
to fl
ag a
ssis
tanc
e re
quire
d
Bed
side
han
dove
r In
itial
pat
ient
safe
ty u
pdat
e at
nur
ses’
stat
ion
follo
wed
by
hand
over
at t
he b
edsi
de.
Col
our c
odin
g of
cha
rts
Des
igna
ted
colo
ur fo
r eac
h ba
y’s e
nd o
f bed
cha
rts a
nd m
edic
al c
harts
Mul
tidis
cipl
inar
y te
am m
eetin
gs
Gre
ater
coo
rdin
atio
n of
mee
tings
and
bro
aden
ing
of te
am.
Clin
ical
com
mun
icat
ion
stra
tegi
es
SBA
R1 fo
r clin
ical
com
mun
icat
ion
and
com
mun
icat
ion
train
ing
for a
ll st
aff.
Rou
ndin
g H
ourly
che
ck o
f the
ir pa
tient
s by
nurs
es
Patie
nt
Cen
tred
St
aff i
dent
ifica
tion
sign
s Si
gns s
tatin
g ‘y
our n
urse
toda
y is
...’ p
lace
d in
side
/out
side
eac
h ba
y.
Prot
ecte
d m
eal t
imes
D
iet c
odes
on
beds
ide
whi
tebo
ards
, tab
les c
lear
ed to
rece
ive
mea
l tra
y, n
ursi
ng st
aff
stag
ger b
reak
s to
ensu
re st
aff a
vaila
ble
to a
ssis
t pat
ient
s eat
ing
Staf
f V
italit
y
Rew
ard
and
reco
gnis
e st
aff a
ctiv
ely
parti
cipa
ting
M
orni
ng te
as, s
peci
ally
prin
ted
mug
s giv
en to
staf
f
Abo
ve a
nd b
elow
the
line
beha
viou
rs
Post
er d
escr
ibin
g ac
cept
able
staf
f beh
avio
ur
Staf
f res
ourc
e tra
ffic
light
s U
ses ‘
traff
ic li
ghts
’ for
staf
f to
com
mun
icat
e th
eir w
orkl
oad
Val
ue
adde
d
5S2
Org
anis
atio
n of
stor
es, s
impl
ifies
wor
kpla
ce, r
educ
es w
aste
Alli
ed H
ealth
iden
tific
atio
n si
gns
Boa
rd d
ispl
ayin
g lis
t of n
ames
and
con
tact
det
ails
Alli
ed H
ealth
refe
rral
gui
de a
nd
stat
ion
Su
mm
ary
of h
ow a
nd w
hat t
o re
fer a
nd o
utlin
e of
role
s
Not
e. 1 SB
AR
= si
tuat
ion,
bac
kgro
und,
act
ion,
reco
mm
enda
tions
com
mun
icat
ion
tool
; 2 5S =
sort,
set,
shin
e, st
anda
rdis
e, su
stai
n; S
=sur
gica
l uni
ts; M
=med
ical
uni
t
65
3.5 Phase One: Relationship between Transforming Care and Nurse-sensitive
Indicators
3.5.1 Study Design
Phase One used a non-equivalent control group design with historical
controls and an uncontrolled interrupted time series, which refers to a large series
of observations made on the same variable consecutively over time (Benneyan,
Lloyd, & Plsek, 2003; Shadish, Cook, & Campbell, 2002; Speroff & O'Conner,
2004). An interrupted time series is used to assess treatment impact and to detect
whether an intervention has had an effect significantly greater than the underlying
trend (Shadish et al., 2002). All data was retrospective. Two NSIs were used as
outcome measures (section 3.5.3). Figure 1 provides a diagramatic representation
of the study design (Polit & Beck, 2012, p. 265).
O1 O2 O3 O4 O5 O6 O7 O8 O9 O10 O11 O12 O13 O14 X O15 O16 O17 O18 O19 O20 O21 O22 O23 O24 O25 O26 O27
Figure 1. Time Series Data-points
Note. O = one month; X= initial implementation period of 3 months.
As identified in Figure 1, in this 30 month study there were 27 data-points,
14 pre and 13 post intervention. ‘X’ denotes the initial three month intervention
period during which data were not collected (Figure 1). This was due to the
majority of interventions being implemented during this period. Time series
design methodology is useful in quality improvement research for evaluating the
effects of interventions when it is difficult to randomise or identify an appropriate
control group (Eccles, Grimshaw, & Campbell, 2003). This is also a weakness of
the design as there is a failure to control history (Speroff & O'Conner, 2004).
Also, time series cannot determine the impact on a individual patient.
66
Performance may change without the intervention due to other factors or natural
variation. This requires a need to establish a stable estimate of the underlying
trend which is addressed in ensuring there are enough pre intervention data-points
(Eccles et al., 2003). Therefore the 27 data collection points used in this 30 month
study, were considered appropriate to perform analysis using statistical process
control (Section 3.5.5).
3.5.2 Sample
This study used a cohort sample consisting of all patients discharged from
the four study units, two medical and two surgical, from July 2008 to December
2010. Patients who were discharged during the initial three months of
implementation, September to November 2009, were excluded. In total, 12,632
patients were included, 6,375 prior to the intervention period and 6,257 post
intervention, across the four units.
Appropriate sample size is a fundamental feature of sound research design
(Bernstein, 2008). The sample size is determined by the frequency of the measure
to be observed, accessibility of the data and statistical requirements. It has been
stated that adverse outcome rates can often be less than 2% and sometimes less
than half a percent (Mattke, Needleman, Buerhaus, Stewart, & Zelevinsky, 2004).
Rates for HAPU reported include 6.1% in the US (VanGuilder, Amlung,
Harrison, & Meyer, 2009) and 7.4 to 17.0% across Australia (Mulligan, Prentice,
& Scott, 2011). Fall rates are reported mainly per 1,000 patient bed days and have
ranged from 0.6 to 1.44 per 1,000 bed days for falls and of those, 27.4 to 71.4 %
have resulted in injury (Koh, Manias, Hutchinson, & Johnston, 2007).
67
The disparity in percentage of events found by different studies has been
explained by methodological differences (Neale & Woloshynowych, 2003) and
consideration needs to be given to the rarity of the incidents (Brown, Hofer, &
Johal, 2008a). With such a small number of events, a sizeable sample is required.
This has led to studies often relying on the use of large administrative databases
sometimes in conjunction with risk adjustment models. The focus of the analysis
is whether a hospital had more or less adverse events than predicted by the risk
model, avoiding the need to document lapses in care from patient charts (Mattke
et al., 2004). Conversely, this has been challenged by discussion of the different
measures used by organisational databases when attempting meta-analysis such as
the lack of discernment between inpatients or outpatients (Harless & Mark, 2010).
3.5.3 Outcome Measures
Outcomes used as measures of patient safety in this study were those
identified as nurse-sensitive. A review of the selection of NSIs was performed
(section 2.4.1). The measures for this study were selected for several reasons; all
patients in the chosen study population had the potential for these events, they are
not treatment or disease specific, they are likely to be reported in the patient chart
if harm had occured and they are influenced by nursing care as identified in a
review of the literature (Burston et al., 2014). Other NSIs such as failure to rescue
were not used due to the challenges of determing this from the coding in such a
large sample size.
The NSI measures were identified using data derived from the patient
medical records coded using the International Statistical Classification of Diseases
and Related Health Problems 10th Revision, Australian Modification (ICD-10-
AM). This coding system is based on the International Classification of Disease
68
(ICD) developed by the WHO (2014), a new Australian classification of
procedures based on the Medicare Benefits Schedule (MBS) and Australian
Coding Standards (Heslop, Gardner, Diers, & Poh, 2004). It is used to provide a
standard diagnostic tool for epidemiology and quality purposes (WHO 2014).
3.5.3.1 Falls
Several definitions of falls have been described with most indicating they
are involuntary. Some identify whether the mechanism of the fall relates to a
medical condition or could be due to any cause (Agostini, Baker, & Bogardus,
2001; Reed, Blegen, & Goode, 1998). In relation to this study, the broader
conceptual definition ‘An unplanned descent to the floor with or without injury to
the patient’ was adopted (American Nurses Association, 2012 ; Lamb, Jorstad-
Stein, Hauer, & Becker, 2005). This includes all types of falls, whether they
resulted from physiological or environmental reasons (American Nurses
Association, 2012). Falls have been used as outcome measures in other studies
exploring the quality of nursing care (Patrician et al., 2011; Van den Heede et al.,
2009).
The data for falls was derived from the existing coded medical record data.
An inpatient fall was identified, if associated with a location code, Y92.2,
indicating the fall took place in hospital. The response was binominal, coded as
‘yes’ or ‘no’. If a patient had multiple inpatient falls, these were not counted
separately but included in the initial ‘yes’ response. The measure was
operationally defined as:
69
• Did the patient experience a fall with or without injury in hospital
which was coded according to ICD-10 AM codes W01, W03, W04,
W05, W06, W07, W17-19? Yes or No?
3.5.3.2 Hospital-acquired pressure ulcers
A pressure ulcer has been described as “localised injury to the skin and/or
underlying tissue usually over a bony prominence, as a result of pressure, or
pressure in combination with shear and/or friction” and can be classified by
stages from one to four (European Pressure Ulcer Advisory Panel and National
Pressure Ulcer Advisory Panel, 2009, p. 7). A ‘hospital-acquired pressure ulcer’
(HAPU), denotes that it occurred in hospital. Pressure ulcers are also referred to
as ‘pressure injuries’ in Australia (Australian Wound Management Association,
2012). The use of the term ‘pressure ulcer’ defers to the international terminology
(National Pressure Ulcer Advisory Panel European Pressure Ulcer Advisory Panel
and Pan Pacific Pressure Injury Alliance, 2014). Patients with a pressure ulcer
coded with the ‘present on admission flag’ were to be excluded from the study.
The response was binominal, coded as ‘yes’ or ‘no’. If a patient had more than
one HAPU these were not calculated separately but included in the initial ‘yes’
response. The measure was defined as:
• Did the patient have a hospital-acquired pressure ulcer coded
according to ICD 10 codes AM L89-89.9? Yes or no?
3.5.4 Data Collection
Coded data were acquired electronically from the hospital administrative
database via the relevant unit, Decision Support Services (DSS). This data was
recorded by clinical coders for the purposes of maintaining statistical and clinical
70
coding data and to assist mandatory reporting required of the hospital. Coded data
were used to identify all patients discharged from the four study units in the study
period and the subsets who fell at least once and/or acquired a pressure ulcer
during their hospital stay. The data were transferred electronically from the
hospital administrative database to the research database. Other variables obtained
electronically included age, sex, length of stay, unit admitted to, unit from which
discharged, primary diagnosis and associated ICD-10-AM codes. In addition,
secondary diagnosis, associated ICD-10-AM codes and whether a pressure ulcer
was present on admission and location code associated with a fall were also
obtained.
3.5.5 Data Analysis
Data cleaning was performed prior to analysis being undertaken. First, the
Microsoft Excel® spreadsheet provided by Decision Support Services (DSS) was
checked for each relevant ICD-10-AM code pertaining to the outcome measures
and a ‘1’ denoted for that patient in a column for falls or HAPU if they had one
coded and it met the criteria. Second, the patient data was rearranged to one line
per patient to assist in data cleaning, allowing for any duplications of patients to
be clarified and removed and to provide the demographic and clinical data for the
sample characteristics and monthly sample size. No duplications were found,
however eight babies accompanying their parent/carer who was the patient were
excluded. Missing data was not evident. One patient from surgical unit, S1 was
excluded as an outlier. The patient had a length of stay of 308 days and had been
discharged in October 2010.
Two files were created in SPSS Statistics for Windows version 20.0 (IBM,
New York, NY, US). The first file allowed for statistical analysis of the sample
71
characteristics and included age, gender, length of stay, primary diagnosis, date of
discharge, unit discharged from and whether they were pre or post intervention.
The t-test was undertaken for the continuous variables, age and length of stay and
Chi-square for the categorical variable gender. Codes were applied for this
purpose as described in Table 3. The second file contained the number of patients
discharged per month for each unit and the number of patients that experienced an
inpatient fall or HAPU per month for each unit for the NSIs analysis.
Table 3 Coding Variables
Description Code
Sex Male= 0, Female= 1
Study unit 1,2,3,4
Fall No= 0, Yes= 1
HAPU No= 0, Yes= 1
ICD-10-AM codes As per WHO classification I-XX
Month 1 to 27
Time Pre ‘1’, Post ’2’
Age Years
Length of stay (LOS) Days
Statistical process control (SPC) analysis was used to analyse the effect
locally developed transforming care interventions had on the two outcome
measures (Benneyan et al., 2003; Speroff & O'Conner, 2004). This is an analytic
technique first described in the 1920s in relation to manufacturing processes and
its application has been broadened since (Benneyan et al., 2003). It is increasingly
used in healthcare to guide action for continual improvement (Mohammed &
72
Worthingon, 2013). For example, SPC has been used to demonstrate improvement
following the introduction of a process change to medication administration by
nurses and introducing a care bundle aimed at reducing ventilator-associated
pneumonia (Morris et al., 2011; Richardson, Bromirski, & Hayden, 2012). The
analysis describes process variation and then determines if this variation is likely
due to chance (i.e. random or common cause variation) or some other event
(i.e.special cause variation). Natural variation will always create intrinsic common
cause variation (Mohammed, Panesar, Laney, & Wilson, 2013; Olatunde, 2009).
This needs to be recognised to allow special cause variation to be identified which
can be potentially either positively or negatively attributed to the intervention.
Therefore an advantage of SPC is that it provides a clear statistical indication of a
special cause and if that change is stable and or sustained (Callahan & Barisa,
2005).
SPSS Statistics for Windows version 20.0 was used to create the SPC
charts (IBM, New York, NY, US). In total, 27 data-points were used to generate
the charts, 14 pre and 13 post intervention. Sufficient data-points are required to
calculate the upper and lower control limits to develop the control charts
(Benneyan et al., 2003). Recommendations of 12 to 25 or more data-points have
been made to create a baseline (Lee & McGreevey, 2002; Polit & Chaboyer,
2012; Stapenhurst, 2005; Wheeler, 2000). It is often difficult to collect sufficient
data-points unless routine data sources are available (Grimshaw, Campbell,
Eccles, & Steen, 2000). These data-points were then used to develop the control
charts. Collecting more data-points increases the likelihood that some changes in
practice (i.e. history) may be falsely attributed as special cause variation (Polit &
Chaboyer, 2012).
73
The type of control chart selected was determined by the data under
analysis. A ‘p chart’ was used to monitor the proportion of events or attributes
under examination (Polit & Chaboyer, 2012). It is therefore appropriate for the
data derived from this study which was binary in nature (Mohammed &
Worthingon, 2013). The x-axis represents the time scale (i.e. months) and the y-
axis represents the proportion of the variable. The mean proportion is illustrated
by the solid centre line on the chart. Upper and lower control limits for the
inherent variation of the data are then generated by calculating three standard
deviations from the mean and drawing a line above and below the mean at this
value. These limits identify the range between which the data will be found
99.73% of the time when the process is stable and unchanged (Chetter, 2009).
Control limits are also calculated for one and two standard deviations from the
mean and some ‘rules of interpretation’ pertain to these limits.
The data for each NSI was analysed for each of the four study units to
calculate the overall mean and upper and lower control limits. A secondary
analysis was then performed to aid understanding of the findings. This split the
data to calculate the mean proportion of patients experiencing an inpatient fall or
HAPU in the pre and post intervention periods.
There are various ‘rules’ to interpret the statistical process control chart to
identify process improvement. In this study, process change (special cause
variation) was considered if one of Benneyan’s conditions were met after the
implementation of the initiative (Benneyan et al., 2003):
• one point outside the upper or lower control limits;
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• 2 out of 3 successive points > 2 standard deviations from the mean on the
same side of the centre line;
• 4 out of 5 successive points > 1 standard deviations from the mean on the
same side of the centre line;
• 8 successive points on the same side of the centre line; or
• 6 successive points increasing or decreasing (a trend).
We anticipated that the transforming care interventions would result in
process improvement. If consistent patterns of process improvement were seen
across the four units, it would enhance the generalisability of the findings. That is,
if consistent improvement emerges for both NSIs, across all four units, it increases
the likelihood that this improvement was due to the transforming care initiative.
3.5.6 Reliability and Validity
The reliability and validity of this phase requires consideration. The
reliability of the data for this phase is focused on the use of coded data, a
secondary source of data derived from the medical record. First, the data itself
may be limited by being incomplete within the record, lacking specific
information, difficult to interpret or verify, use of abbreviations and finally by the
general quality of documentation by heath care personnel (Farzandipour,
Sheikhtaheri, & Sadoughi, 2010; Gearing, Mian, Barber, & Ickowicz, 2006).
Health Information professionals can only code what has been documented, they
do not diagnose (Heslop et al., 2004). Therefore if the documentation is not clear
and complete, the accuracy of the coding will reflect this. However, a review of
eight methods of detecting adverse events in healthcare concluded that
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administrative data was less susceptible to ascertainment and selection bias than
other methods (Thomas & Petersen, 2003).
Second, inter-rater reliability of coded data is a potential further limitation.
Trained coders assign a code to diagnoses entered in the patient medical record by
healthcare professionals. The need to transcribe the data for electronic entry
creates the potential for transcription errors. Other coder-related factors such as
misunderstanding diagnoses and lack of attention to the International
Classification of Diseases principles can lead to miscoding (Farzandipour et al.,
2010). Importantly, to ensure accuracy and consistency, coders receive regular
training and an ongoing quality assurance, audit process is in place to assist with
addressing this issue.
External validity concerns whether the results can be generalised to other
settings and populations (Polit & Beck, 2012). The four study units were from one
hospital which weakens the potential to apply the results to other settings.
However the sizeable sample, and its cohort nature across four medical-surgical
units which included all patients discharged in those months, strengthens external
validity and reduces potential sampling bias.
With regard to internal validity, several factors associated with the
inference that the transforming care initiative influenced the NSIs, weaken this.
First, the use of coded data allowed a large amount of data to be collected but may
be confounded by in-hospital patient movement that occurred. The fall or
acquisition of the pressure ulcer may not have occurred in the study units as the
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associated ‘admission to’ and ‘discharge from’ unit information may not reflect
all intra-hospital movement.
A further limitation is the inability to control history. As this is a
retrospective study, it is not known whether other occurrences in the study units at
the time may have impacted on the outcome measures despite careful
documentation of the transforming care interventions being undertaken. With
regard to the sample, analysis of the pre and post sample groups attempted to
address this in order to examine whether there was a significant difference
between the groups. Further, other strategies to improve falls or pressure ulcer
management or other unanticipated events may have occurred outside of the
transforming care intervention. Finally, ‘the novelty’ of the transforming care
initiative may have led the staff altering their behaviour and becoming more
diligent in reporting and recording adverse events, the ‘hawthorne effect’ (Thomas
& Petersen, 2003). This could therefore have impacted on the post intervention
data.
3.6 Phase Two: Perceptions of the Impact and Sustainability of the
Transforming Care Initiative
3.6.1 Study Design
The second phase of the study used an interpretive approach to explore the
phenomenon of the implementation and sustainment of a local transforming care
initiative. Data were collected from semi-structured interviews. The questions
were focused on the implementation and sustainability of the initiative including
what may have or have not helped the initiative to have a sustained impact and the
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perceived benefits. This phase of the study was informed by the interpretive
paradigm.
The interpretive paradigm enables understanding gained through
interpretation of participants perceptions (Lincoln, Lynham, & Guba, 2011). A
paradigm can be considered as a set of beliefs or a frame of reference or a
worldview (Guba & Lincoln, 1994). It is a “broad view or perspective of
something” (Taylor, Kermode, & Roberts, 2007, p.5). This interpretive paradigm,
emphasises the understanding and meaning that individuals assign to their actions
and the reactions of others (Weaver & Olson, 2006). To clarify the methodology
selected for this study, the interpretive paradigm applied is considered in relation
to its ontological, epistemiological and methodological bases.
The interpretive paradigm views ontology (i.e. the world view) as reality
that is locally and specifically constructed (Guba & Lincoln, 2005). Knowledge is
constructed through the lived experiences of participants (Lincoln et al., 2011),
guided by the “researcher’s set of beliefs and feelings about the world as how it
should be understood and studied” (Denzin & Lincoln, 2005, p. 22). As reality
differs for everyone, there may be multiple realities as many views are represented
by the use of the actual words of participants (Creswell, 2007; Houghton, Hunter,
& Meskall, 2012). The ontological position in this study was influenced by the
particpants’ and the researcher’s views of working in the acute medical-surgical
units and implementing a transforming care initiative. Therefore as the researcher,
there was a need to be aware of my own experience, the social and contextual
meaning of the setting and phenomenon being explored. As the researcher, my
background in acute medical-surgical nursing was acknowledged, as was my role
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as a Nurse Educator working across the four pilot units. Shortly after the initiative
commenced, my role changed to a position which did not have direct
responsibility for the study units. Therefore as the researcher, I had some
understanding of the local context. On reflection of my values and prejudices,
there was an awareness of the potential to improve the safety and quality of care
and of the potential constraints to ‘best practice’ such as lack of time,
geographical layout of the units and skill mix, which may have contributed to a
general sense of a culture that was slow to accept or adopt practice changes. It is
also crucial to acknowledge that the participants were work colleagues of mine
and I therefore had a pre-existing relationship with them.
Epistemology, is concerned with the nature and scope of knowledge and
considers what the relationship is between the researcher and the phenomenon
being researched (Creswell, 2007; Denzin & Lincoln, 2011). In the interpretive
paradigm the relationship is transactional; that is findings are co-created as
meaning is generated from interaction between both the researcher and the
participant (Charmaz, 2006; Guba & Lincoln, 2005), through interview and
dialogue. Individual interviews were therefore used in this study to understand the
participants’ perspective of the phenomenon, implementating and sustaining a
transforming care initiative. Also, I was the sole interviewer of the participants
and therefore was able to realise the constructed realities of all participants and
ensure knowledge was reflective of both the the participants and my own realities
(Lincoln et al., 2011). However, as the epistemology is subjective I needed to be
aware of the impact of my perceptions on the study (Houghton et al., 2012). I
addressed this by using probes to ask participants to explain and expand on their
responses. Further, as the aim was to explore the ideas and perceptions of the
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participants in their natural settings, I exerted no control on the phenomena being
studied (Denzin & Lincoln, 2013).
Finally, the methodology (i.e. the process as to how new knowledge is
sought), was chosen to reflect the ontological and epistemological bases and
capture the participants’ experience (Guba & Lincoln, 1994; Houghton et al.,
2012). In this study, individual interviews and inductive content analysis were
used to collect and analyse the data to gain understanding of the individual
constructs around the phenomenon. This was congruent with the interpretive
paradigm. The emerging theory was my interpretation of the data.
To understand the data, it is necessary to be familiar with the participant’s
world (Holloway & Wheeler, 2010). This needs to be balanced with a
commitment to reflexivity, writing oneself into the research, rather than
reflectivity which requires the researcher to take a critical stance to their work and
was undertaken to assist in the analysis of the findings of this study (Walshaw,
2009; Holloway & Biley, 2011). Reflexivity is a means to negate non-evidenced
assumptions and ill-founded beliefs from influencing the interpretation of the data
(Dowling, 2006; Holloway & Biley, 2011). In this study I addressed being
reflexive by acknowledging my own reactions to the study, position and
preconceived ideas of the context, and the relationships encountered. I
acknowledged the potential influence and bias of my values and experiences on
the phenomena. The challenge was to not take what was thought known about the
setting for granted, but question assumptions about the setting (Holloway &
Wheeler, 2010). Notes were recorded as the study progressed of thoughts and
activities related to the study to promote reflexivity (McGhee, Marland, &
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Atkinson, 2007). Practicing reflexivity, building trust and rapport, maintaining
confidentiality and self-disclosure are integral to ensuring ethical conduct in these
circumstances and were strategies used (McDermaid, Peters, Jackson, & Daly,
2014). For example, I did not discuss who had agreed to participate in the study
with other work colleagues.
3.6.2 Sample
The purposive sample consisted of eight Registered Nurses (RNs) who
undertook various leadership roles. They included members of the transforming
care executive team, project team, nurse unit managers and clinical nurses. They
had been in their current roles from one to in excess of 25 years with some having
changed roles since the initial implementation. To preserve anonymity the sample
can only be described to a limited extent. The goal of selecting a purposeful
sample was to obtain cases deemed information-rich for the purposes of the study
and to learn about issues of central importance to the research (Patton, 2002;
Sandelowski, 2010). This sampling method is useful to achieve representation of
the setting, individuals or activities to assist in establishing comparisons between
settings or individuals (Maxwell, 2009). Several methods of selecting a purposive
sample have been identified (Patton, 1990) and applied to implementation
research (Palinkas et al., 2013). The critical criteria for this sample was that the
participants’ had been directly involved in the implementation of the local
transforming care initiative and continue their employment at the implementation
site. A range of nursing leadership roles were targeted. This reflected a criterion-
based selection method of purposive sampling (Palinkas et al., 2013).
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After the first six participants’ were interviewed, no new data was
emerging however, a further two participants’ were interviewed to ensure data
saturation was reached, also termed ‘informational redundancy’ (Lincoln & Guba,
1985). Preliminary analysis of the data after each interview assisted in confirming
that no new concepts or additional data was emerging. In the absence of published
guidelines for estimating sample size or rules, an adequate sample size is reliant
on comprehensiveness of the data, what will have credibility and what can be
done (Morse, 1995; Patton, 1990).
3.6.3 Data Collection
Individual interviews were used to collect data approximately 5 years after
commencement of the initiative. This was appropriate as the experiences, views
and beliefs regarding the phenomenon were being explored and it was expected
that individual constructions would have occured (Lambert & Loiselle, 2007). A
semi-structured interview format was selected. This type of interview provided
the interviewer with the option to ask further questions and probe in response to
spontaneous issues that arise (Ryan, Coughlan, & Cronin, 2009). Questions were
contained in an interview guide (Appendix A). The questions were not necessarily
asked in the same sequential manner at each interview, which provided flexibility
but ensured similar types of data were collected from all participants’ (Holloway
& Wheeler, 2010). Some notes were taken during the interview to assist the
researcher with probing. The probes were helpful in seeking further information
and meaning (Holloway & Wheeler, 2010). It is one of the advantages of
interviewing that clarification can be sought at the time through probing with
focused follow up questions (Doody & Noonan, 2013). The semi-structured
interview was used in this study as the researcher was not able to predict the
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impact and sustainability the participants thought the transforming care initiative
had, therefore it was necessary to have some questions prepared but retain the
capacity to add extra questions and probes to follow up on any new information.
The interviews were conducted at the participant’s convenience in a quiet
room with an attempt made to avoid disruptions such as telephones being
switched off and the chance of being overheard reduced (Doody & Noonan,
2013). An information sheet was given to participants and they provided their
verbal and written consent to be interviewed. Participants were asked to confirm
they were agreeable for the interview to be recorded and were advised they could
withdraw at any time if they felt uncomfortable. The interviews were digitally
recorded and transcribed by an experienced transcriber. The anonymity of
participants was preserved by the de-identification of the transcripts with the
removal of names from the transcript text. Although a transcriber was used, the
researcher listened to the recordings and proofed the transcripts, checking for
misspellings, omissions and to remove any identifying names. This also provided
an opportunity to reflect on the interview, add notes to the transcript, reflect on
any important issues and contribute to the contact summary sheet. These were
reflective notes written after the interview that for example, commented on
potential codes that were emerging.
3.6.4 Data Analysis
Data analysis involved a seriers of steps. First, contact summary sheets
were completed after each interview (Miles & Huberman, 1994). A contact
summary sheet written after the interview provided a reflection on the interview.
It was one basis for analysis through the identification of potential categories. It
83
acted as a reminder of the interview and a guide for planning future interviews
such as additional questions that may be asked (Hays & Singh, 2012; Miles &
Huberman, 1994). This assisted in the identification of potential emerging codes
and data saturation.
An inductive approach was taken to analyse the data. This meant there was
no predetermined theory, structure or framework with the data used to derive the
structure (Burnard, Gill, Stewart, Treasure, & Chadwick, 2008). The research
findings emerged from the raw data as frequent, dominant or significant
categories (Thomas, 2006). This is in contrast to a deductive approach, which
tests whether data is consistent with a predetermined framework (Burnard et al.,
2008; Thomas, 2006). In this way, content analysis was used to analyse the
qualitative data in an inductive way to build a model to describe the phemomenon
in a conceptual form (Elo & Kyngas, 2008).
Of the several inductive approaches to content analysis, this study used a
three phased process: preparation, organising and reporting (Elo & Kyngas,
2008). In the initial ‘preparation’ phase, the transcripts were read and reread and
notes recorded to increase familiarity with the data. Meaning units were generated
from the verbatim text of the interviews that related to each other through their
content and context (Graneheim & Lundman, 2004). The meaning units were then
assigned labels referred to as codes, which were mainly ‘in vivo’, using a word or
phrase from the verbatim text (Saldaña, 2013). In the following ‘organising
phase’, the data were organised through open coding, creating sub-categories and
abstraction of the data (Burnard et al., 2008; Elo & Kyngas, 2008; Graneheim &
Lundman, 2004). Categorising words and phrases assumes that they share the
84
same meaning (Cavanagh, 1997). Initially, the codes were organised into sub-
categories. The sub-categories were reviewed several times as familiarity with the
data was developed following rereading of the transcripts. Finally, through
abstraction, the sub-categories were grouped into the main categories, named with
content-characteristic words (Elo & Kyngas, 2008). Discussion with the
researcher’s academic supervisors ensured the categorisation was reflective and
representative of the data. The final ‘reporting phase’ was undertaken resulting in
a conceptualisation of categories and a ‘paper in draft’ to be submitted for
publication.
3.6.5 Trustworthiness
There is a need in all studies to demonstrate the validity of the
methodology. The results need to form an accurate reflection of the underlying
concept intended for the data (Brown, Hofer, & Johal, 2008b). Four criteria have
been suggested to assess the trustworthiness of qualitative inquiry: credibility,
transferability dependability and confirmability and were used in this study
(Graneheim & Lundman, 2004; Lincoln & Guba, 1985).
With regard to credibility, the participants were all exposed to the
initiative being studied and held positions both internal and external to the study
units. This provided a holistic perspective on the sustainability of the initiative
and could describe their perceptions of the transforming care initiative. Member
checking to improve trustworthiness could be used but this risks the participants
changing their minds and not recognising the data presented to them due to data
abstraction across all participants (Houghton, Casey, Shaw, & Murphy, 2013;
Morse, 1999; Sandelowski, 1993). Therefore the findings were checked against
85
other studies for congruence which also addressed transferability. In addition, a
detailed description of the study context and categories was provided to try to
generate a ‘thick description’ of the phenomenon (Lincoln & Guba, 1985). The
detailed description regarding the context and the inclusion of raw data assists
those seeking to appraise the extent to which the conclusions drawn are
transferable (Houghton et al., 2013).
To demonstrate dependability which is closely linked to credibility, a clear
description of the steps taken to manage, analyse and report the data was
maintained providing an audit trail (Lincoln & Guba, 1985). This should provide
information as to how repeatable the study may be (Krefting, 1991). This also
addresses confirmability as does the detail of the methodology and reflexivity and
reflection on my assumptions and beliefs (Shenton, 2004). The categories were
derived from the inductive analysis of the data and the voice of the participants is
heard in some of the category titles, assisting the reader to decide how the data
and emerging constructs may be applied (Shenton, 2004).
Researcher triangulation is a strategy to assist demonstration of
trustworthiness (Miles & Huberman, 1994). In this study, the researcher’s
academic supervisors assisted in the interrogation of the data and emerging codes
and categories and listened to ideas and concerns. This was with a view not to
achieve consensus, but to uncover a deeper meaning (Patton, 2002).
3.7 Ethical Consideration
This low risk study complies with National Health and Medical Research
Council (NHMRC) guidelines for the ethical conduct of the research (NHMRC
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2007). Approval for this study was received from the relevant hospital and
university Human Research Ethics Committees (HREC/10/QGC/1 and
NRS/06/11/HREC). A successful application was also made to Queensland Health
under Chapter 6 Part 4 of the Public Health Act (PHA), 2005 in order to access
patient medical record information.
Ethical principles guide all research. The priniciple of beneficience, to do
good, and non-maleficence, to avoid harm, are demonstrated by the low risk
nature of this study in that it did not expose individual nursing staff or patients to
unacceptable risks or harm. The implementation of locally developed
transforming care interventions were adopted as part of routine clinical practice
improvement (i.e. quality improvement), therefore no forseeable harm to patients
was identified. Patients were not recruited to this study, it was retrospective with
no patient care component, although PHA approval had been received. Individual
nurses were recruited for Phase Two and informed consent was obtained from the
participants (Appendix B and C).
With regard to the ethical principle of justice, in Phase One, the rights of
patients were protected by the use of de-identified data in an aggregated manner in
both the study and subsequent publications. In Phase Two, the participants’
privacy was protected by the de-identification of the data which was stored
securely on a password protected computer. Moreover, in Phase Two, the
informed consent of participants was sought and they were advised they could
withdraw at any time, who they could contact if they felt they were unfairly
treated in the study and that the risk/benefit ratio was low. Informed consent also
respected the principle of individual autonomy in that the nurses were informed as
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to the nature and consequence of the study. Reassurance was provided that
participation would not adversely affect their jobs and would not be used against
them. Careful consideration was given to the description of the sample to reduce
the potential for identification of the participants. No incentive was offered to
participants for their participation.
3.7.1 Confidentiality
All data from this study will be kept for seven years, as per ethical
requirements. Computer files are stored on password protected computers in
locked offices. Any paper data is kept in a locked filing cabinet in a locked office.
No identifying data will be used in publications resulting from this study.
3.8 Summary
This chapter has provided an overview of the method for both phases of
the study. The research questions have been clarified and the quantitative and
qualitative methods detailed. Phase One was a retrospective study using a time
series design to explore the relationship between the transforming care initiative
and NSIs. All patients discharged from four medical-surgical units that
implemented the transforming care initiative between July 2008 and December
2010, were included. Two NSIs were used to examine the impact of the initiative
on the safety and quality of patient care; inpatient falls and HAPU. Coded data
were collected electronically and analysed using SPC to generate control charts
for each unit and each NSI. Phase Two, an interpretive study, was used to explore
the perceptions of those involved in the implementation and sustainment of the
transforming care initiative. The sample consisted of RN leaders involved in the
implementation of the initiative. Individual digitally recorded, semi-structured
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interviews were undertaken. Following transcription, inductive content analysis
was used to analyse the data. Observance of the ethical principles guiding the
study have also been explored. The results of both phases are presented in the
following two chapters.
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4.2 Introduction
This chapter presents the results of Phase One of the study. The aim of
Phase One was to assess the relationship between transforming care and two
NSIs; inpatient falls and HAPU, in hospitalised patients in four medical-surgical
units. This phase reflects two components of Donabedian’s framework for
assessing the quality of care (Donabedian, 2005), the transforming care initiative
represents the ‘process’ component and the NSIs the ‘outcome’ component. First,
the results of the two surgical units are presented in the form of a summary and a
published paper. This is followed by the results of the two medical units as a
‘paper in draft’.
4.3 The Relationship between the Transforming Care Initiative and Nurse-
sensitive Indicators in Two Surgical Units
This paper presents the results of a cohort study that used historical
controls and time series design to examine the relationship between a
transforming care initiative and two NSIs; inpatient falls and HAPU in surgical
patients. The results demonstrated special cause variation in one unit for inpatient
falls post intervention. This suggests there may have been some improvement in
this NSIs following the implementation of the transforming care initiative
however it was not consistent across both units. After the paper, a secondary
analysis of this data is described, but it was not part of the paper.
4.3.1 ‘The Effect of a Transforming Care Initiative on Patient Outcomes in Acute
Surgical Units: A Time series Study’ (Paper 3)
Citation: Burston, S., Chaboyer, W., Gillespie, B., & Carroll, R. (2014).
The effect of a transforming care initiative on patient outcomes in acute surgical
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units: A time series study. Journal of Advanced Nursing, Advance online
publication July 2014 doi:10.1111/jan.12508
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4.3.2 Secondary Analysis of Data Pertaining to the Two Surgical Units
As part of this study, a secondary analysis of the data was performed, but
was not part of the published paper. This analysis involved splitting the data into
pre and post periods and analysing each separately. This aided the understanding
of the findings from the primary analysis.
The secondary analysis for Unit 1 showed that the mean proportion of
inpatient falls was 1.1% (0.011) pre and 0.5% (0.005) post intervention, however
this difference was not likely due to chance (i.e. special cause variation). The
increase in the mean proportion was significantly different for the two periods.
For Unit 2, the mean proportion of inpatient falls was 0.5% (0.005) pre and 0.4%
(0.004) post intervention, however this difference was likely due to chance (i.e.
common cause variation). The increase in the mean proportion was not
significantly different between the two periods.
The secondary analysis for Unit 1 showed that the mean proportion
experiencing a HAPU was 0.4% (0.004) pre and 1.0% (0.010) post intervention,
however this difference was likely due to chance (i.e. common cause variation).
The increase in the mean proportion was not significantly different between the
two periods. For Unit 2, the mean proportion experiencing a HAPU was 1.3%
(0.013) pre and 0.7% (0.007) post intervention, however this difference was likely
due to chance (i.e. common cause variation). The increase in the mean proportion
was not significantly different for the two periods.
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4.4 The Relationship between a Transforming Care Initiative and Nurse-
sensitive Indicators in Two Medical Units (Paper 4)
The draft of paper 4 presents the relationship between the transforming
care initiative and NSIs in two medical units. This paper has been submitted for
review.
Introduction
Nurses contribute to the safety of patient care, and influence patient
outcomes (Aiken et al., 2014; Blegen et al., 2011; Patrician et al., 2011). The
negative consequences of sub-optimum nursing care have been revealed in a
recent report into the failings of a UK public hospital (The Mid Staffordshire NHS
Foundation Trust Public Inquiry, 2013). Tools and resources are available to assist
nurses to provide quality nursing care from risk assessment frameworks for
specific purposes such as pressure ulcers (Braden & Bergstrom, 1994; Waterlow,
1985), to service delivery initiatives such as Transforming Care at the Bedside
(TCAB) and Releasing Time to Care: The Productive Ward™ (The Productive
Ward) (Institute of Healthcare Improvement, 2012a; NHS Institute for Innovation
and Improvement, 2012). These initiatives introduced in the past decade, are
being implemented, yet their impact on patient outcomes remains unclear.
Evaluation of improvement associated with the implementation of new nursing
practices may assist decision makers such as Nurse Managers to determine future
improvement activities.
TCAB, aimed at improving the safety and quality of patient care is based
on four pillars; safe and reliable care, patient-centred care, value added processes
and staff vitality (Rutherford et al., 2009). Specific interventions such as use of
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whiteboards for communication in patient rooms and clinical handover at the
bedside and hourly rounding (Needleman et al, 2009; Dearmon et al, 2013). The
Productive Ward is similarly aimed at improving the reliability and safety of
nursing care and particularly focuses on making more time for patient care
(Foster, Gordon, & McSherry, 2009). The implementation of nursing
interventions to transform nursing care is a key focus of both initiatives with the
nursing teams identifying the interventions appropriate to address issues specific
to their units.
There have been limited reports of the impact of TCAB and The
Productive Ward on patient outcomes with equivocal findings. Reduction in the
patients experiencing falls resulting in harm have been reported in the US and
Australia following implementation of TCAB initiatives (Chaboyer, Johnson,
Hardy, Gehrke, & Panuwatwanich, 2010; Dearmon et al., 2013; Needleman et al.,
2009). One of these studies conducted in the US also reported a reduction in
readmissions within 30 days but it was noted other clinical outcomes did not
demonstrate improvement (Needleman et al., 2009). A significant reduction in the
proportion of medication errors resulting in harm was also reported in an
Australian study (Chaboyer et al., 2010).
No improvement has also been reported in HAPU following
implementation of transforming care initiatves in two Australian studies (Burston,
Chaboyer, Gillespie & Carroll, 2014; Chaboyer et al, 2010) but a downward trend
in the prevalence of HAPU in a UK hospital that implemented The Productive
Ward has been demonstrated (Bloodworth, 2011). Improvement in hospital-
acquired infection rates have also been reported in the UK following
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implementation of The Productive Ward (Shepherd, 2008; Smith & Rudd, 2010).
For example the rate of Clostridium Difficile in one UK trauma-orthopaedic unit
reduced from six cases to zero in an eight month period compared with the same
eight month period the following year after the implementation of The Productive
Ward (Smith & Rudd, 2010).
The purpose of this study was to identify the relationship between
implementation of a transforming care initiative and two nurse-sensitive
indicators (NSIs), inpatient falls and hospital-acquired pressure ulcers (HAPU), in
two acute medical units.
Methods
Design
A time series analyses of administrative data were performed and non-
equivalent historical controls were used. Due to the rapid introduction of the
intervention in the study site, an experimental design was not possible, creating
the reliance on historical controls.
Setting
The study was conducted in two acute 28-bed medical units based in a 450
bed regional general teaching hospital in Australia that provided a wide range of
services except major burns or cardiac surgery. At the time the initiative
commenced, the nursing workforce of Unit 1 had 36.2 Full Time Equivalents
(FTE) nurses; of which 22.8 FTE were Registered Nurses (RNs). Unit 2 had 39.7
FTE nurses, of which 23.6 FTE were RNs.
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Participants
Participants included all 5,507 patients discharged from the two units
during the 30 month study period, with the exclusion of patients discharged from
the study units during the initial implementation period (September to November
2009). Each patient was only included once during their hospital stay, in the
month of discharge.
Measures
The NSIs selected as measures, inpatient falls and HAPU, were identified
by their ICD-10-AM codes, a coding system based on the International
Classification of Disease (ICD) developed by the World Health Organisation
(World Health Organisation [WHO], 2010) as described in Table 1. Their
selection was determined by their suggestion as outcome measures for TCAB
(Institute of Healthcare Improvement, 2012b), use in several studies measuring
the impact of nursing on patient outcomes (Schuelke, Young, Folkerts, &
Hawkins, 2014; Shuldham, Parkin, Firouzi, Roughton, & Lau-Walker, 2009) and
inclusion in the American Nurses Association set of indicators (American Nurses
Association, 2014).
An inpatient fall was identified as either ‘yes’ or ‘no’ for each patient. If a
patient had multiple falls these were included in the initial ‘yes’ response. The
same occurred for HAPU. If a patient had more than one HAPU these were not
calculated separately but included in the initial ‘yes’ response.
Data collection
Coded data were electronically sourced from the hospital administrative
database and transferred to the research database. Data for the pre intervention
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period were collected at 14 data-points (months), from July 2008 to August 2009.
The post intervention period data comprised 13 data-points (months), from
December 2009 to December 2010. Age, gender and the clinical characteristics of
primary diagnosis and associated ICD-10-AM codes (WHO, 2010), secondary
diagnosis and associated ICD-10-AM codes, unit admitted to, unit from which
discharged, length of stay and whether the pressure ulcer was present on
admission were retrieved from coded data. Pressure ulcers flagged as present on
admission would not be included in the data set.
Table 1 Nurse-sensitive Indicators
NSI Description ICD-10 codes
(WHO, 2010)
Inpatient fall ‘An unplanned descent to the floor with or without
injury to the patient, and occurs on an eligible
reporting nursing unit. All types of falls are
included, whether they result from physiological
reasons or environmental reasons’ (American
Nurses Association, 2014).
W01, W03,
W04-7, W017-
19
Hospital-
acquired
pressure ulcer
A “localised injury to the skin and/or underlying
tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear
and/or friction” (National Pressure Ulcer Advisory
Panel and European Pressure Ulcer Advisory Panel,
2009).
L89.0-89.9
Transforming care initiative
A local transforming care initiative had been developed based mainly on
the strategies of TCAB (Institute of Healthcare Improvement, 2012a) and The
Productive Ward (NHS Institute for Innovation and Improvement, 2012). A
110
project team consisting of a project manager and two project officers supported
the implementation. Two project officers had a nursing background and one an
allied health professional background. An executive team for the project was also
established to provide support. Staff engagement was encouraged through the
provision of local workshops to identify the issues that staff considered impacted
on their ability to maintain the safety and quality of nursing care. Communication
regarding the initiative was maintained through meetings, use of communication
notice boards in the units, conferences and workshops.
In response to the issues raised by staff, 10 specific interventions were
adopted and/or adapted by each unit. Nine specific interventions were common to
both units. Those implemented were categorised to one or more TCAB pillars
(Table 2). No attempt was made by the research team to influence these
interventions. The interventions were implemented concurrently, concentrated in
the initial three month implementation period.
Ethical considerations
National Health and Medical Research Council guidelines (2007) were
complied with for the ethical conduct of this study. Approval was given by the
relevant Human Research Ethics Committees; the study was considered to be low
risk as interventions were part of routine quality improvement. Individual patient
consent was not required.
Tab
l
e 2
Inte
r
vent
i
ons
Impl
emen
ted
Initi
a
lly
per
Med
i
cal
Uni
t
Sa
fe a
nd R
elia
ble
Car
e Pa
tient
Cen
tred
ness
St
aff V
italit
y V
alue
Add
ed
Bot
h un
its
Beh
ind
the
bed
whi
tebo
ards
To
flag
mob
ility
stat
us, e
xpec
ted
disc
harg
e da
te
Staf
f ide
ntifi
catio
n si
gns
Allo
cate
d nu
rse
iden
tifie
d ei
ther
at
bed
side
or a
t ent
ranc
e to
bay
Rew
ard
and
reco
gnis
e st
aff
activ
e pa
rtic
ipat
ion
So
cial
eve
nts
Org
anis
atio
n of
stor
es
5S1 u
sed
to re
arra
nge
stor
es to
re
duce
tim
e lo
okin
g fo
r eq
uipm
ent
Col
our
codi
ng o
f cha
rts
Des
igna
ted
colo
ur fo
r eac
h ba
y,
end
of b
ed c
harts
and
med
ical
ch
arts
Bed
side
han
dove
r In
itial
pat
ient
safe
ty u
pdat
e at
nu
rses
’ sta
tion/
jour
ney
boar
d fo
llow
ed b
y ha
ndov
er a
t the
be
dsid
e.
Tra
inin
g in
com
mun
icat
ion
stra
tegi
es e
.g. S
BA
R
Staf
f atte
nded
loca
l tra
inin
g pr
ogra
ms,
abov
e an
d be
low
the
line
beha
viou
r
Incr
ease
d fr
eque
ncy
of
mul
tidis
cipl
inar
y te
am
mee
tings
G
reat
er c
oord
inat
ion
of m
eetin
gs
and
broa
deni
ng o
f tea
m.
R
ound
ing
Hou
rly c
heck
by
nurs
es o
f the
ir pa
tient
s
Uni
t 1
A
llied
Hea
lth id
entif
icat
ion
sign
s W
hite
boar
d in
trodu
ced
to li
st
nam
es a
nd c
onta
ct d
etai
ls U
nit 2
Alli
ed H
ealth
ref
erra
l gui
de
and
stat
ion
Sum
mar
y of
how
an
d w
hat t
o re
fer a
nd o
utlin
e of
ro
les
112
Not
e. 1 5
S =
Wor
kpla
ce o
rgan
isatio
n, so
rting
, set
in o
rder
, sys
tem
atic
cle
anin
g, st
anda
rdisi
ng, a
nd su
stai
ning
2 S
BA
R=
Situ
atio
n, b
ackg
roun
d, a
ctio
n, re
com
men
datio
ns
111
112
Data analysis
Descriptive and inferential statistics were used to analyse the
characteristics of the sample. The number of participants, age range, range of
length of stay and the percentage of males in each group were reported for each
unit pre and post the intervention period. Analysis using the t-test and Chi-square
to examine for differences between the two time periods was undertaken for the
continuous variables, age and length of stay and categorical variable gender,
respectively.
To analyse the outcome data, statistical process control (SPC) charts
(Benneyan et al., 2003; Speroff & O’Connor 2004) were created using SPSS
Statistics for Windows version 20.0 (IBM, New York, NY, US). SPC is advocated
by the Institute of Healthcare Improvement based in the US and the National
Health Services in the UK to guide quality improvement (Duncan & Haigh,
2013). The charts identify whether variation that occurs in the number of patients
experiencing an inpatient fall or HAPU was likely due to chance (common cause
variation) or for some other reason (special cause variation). This method of
analysis acknowledges that some natural variation occurs in processes but if the
process is out of control, ‘special cause variation’ will be identified. SPC has been
recommended for use in exploring process change and to monitor quality in
healthcare (Coory, Duckett, & Sketcher-Baker, 2008; Thor et al., 2007). Once
special cause variation has been detected, further examination needs to occur to
determine what might explain it.
Of the different types of SPC charts that can be used, a ‘p’ chart was
deemed appropriate (Polit & Chaboyer, 2012). The outcome data were binominal
114
(no/ yes), and referred to the proportion of occurences at fixed data-points (i.e.
months). The x-axis depicts the sample months and the y-axis the proportion of
patients that experienced the NSI under examination. The solid centre line
represents the mean proportion of the NSI and the irregular stepped dotted line
above and below the mean represent the upper and lower control limits for the
chart. The data will be found within the upper and lower control limits denoting
three standard deviations from the mean 99.73% of the time (Chetter, 2009). To
develop an SPC chart a minimum number of data-points are required to calculate
the upper and lower control limits (Benneyan et al., 2003). Lines can also be
drawn at one and two standard deviations above and below the mean for
interpretation.
Rules of interpretation have been developed relating to the control limits
to examine whether data is randomly distributed between the control limits
(Benneyan et al., 2003). Examples are one point outside the upper or lower
control limits and four out of five successive points more than one standard
deviation from the mean on the same side of the centre line. Process change was
considered if one of these rules were met following the implementation period.
Two SPC charts were completed for analysis. Initially, the data for each
NSI per unit was analysed to calculate the overall mean and upper and lower
control limits. A secondary analysis was then performed, splitting the data to
calculate the mean proportion of patients experiencing an inpatient fall or HAPU
for each unit in the pre and post implementation periods.
115
Results
In the two medical units studied, 2,817 (51.2%) patients were discharged
in the 14 months pre intervention and 2,690 (48.8%) patients were discharged in
the 13 months post the intervention, providing sizeable sample groups. There
were no significant differences between the two groups with respect to age, length
of stay and gender (Table 3). The diagnostic groupings of the patients in each unit
was different, reflecting the variation in service profile. The top three ICD-10-AM
categories for Unit 1, across both the pre and post intervention time periods, were
IX (Diseases of the circulatory system), XVIII (Symptoms, signs of an abnormal
clinical and laboratory findings, not elsewhere classified) and VI (Diseases of the
nervous system). For Unit 2, the top three ICD-10 categories were X (Diseases of
the respiratory system), XVI (Diseases of the digestive system) and VI (Diseases
of the nervous system). No patients were coded as having a pressure ulcer pre-
admission.
The overall mean proportion of patients experiencing a fall in Unit 1 was
0.7% (0.007) and the same for Unit 2 (Figures 1). First in Unit 1, no ‘special cause
variation’ was evident in the pre or post intervention period (Figure 1a). The
secondary analysis showed that the mean proportion of inpatient falls in Unit 1
was 0.4% (0.004) pre and 0.8% (0.008) post, however this difference was likely
due to chance (i.e. common cause variation). The mean proportion was not
significantly different between the two periods. Second, in Unit 2 ‘special cause
variation’ was evident in the pre and post intervention period (Figure 1b). In
October 2008 and February 2009, pre intervention data-points were above the
upper control limit suggesting a higher proportion of patients were coded with
T
able
3. S
ampl
e C
hara
cter
istic
s of S
tudy
Uni
ts
M
edic
al U
nit 1
M
edic
al U
nit 2
Cha
ract
erist
ic
Pre
n=14
99
x̄ (S
D)
Ran
ge
Post
n=15
20
x̄ (S
D)
Ran
ge
p va
lue
Pre
n=13
18
x̄ (S
D)
Ran
ge
Post
n=11
70
x̄ (S
D)
Ran
ge
p va
lue
Age
(yea
rs)
62.9
(19.
4)
16-9
9
62.9
(20.
1)
16-9
6
0.9
60.4
(20.
1)
15-1
02
58.4
(20.
0)
17-9
7
0.1
Len
gth
of st
ay (d
ays)
4.
9 (6
.1)
1-74
4.8
(5.6
)
1-95
0.7
5.1
(5.1
)
1-50
5.3
(6.1
)
1-88
0.3
n
(%)
n (%
) p
valu
e n
(%)
n (%
) p
valu
e
Gen
der
(mal
e)
753
(50.
2)
763
(50.
2)
1.0
658
(49.
9)
592
(50.
6)
0.8
115
117
Figure 1a. P-charts: Proportion of patients coded as experiencing a fall in Unit 1 pre
and post intervention
Figure 1b. P-charts: Proportion of patients coded as experiencing a fall in Unit 2 pre
and post intervention
Figure 1. P-charts: Proportion of patients experiencing a fall coded pre and
post intervention
118
experiencing an inpatient fall. Also, two out of three data-points up to October
2008 were outside the second control limit line (line not shown). In the post
intervention period, eight consecutive data-points were below the mean as no
inpatient falls were coded during this period, suggesting process improvement.
The secondary analysis showed that the mean proportion in Unit 2 was 1.1%
(0.011) pre and 0.3% (0.003) post intervention. This difference was significant as
it suggests the variation was not due to chance, that improvement was shown.
The overall mean proportion of patients coded as developing a HAPU in
Unit 1 was 1.1% (0.011) and in Unit 2 was 1.5% (0.015) (Figures 2a and 2b). No
‘special cause variation’ was evident in Unit 1 in the pre or post intervention
periods. The secondary analysis showed that the mean proportion of patients
acquiring a pressure ulcer was 1.1% (0.011) pre and 0.9% (0.009) post in Unit 1,
however this difference was likely due to chance (i.e. common cause variation).
The decrease was not statistically significant. In Unit 2, none of the rules for
‘special cause variation’ were met (Figure 2b). The secondary analysis showed the
mean proportion of patients acquiring a pressure ulcer was 1.4% (0.014) pre and
1.8 % (0.018) post in Unit 2, but this difference was likely due to chance (i.e.
common cause variation). The increase in the mean proportion was not
significantly different between the two periods. Consequently, significant
improvement in the number of patients experiencing a HAPU did not occur.
119
Figure 2a. P-chart: Proportion of patients coded as acquiring a pressure ulcer in
Unit 1 pre and post intervention
Figure 2b. P-chart: Proportion of patients coded as acquiring a pressure ulcer in
Unit 2 pre and post intervention
Figure 2. P-charts: Proportion of patients acquiring a pressure ulcer coded
pre and post intervention
120
Discussion
The proportion of patients experiencing an inpatient fall or HAPU did not
appear to improve consistently across both units following the implementation of
the transforming care initiative. That is, there was improvement in only one NSI,
inpatient falls, in one unit. A decrease in falls resulting in harm, a different
measure to this study, has been demonstrated consistently in a large scale
evaluation of TCAB conducted in medical-surgical units in the US (Needleman et
al., 2009) and across two medical units in Australia that implemented a
transforming care initiative (Chaboyer et al., 2010). Whilst one unit in this study
demonstrated a potential improvement against one outcome, inpatient falls, it is
important to consider other potential explanations. The findings could be related
to the staff response to the initiative or factors surrounding the implementation
process including, availability of resources, leadership strategies, facilitation of
the change, preparation of Nurse Managers, communication strategies and
identification of specific problems to be addressed. Consideration of the
implementation process and reasons measurable improvement may not have been
achieved can offer insights for decision makers such as Nurse Managers looking
to implement and sustain improvement in nursing care.
With regard to the findings, other quality improvement activities may have
occurred in the units during the study timeframe which may have influenced the
findings. Additionally, staff were involved in the implementation of the initiative
and therefore were aware there was a focus on improving the safety and quality of
patient care. This may have led to an improvement in reporting and
documentation of adverse events such as inpatient falls and pressure ulcers. As the
data was sourced from the medical record, this could explain the findings. Under
121
reporting may have occurred pre intervention. The use of existing data for
research purposes is limited due it being recorded for reasons other than research
and is often not standardised, complete and is prone to subjectivity (Cheng,
Gilchrist, Robinson, & Paul, 2009; Jansen et al., 2005).
Availability of, and access to, resources including time may have impacted
on the success of this initiative due to the organisational context at the time of the
study. Demand for acute hospital services are high and nurses are faced with
increasing patient acuity, changing technology and meeting quality improvement
requirements, all of which generate additional work and staff shortages (Draper,
Felland, Leibhaber, & Melicher, 2008; Needleman, 2013). Nurses are constantly
challenged to reprioritise to meet these competing demands and finding time for
improvement activities is difficult and may create additional stress for the nursing
team (Davis & Adams, 2012). Therefore, Nurse Managers and their teams may
need to give themselves permission to redirect their energy in times of ‘stress’,
until they are able to refocus when the situation allows (Armitage & Higham,
2011). The important point is not to allow the change process to decay, but to
embed the new practices into current work routines and acknowledge that at a set
time the implementation of new interventions may recommence.
The leadership strategy used to implement the initiative in this study, may
have influenced the findings of this study due to inconsistency of membership and
maintenance. Leadership was provided initially by an executive team, a
multidisciplinary project team and Nurse Unit Managers, which was consistent
with strategies used to support implementation of comparable transforming care
initiatives (Farrell & Casey, 2011; McLaughlin & Burke, 2010; Robert et al.,
122
2011). Commitment of executive level support has been identified as core to the
success of such initiatives (Wilson, 2009). Additionally a benefit of the leadership
of the Nurse Unit Managers is that they know their staff and are positioned to
choose the right team members to assist with implementation (Davis & Adams,
2012). Although these initiatives promote a ‘bottoms up’ approach, the advocacy
and support of leadership at a senior level may have provided organisational wide
support and assistance with challenges. Therefore the disbandment of the
executive and project teams reduced the support available to the Nurse Unit
Managers.
A further impact on the findings may have resulted from a key part of the
leadership strategy, the facilitation of the change by a project team. The
experience in facilitating change of the project team members was not explored.
However, dedicated project leadership including clinical facilitation has been
identified as a key facilitating factor for similar initiatives (Robert et al., 2011).
Change agents, whether external or internal, create different challenges. The
project team members were mixed, with one drawn from a study unit and two
external to the study units. External change agents require credibility in the eyes
of the end-users, and should be trained in developing interpersonal relationships
with the end-users, to be successful (Rogers, 2003). Conversely, internal change
agents drawn from other roles may not possess the skills or knowledge in change
theories and strategies (Saka, 2003). Regardless of internal or external origin,
facilitators need to have the expertise to be able to recognise the requirements of
the situation and adapt (Rycroft-Malone et al., 2002).
123
The leadership experience and preparation of those leading the initiative
could account for the findings of this study if they were inexperienced in leading
change. In associated transforming care initiatives, Nurse Managers identified
personal benefits such as growing their leadership skills, gaining confidence and
using their initiative (Armitage & Higham, 2011; Davis & Adams, 2012). The
potential for leadership development was not always recognised upfront, but was
seen as an unexpected benefit (Davis & Adams, 2012). Respondents to a survey
exploring the implementation of The Productive Ward, identified that the
initiative had acted as a ‘practical leadership programme’ (Robert et al., 2011). In
contemporary initiatives preparation training was given to Nurse Managers to lead
group sessions and to generate ideas for improvement (Farrell & Casey, 2011;
Martin et al., 2007; Stefancyk, 2008b). Preparation of Nurse Managers to lead
changes in nursing practice and improvement therefore requires consideration.
Communication strategies may also have influenced the findings if staff
did not feel engaged with the process. Strategies used during the implementation
of this initiative included ward meetings, notice boards and conferences and were
congruent with those used in analogous initiatives (Davis & Adams, 2012; Farrell
& Casey, 2011; McLaughlin & Burke, 2010). Communication of change and
engagement of staff is important to sustainment of quality improvement initiatives
as this empowers staff and provides them with a sense of ownership (Smith &
Rudd, 2010). This is not always easy to achieve. Variable working times of staff
across day, evening and night shifts can make communication and teamwork
difficult (Armitage & Higham, 2011). Communication strategies are required to
identify interventions and to communicate decisions. The impact on the
124
engagement of staff was not measured so an assessment cannot be made of the
effectiveness of the communication strategy.
Finally, ideas for improvement were generated by staff in the study units
taking part in workshops. The use of group meetings to generate ideas is
consistent with methods used in similar initiatives (Martin et al., 2007; Viney et
al., 2006). Group sessions termed ‘deep dives’, led by a designated TCAB team,
enabled staff to share their knowledge, make observations on current conditions
and brainstorm and model ideas (Viney et al., 2006). ‘Snorkels’, a smaller version
of the ‘deep dive’, which Nurse Unit Managers considered important to the
engagement of staff, have also been used to implement TCAB (Parkerton et al.,
2009). The discovery workshops used locally resembled the ‘snorkel’ approach.
In the US, in Phase II of the TCAB pilot in excess of 400 innovations were tested
to respond to ideas collated from brainstorming sessions, staff suggestions and
ideas implemented at other hospitals (University of California Los Angeles-
RAND Evaluation Team, 2007). This provides an example of the wealth of ideas
that can be generated by easily accessible sources. In this study, nine out of the 10
interventions implemented by the two units were the same. This may have been
due to the staff in the two units identifying similar issues they wished to address at
the ‘snorkel’ sessions. Alternatively, the project team may have been influential in
the selection of interventions, although it may not have been intentional.
Limitations
This study was limited in several ways. First, this study was undertaken in
two units in one hospital. The interventions were therefore contextual to those
units. However, this reflects the strategy of TCAB, tailoring the interventions to
125
the needs of specific units. Second, the reliance on coded data is another potential
limitation. The integrity of data obtained from the medical record is reliant on the
quality and accuracy of recording and transcription by healthcare professionals
and health information staff which can be impacted by factors, not least human
error. However, health information staff who perform the coding are trained and
retrained and regular audits are performed to ensure high quality coding.
Additionally, coded data may not contain important information that might help
with understanding the analysis and findings as it is not primarily undertaken for
research purposes. Third, there was no guarantee that interventions were occurring
on every shift. This could have impacted on the time taken to embed changes in
practice and for them to become the accepted norm with interventions becoming
adopted as ’the way it is done here’. Finally, due to the lack of control over
implementation of the intervention, retrospective historical data was analysed as
the available data source. This means that other interventions occurring in the
study units may be responsible for the findings, SPC allows process change to be
identified but it does not allow cause-effect relationships to be determined.
Conclusion
Despite the change process including elements similar to other
contemporary transforming care initiatives and the implementation of 10
interventions, the benefits of this initiative for patient outcomes remain unclear.
When implementing a transforming care initiative, Nurse Managers must invest in
planning to ensure local factors are considered. They need to discern at the outset
how they will know the impact of the initiative to inform a robust measurement
strategy. Nurse Managers are not alone in trying to achieve sustained
improvement in the safety and quality of patient care and need to continue to
126
explore the options for implementation, interventions and robust methods of
monitoring outcomes, until improvement is achieved.
4.5 Summary
The aim of this phase was to examine the effect of the implementation of a
transforming care initiative on two NSIs, inpatient falls and HAPU. This study
used retrospective controls and coded medical record data of patients discharged
from four acute medical-surgical units. Between 10 and 12 interventions were
introduced in each unit. Transforming care nursing interventions introduced as
part of the initiative across all units included bedside handover, behind the bed
‘whiteboards’ and increased multidisciplinary team meetings. The data were
analysed using statistical process control. A consistent improvement was not
shown across the four study units with only some improvement demonstrated with
respect to inpatient falls in one surgical and one medical unit as summarised in
Table 4. That is process improvement was identified in two of the eight SPC
analyses. The benefits of the initiative on NSIs is unclear in this study.
Table 4 Summary of Improvement of NSIs
Unit Inpatient falls HAPU
S1 Improvement No change
S2 No change No change
M1 No change No change
M2 Improvement No change
Note. S= surgical unit, M= medical unit
127
128
CHAPTER 5
Phase Two Findings
5.1 Introduction
This chapter presents the findings of Phase Two of the study, which
explored the perceptions of nurse leaders involved with the transforming care
initiative with regard to implementation and sustainability. Some of the structural
and process factors associated with the implementation and sustainability as
perceived by the nurses involved were explored using Donabedian’s ‘Structure,
Process and Outcomes’ framework (Donabedian, 2005). The findings are
presented as a ‘paper in draft’. The ‘paper in draft’ provides the study background,
methods, findings and a discussion.
5.2 Implementation and Sustainment of a Local Transforming Care
Initiative: People, Process and Product (Paper 5)
The draft of paper 5 presents the perceptions of nurses who participated in
the implementation and sustainment of the local transforming care initiative.
Introduction
The majority of improvement efforts in healthcare fail to result in
sustained change, waste associated resources and can be slow to spread (Berwick,
2003a; Essén & Lindblad, 2013; Hovlid et al., 2012). Yet, quality improvement in
healthcare is required, as hospitalised patients continue to be at risk of
experiencing adverse events (D'Amour et al., 2014; de Vries et al., 2008).
Globally, nurses have recognised the need to improve this situation and are
making concerted efforts to address issues concerning the safety and quality of
patient care. Nurse-led initiatives are being implemented into a dynamic and
129
challenging clinical environment informed by limited studies that focus primarily
on sustainability of complex innovations, (Greenhalgh et al., 2004; Stirman et al.,
2012). This paper reports the perceptions of nurses involved with the
implementation and sustainability of a ‘transforming care’ initiative providing
insight into the potential of these initiatives to improve the safety and quality of
patient care.
Background
Several international inquiries into healthcare have highlighted concerns
regarding the safety and quality of patient care, asserting that acceptable standards
of healthcare are not being met (Queensland Public Hospitals Commission of
Inquiry, 2005; The Mid Staffordshire NHS Foundation Trust Public Inquiry,
2013). Concurrently, nurses are voicing concerns over not being able to meet
patient and carer expectations (Ford, 2012). Further, an increasing emphasis on
the need to introduce improvement in healthcare provision is driven by clinical
evidence, technological change and regulatory and governance change. Nurses are
therefore trying to change the way they work, introducing innovation to improve
the safety and quality of care. Implementation of quality improvements is not
straightforward and can be difficult to sustain. The explanation may be related to
the implementation, rather than the new strategies or goals being inappropriate or
ineffective (Caldwell et al., 2008; Nembhard, Alexander, Hoff, & Ramanujam,
2009). Frameworks may offer some guidance to introducing improvement
interventions and promote sustainability.
Health care systems are complex (Best et al., 2012; Lipsitz, 2012), and
making changes to patient care is challenging (Grol et al., 2007). Theories of
130
change have been developed from a variety of disciplines including social science,
research utilisation in nursing and organisational management (Estabrooks et al.,
2006) and can be grouped according to their level of impact; individual, group or
organisational (Rycroft-Malone & Bucknall, 2010). For example, theories related
to changing individual behaviour include the Theory of Planned Behaviour
(Ajzen, 1991), ‘Adult Learning Theory’ (Knowles, 1980) and the
‘Transtheoretical Model of Behaviour Change’ (Prochaska & DiClemente, 1983).
These theories are limited in their direction on how to go about the process of
implementing change. In contrast, linear theories of change offer staged
approaches (Lewin, 1951; Rogers, 2003). These theories are by nature more
prescriptive. However, it has been argued that these theories of change do not
address the complexity of change and are process focused (Burnes, 2004; Grol et
al., 2007). Alternatively, contemporary models such as the ‘Behaviour Change
Wheel’ (Michie et al., 2011) have been applied to translate knowledge to practice.
This model attempts to draw together aspects of several constructs of all these
theories (Brehaut & Eva, 2012). Models of change should reflect the need to
address change at multiple levels and be cognisant of the context in addition to
activities at each stage of the process. Accordingly, application of more than one
theory may be necessary to implement complex interventions (Rycroft-Malone &
Bucknall, 2010).
Irrespective of the theory of change applied, multiple factors can facilitate
or hinder the implementation of change including, leadership, relevancy,
partnerships, facilitation support, integrating change with existing programs,
contextual issues, teamwork, engagement or ownership and resource deficits
(Bradley et al., 2004; Dogherty et al., 2013; Irwin et al., 2013; Solomans &
131
Spross, 2011). Consideration needs to be given to these factors to promote
sustainability, “a point at which new ways of working become the norm and the
underlying systems and ways of working become transformed in support”
(Greenhalgh et al., 2004, p.32). This proposes that the new practice has been
integrated and desired outcomes continue to be delivered (Doyle et al., 2013; NHS
Institute for Innovation and Improvement, 2007). However, a perceived successful
implementation may not continue as planned (Stirman et al., 2012) or
‘improvement evaporation’ may occur (NHS Institute for Innovation and
Improvement, 2007). Reports of the implementation and sustainment of
transforming care initiatives have been undertaken primarily in the US and UK
(National Nuring Research Unit [NNRU] and the NHS Institute for Innovation
and Improvement, 2011; Parkerton et al., 2009; Robert et al., 2011; University of
California Los Angeles-RAND Evaluation Team, 2007). These have underscored
the challenges of introducing nursing practice change. There remains a need to
understand what and how improvement interventions in health care are
implemented and sustained to assist future improvement initiatives. In fact, the
longevity of transforming care initiatives is far less understood than initial
implementation.
Aim
The purpose of this study was to explore the implementation and
sustainability of a local transforming care initiative implemented in four acute
medical-surgical units.
Design
An interpretive approach was used to explore the phenomenon of the
implementation and sustainment of a local transforming care initiative.
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Sampling
The purposive sample consisted of Registered Nurses (RNs). Participants
were interviewed until it was felt that no new data appeared to be emerging. At
this point, a further two participants were interviewed to ensure data saturation.
Inclusion criteria were that participants were directly involved in the
implementation of the local transforming care initiative and continued their
employment at the implementation site.
Transforming care initiative
In 2009 a local transforming care initiative commenced as a pilot in four
medical-surgical units. It was based on the implementation frameworks and
strategies of Transforming Care at the Bedside (TCAB) (Institute for Healthcare
Improvement 2012) and Releasing Time to Care: The Productive Ward™ (The
Productive Ward) (NHS Institute for Innovation and Improvement 2012). Both
are nurse-led and patient-focused and are aimed at trying to improve the safety
and quality of patient care, improve work processes and environments for nurses
and give nurses more time for direct patient care. Executive and project teams
were formed to provide support. Unit staff were facilitated in identifying issues
they considered impacted on their ability to maintain the safety and quality of
nursing care and to source solutions. Interventions implemented related to
handover of clinical information, increasing patient participation in care,
improving team communication and increasing multidisciplinary collaboration.
Data collection
Semi-structured, face-to-face, digitally recorded interviews were
conducted in 2014. In order to understand not only the immediate implementation
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of transforming care but its longevity, this data was collected about five years
after transforming care was initiated. An interview schedule was developed with
questions focused on the implementation and sustainability of the initiative
including what may or may not have helped sustain it and the perceived benefits.
Examples of the questions are, ‘What do you think have been the benefits of [the
initiative] since implementation?’, and ‘What do you think may have sustained
[the initiative]?’ Field notes were made during the interviews to note points for
further discussion. Interviews were transcribed and anonymity of participants
preserved by de-identification of the transcripts.
Ethical considerations
This study adhered to the guidelines for the ethical conduct of the research
of the National Health and Medical Research Council (NHMRC 2007) with
approval received from the relevant Human Research Ethics Committees. The
project was considered low risk. Informed consent was given by the participants
and they were assured that confidentiality would be maintained. Participants were
identified A to H, to preserve anonymity.
Data analysis
Inductive content analysis was used to analyse the data (Elo & Kyngas,
2008). This meant there was no predetermined theory, structure or framework, the
data being used to derive the structure (Burnard et al., 2008). The analysis
included three stages: preparation, organising and reporting (Elo & Kyngas,
2008). The meaning units of analysis selected in the ‘preparation’ phase was
generated from the verbatim text of the interviews that related to each other
through their content and context (Graneheim & Lundman, 2004). These meaning
units were then assigned labels, ‘codes’, and the transcripts were read and reread
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and the codes applied. During the ‘organising’ phase, the codes that were
considered to be related were grouped into sub-categories. The sub-categories
were reviewed several times as familiarity with the data developed following
further rereading of the transcripts. Finally, relationships were determined
between sub-categories and they were grouped accordingly into the main
categories. Some of the code and category titles were ‘in vivo’, derived directly
from the data. The final ‘reporting’ phase is addressed by the dissemination of the
findings including publication.
Trustworthiness
Four criteria have been suggested to assess the trustworthiness of
qualitative inquiry: credibility, dependability, confirmability and transferability
(Lincoln & Guba, 1985). First, credibility was addressed by the participant’s
exposure to the initiative being studied and that they held positions both internal
and external to the study units. This provided a holistic perspective on the
sustainability of the initiative. Second, to address dependability, discussion with
the researcher’s academic supervisors ensured the categorisation was reflective
and representative of the data (Thomas, 2006). A clear description of the steps
taken to manage, analyse and report the data was maintained providing an audit
trail (Appendix D) to assist dependability and confirmability (Lincoln & Guba,
1985). Lastly, the results were checked against other studies for congruence, also
addressing transferability.
Findings
The sample of eight RNs consisted of members of the transforming care
executive team, project team, nurse unit managers and clinical ‘bedside’ nurses.
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All four pilot units were represented. These nurse leaders held management and
clinical roles, and were nurse grades six to nine. In the Queensland Health nurse
grade classification, RN grade six tend to work clinically at the bedside. Grade
seven and above work in advanced practice roles, management, lead education or
research positions. Participants were all female with an average age of 47.6 years,
with a range of 30 to 66 years. They had been in their current roles for one to in
excess of 25 years. Some had changed roles since the initial implementation. The
interviews ranged in duration from 14 minutes to 37 minutes.
Six categories emerged from the data relating to the implementation and
sustainment of the initiative; 1) Engaging the team, 2) “Shifting culture”, 3)
Rolling out transforming care, 4) Leading the change to transforming care, 5)
“Seeing the change” and 6) Entrenching the new ways of working (Table 1). Each
category is presented with verbatim quotes to illustrate the findings.
Engaging the whole team
The category, ‘Engaging the whole team’, reflected the participants’
perceptions of the need to include other health professionals and staff groups, not
just nurses. ‘Engaging’ refers to the participants’ view of being inclusive and
collaborative. ‘The whole team’ refers to participants’ perception of the need to
include all staff: nurses, ancillary, allied health and medical staff. Three sub-
categories blended together to form this category; ‘Building team cohesiveness’,
‘Communicating information in the nursing team’ and ‘Partnering with other
teams’. The sub-categories explicated strategies that participants perceived
engaged staff in the initiative and associated interventions.
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Table 1 Sub-categories and Categories Derived
Sub-categories Categories
Communicating information in the nursing team Engaging the whole team
Partnering with other teams
Building team cohesiveness
Resisting change Shifting culture
Shifting culture
Planning implementation of transforming care Rolling transforming
care out Implementing the initiative
Introducing transforming care interventions
Adapting transforming care to context
Aligning transforming care to other initiatives/
priorities
Leading the change to
transforming care
Reorganising services
Leading the change
Managing resistance to change
Participating in transforming care
Focusing on the patient and family in transforming
care
Knowing the benefits of transforming care
Seeing the change
Embedding the change
Sharing what you are doing to learn what works
best
Entrenching new ways of
working
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Various engagement strategies were described by participants. These
included collaborative decision making, open communication to encourage the
team to sustain interventions and encourage the flow of information and team
building strategies, such as having fun through unit events and the recognition of
achievements. Strategies included, “Always keeping people informed and having
an open door policy” (E).
“I think for staff, it did give them an opportunity to join in and some did
get really quite enthused about making changes and getting involved” (F)
The effort to engage staff appears to have impacted on the participants
leadership style as they adapted their decision making approach, “A lot of the
decisions are made with the staff. It's not me dictating how they do their work”
(D), recognising “really it was devolved leadership” (A)
The need to involve all staff in the initiative was strongly perceived by
most participants, “We have to include everyone from cleaners all the way
through to your, well, my line manager, so your DONs and things like that” (D).
Engaging with the medical and allied health practitioners appeared to be highly
valued, “I would say that it was really well received. We had consultants coming
to groups and discussions fairly early on in the piece” (F). However, mixed
feelings were also apparent with regard to the involvement of medical officers.
One participant suggested there was some resistance from medical officers and
that they had to provide supporting evidence regarding interventions, prior to
medical officer participation. Nearly all the participants were positive regarding
team functioning and perceived the resulting collaboration and team cohesiveness
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positively. One participant expressed that their team was, “more connected as a
service with where we're going with our patients” (E).
“Shifting culture”
The category, “Shifting culture”, was related to the participants’
perceptions of the impact of culture on the implementation and sustainment of the
initiative. ‘Shifting’ refers to the participants’ perceptions that the existing culture
needed to change. Two sub-categories came together to form this category;
‘Resisting change’ and ‘Shifting culture’. These sub-categories overlap in that
resistance to change was perceived as a reflection of the historical culture that
needed to be changed. Participants described strategies aimed at changing
behaviour and moving to a culture of willingness to change practice and accept
change.
Several participants’ perceived that there had been resistance to
implementing changes to nursing practice by some nursing staff. The participants
described a historical nursing culture that was “still very underpinned by the old
culture” (A), and was, “not patient focused” (C).
“There wasn’t a lot of room for new or different staff to come into our unit
and bring their wealth of years of knowledge and different ways of doing it
and knowing, into the unit because it was quite a stagnant environment
and the philosophies hadn’t changed for many, many years.” (E)
A few participants offered their insight into resistance and non-
engagement. These included nurses having their own routine on other shifts as
they were not involved in decision making and therefore by implication, not
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engaged. Additional suggestions included a reluctance to challenge colleagues’
practice, staff not trained in the new practices and not getting feedback. Further, a
couple of participants also perceived that some staff were more willing to accept
change than others. One participant expressed frustration, “I can accept change
and I can't understand why others can't.” (H).
A perception of some participants seemed to suggest that the initial
implementation had been successful, “It has changed culture” (C).
Communication strategies that had been implemented included educating staff in
how to respond to poor communication and reinforce appropriate behaviour,
giving staff permission and the words to speak up. Conversely, one participant
appeared less positive, perceiving that the cultural change achieved was not to the
extent that had been anticipated.
“I think there's elements of it that's still around but to the complete change
of culture to what they were advocating right at the beginning, no.” (A)
Rolling transforming care out
The category, ‘Rolling transforming care out’, was related to the
participants’ perceptions of various aspects of implementing the transforming care
initiative, at both organisational and unit levels. The category title was derived
from the verbatim text used by a participant, “Roll it out” (C). Implementation at
the organisational level was described in relation to the formation of executive
and project teams and the support these offered. Participants also described the
implementation of the initiative and interventions at a unit level and how these
were adapted locally. Four sub-categories came together to create this category;
‘Planning implementation of transforming care’, ‘Implementing the initiative’,
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‘Introducing transforming care interventions’ and ‘Adapting transforming care to
context’. Important aspects of implementation were the strategy, the facilitation
and adaptation to the unit context. These sub-categories, although distinct,
overlapped as they described aspects of the actual process of implementation
across the pilot units.
“So we tried to roll it out in a coordinated way and a way that was going
to be sustainable” (C)
A focussed implementation strategy that included goals, core (pilot) units
and a facilitation plan was described by some participants. Objectives in the form
of goals and milestones appear to have been set at organisational and unit level.
One participant suggested these milestones “we wanted to hit” (C), were not
achieved due to others having different priorities, although it was not clear who is
meant by ‘others’. This impacted on expectations of achievements. In addition, a
decision was made, although it is unclear by who from the data, to limit initial
implementation to four core units. The use of core units created the situation
where concurrently, some units were not implementing the initiative. Some
participants viewed this as a potential issue for patients who may have
expectations of nursing practices from their experience on a core unit, “when one
patient moves from one ward to the other ward, they tend to not know what's
going on” (E). This reflected the reality that patients were often transferred within
the hospital following admission.
Implementation was facilitated by project and executive teams. The initial
facilitation provided was viewed positively and encompassed assistance accessing
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resources, initiating transforming care in the units and introducing associated
interventions. A couple of the participants mentioned the assistance the project
team provided in the units, role modelling the interventions such as bedside
handover. The team may have acted as a driver to maintain the momentum and it
was identified that “If you don't have anyone driving it, then that's when you can
fall off the bandwagon” (B). Some participants’ perceived a loss of support and
momentum for implementation as time went on.
All participants considered there was flexibility for units to localise the
initiative and interventions at unit level. A ‘one size fits all’ approach to
implementation was eschewed by participants. Units were empowered to select
the interventions they wished to introduce as part of the initiative.
“I'd be disappointed if they did alter it or change it or tell us how best to
do our business when I think it's up to every ward in how they utilise it and
what benefits they get out of it.” (D)
As a core unit there was no precedent regarding interventions to be
implemented, although participants described the importance of ensuring those
interventions introduced were evidence based. Participants valued the prerogative
to try interventions and indicated a willingness to “just give it a go” (B). If an
intervention did not work feedback was sought and then they would try the
revised intervention or try something different.
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“we created a bedside handover template and then after some time, I know
we assessed what was necessary and what was not and got rid of some things,
added others” (G).
Leading the change to transforming care
The category, ‘Leading the change to transforming care’, encompassed
the leadership aspects of implementing change at an organisational level and the
leadership strategies participants’ perceived they used. This category was
generated from five sub-categories; ‘Aligning transforming care to other
initiatives and priorities’, ‘Reorganising services’, ‘Leading the change’,
‘Managing resistance to change’ and ‘Participating in transforming care’. These
sub-categories focused on the experience of managing change in a dynamic
environment.
All participants identified two major changes that had occurred in the
organisation since the initiative was implemented. First, there was a restructure of
the organisation and second, there was a relocation of the facility. Participants
were seemingly struggling with the changes brought about by these factors with
several describing a change of key staff, which appeared to lead to a refocusing of
priorities, creating inconsistency. Participants considered this was due to a lack of
understanding of the local context.
“Probably, that change of people, didn't know the discussions that had
been had or the history or whatever. So, you've got people acting in
positions all the time and that probably wasn't a good thing for that
project.” (F)
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Further, a few participants also expressed the need for alignment of new
priorities with the initiative, incorporating existing strategies and terminology.
Moreover, these new priorities meant that staff were learning new technology and
organisational practices, compounding those driven by the initiative.
“we've come a long way, they're familiar with the naming conventions and
what we call things in terms of the safety scrums, all of that sort of
terminology. We shouldn’t move away from that now because we're being
inconsistent as an organisation.” (C)
Participants appeared to perceive resistance to some interventions from
some staff and took different approaches to managing this. A couple of
participants described not giving much attention to those resisting the initiative,
which did result in some nursing staff accepting the changes eventually.
Alternatively, one participant perceived that it was important to work on the
resisters and that it was an ongoing issue, “they do eventually come around and
then by that stage you've got some new people in that you have to work on as
well” (H). In trying to address resistance, education was seen as a strategy, “If
you've not trained them, you can't blame them” (A).
A positive attitude was noted from the participants with regard to their
perception of the change. One participant reflected that “I’ve been nursing for
nearly 30 years and I can see that this is a really good team way of nursing” (G).
The participants also reflected on their ability to lead change and the challenges
faced in regard to their development as a leader. Some participants recognised
they had learnt from the experience, “it was a massive learning curve and I feel
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it's trial and error” (D). Other participants appeared comfortable with leading
change.
“You become very skilled at subtle change and big change and knowing
the difference and how to implement them.” (E)
“Seeing the change”
The category, “Seeing the change”, described participants’ perceptions of
the effect of the transforming care initiative on patients and the organisation.
Demonstrating the effectiveness of any quality improvement initiative is a key
requirement. Participants’ perceived the benefits in relation to staff, patients and
the organisation. Two sub-categories constructed this category; ‘Focusing on the
patient and family in transforming care’ and ‘Knowing the benefits of
transforming care’. These sub-categories reflected the aims of the initiative and
how the participants’ perceived these had been achieved.
All of the participants related that they felt the initiative increased the
patient focus of care. Participants appeared to be positive about the inclusion of
patients and families by nurses and the multidisciplinary team in decision making
regarding their plan of care.
“The staff are in the rooms at the end of the bed including the patients, one of
the pillars, ‘if it's about me, it’s not without me’, is still resounding through the
department” (E).
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Interventions implemented such as rounding, regular visits by the nurse to
check the patients’ status, and clinical bedside handover were perceived to
promote a greater focus on the patient, “patients loved bedside handover, loved
being involved in the discussion” (F). A participant described how rounding was
an opportunity to engage with the patient and deal with complaints actively.
Participants also made performance information available to patients through the
use of whiteboards. This was considered as being open with the patients and their
families. The use of thanks and complaints were viewed by participants as a
measure of feedback on staff performance.
Some measurement of outcomes appeared to have taken place during the
initial implementation year. Participants mentioned the use of audits to review
practice alongside existing tools including patient and staff satisfaction survey
reports. Benefits perceived by some participants were related to less delays to
discharge, fewer missed medications, improved adherence to risk assessments and
a better culture.
“We actually did the proper medication audit that the hospital does. We did it
before and we did it afterwards and there was quite a dramatic
improvement.” (F)
However, a few participants did not seem aware of formal measurement
and analysis of the benefits, ‘We didn’t do any statistics on it’ (E). There was
however some indication that measures were ongoing with whiteboards used to
display related information. Participants mentioned that information was still
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being posted on the white-boards’ in the units several years post initial
implementation.
Entrenching new ways of working
The category, ‘Entrenching new ways of working’, referred to the
participants’ perceptions of how the transforming care initiative had become
embedded in everyday practice. The category comprised of two sub-categories;
‘Embedding the change’ and ‘Sharing what you are doing to learn what works
best’. These sub-categories shared a common notion related to strategies that were
perceived to assist in sustaining the changes in practice.
Most participants described strategies that they considered embedded the
changes into practice. These included the use of tools, prompts, consistent
terminology and integrating the initiative into all other management practices,
such as orientation of staff. Several participants expressed their intention to
continue with transforming care as they felt they had sustained the initiative. One
participant described the initiative as a “living concept” (A).
A continuous improvement focus was evidenced by ongoing adaptation of
interventions. Interventions had been further adapted, prompted by the move to a
new facility such as in response to new ward layouts. This supported the concept
that the initiative continued, “Just taking it as what we do, this is how we provide
our patient care” (G). Further, there were examples of interventions perceived to
be beneficial, spreading to non-core units.
Maintaining momentum was perceived by several participants as being a
challenge to embedding the initiative. “We had a big push right at the beginning,
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and a couple of smaller pushes along the way” (A). It appeared that one of the
explanations for this may lie in the other concurrent changes occurring within the
organisation, disrupting implementation. A further challenge mentioned by a few
participants was constraint on time, particularly when the project team was
disbanded, “because the support went, they were then expected to try and do it in
their own time and it doesn’t happen” (F). Most participants suggested strategies
that they considered would be beneficial to sustainment. These included access to
tools to reinforce practice, workshops, forums, a website and also a person to
‘facilitate’ the initiative. It was also apparent participants wanted to share what
they were doing.
“Seeing what other people do, we’ve just created it and we’re in isolation.
I don’t know what other people are doing and if they’re doing something
that could be working better.” (G)
These six categories derived from the experience of nurses implementing
and sustaining a transforming care initiative, can be conceptualised as a beginning
model for the implementation and sustainment of a new model of nursing care,
‘The 3P’s’ model of sustained implementation of a new model of nursing care’.
The six categories have been organised into three domains: people, process and
product (Figure 1). This new model has arisen due to this PhD study. ‘People’
refers to those factors related to engaging the teams and the team culture.
‘Process’ relates to implementation of the initiative at organisational and unit
level. Finally, ‘product’ refers to the sustainment of the interventions and the
benefits derived and the dissemination ‘marketing’ of those benefits. Each domain
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influences the other, while the nexus could support the implementation and
sustainability of a transforming care initiative.
Figure 1 The 3P’s Model of Sustained Implementation of a New Model of
Nursing Care.
Note. TC= Transforming care
Discussion
The findings of this study, generated five years after the initial
implementation, suggest that there was evidence the local initiative had been
sustained. Despite the challenging circumstances, evidence of interventions
undergoing further adaptation in the units studied and spreading outside of the
four pilot units, suggested that the initiative had continued and been embedded.
This prevented the transforming care initiative from experiencing ‘improvement
People • Engaging the team
• Shifting culture
Product • Seeing the
change • Entrenching new
ways of working
Process • Rolling out TC • Leading the change to TC
TC
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evaporation’, which can occur due to loss of staff, commitment or financial
pressures (National Nursing Research Unit and the NHS Institute for Innovation
and Improvement, 2011). Participants’ responses identified key factors that
contributed to or challenged implementation and sustainment. These factors are
considered in relation to people, process and product.
People
Engagement of staff and a shift in culture were perceived by the
participants as positive factors in the sustainment of the initiative. This was
congruent with benefits resulting from the introduction of a similar initiative
across the UK; teamworking, staff experience and job satisfaction (NHS Institute
for Innovation and Improvement & NNRU, 2010; Van Bogaert et al., 2014). The
need to engage with all those involved in the change and the importance of an
open, transparent supportive culture committed to learning, is well recognised
(Leape et al., 2009; Moss, 2013).
Support of the executive team and team communication may have
contributed to improved team culture and engagement. The commitment shown
by the executive team to support the ideas and solutions offered by the clinical
teams has been acknowledged as an important factor in engaging clinicians,
perhaps due to affording autonomy and some control; a ‘bottoms up approach’
(McGrath et al., 2008; NNRU and the NHS Institute for Innovation and
Improvement, 2011; Pearson et al., 2009). Ownership and the ability to provide
input into improvement projects have been known to empower nurses (Lennard,
2012; Wilson, 2009). Increased engagement also affects nurses’ job satisfaction,
and is associated with factors such as autonomy and co-worker interaction (Hayes,
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Bonner, & Pryor, 2010). These factors reflect characteristics of this initiative and
may have assisted its success in engaging staff.
Some resistance to the change was perceived by participants. Sabotaging
of tidy cupboards and wiping information off ‘wipeboards’ are examples of active
resistance that can occur (Armitage & Higham, 2011). Resistance may be due to
the challenges of communicating to a team that works across the 24 hour
continuum. Poor communication of the vision can cause transformation efforts to
fail (Kotter, 2007). A historical culture could also contribute to resistance,
creating a reluctance to change practice. Challenges arising from a historical
culture were also perceived by participants implementing The Productive Ward
(Davis & Adams, 2012). It is important therefore to understand the reason for the
lack of participation and engagement in order to strategise a response. However,
others have found that an increase in staff engagement with time following the
implementation of TCAB (Needleman et al., 2009).
Participants articulated the opportunity for professional leadership
development offered by implementing the initiative. This corroborates the
findings of comparable initiatives in the US and UK (Kliger, Lacey, Olney, Cox,
& O'Neil, 2010; Morrow et al., 2012; NHS Scotland, 2008). Suggested leadership
training content includes an understanding of the factors that affect sustainability,
action learning skills and skills to communicate and manage change (Allsopp,
Faruqi, Gascoigne, & Tennyson, 2009; Clarke & Marks-Maran, 2014).
Furthermore, inclusion of passive and active strategies to manage resistance of
some members of the team may assist those implementing the change. Further
exploration of the types of education and support for those engaged in
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implementing quality initiatives is required (White et al., 2013). All nurses need
to recognise that with the dynamic nature of contemporary healthcare, change is
inevitable and therefore they need to be equipped to enact and lead change
initiatives to assist sustainment.
Process
The key processes explored were implementation and sustainability.
Several factors appear to impact sustainability: the implementation approach,
alignment with organisational context, leadership, adaptation of interventions and
time constraints. Those leading transforming care in this study did not formally
apply a theoretical approach or conceptual framework to implementation.
However, the initiative was consistent with several strategies suggested by
frameworks to promote knowledge translation and spread such as providing
facilitation, promoting team engagement, affording ownership of the initiative at
unit level, role modelling, providing information and providing feedback
(Abraham & Michie, 2008; Rogers, 2003). The use of multiple strategies reflected
the requirement for change at multiple levels and in different contexts; executive,
unit, professional and individual levels. The formal use of a framework to guide
implementation may have assisted in a more structured approach to the selection
of strategies to support the change. This may have helped to anticipate and
address factors that impacted sustainment of the initiative.
Organisational commitment to the leadership of the initiative was
challenged by the changing organisational context, influenced by a restructure,
changing stakeholders, new priorities and dissolving of the project and executive
teams, yet the transforming care initiative continued. Participants demonstrated
persistence and concurrently responded to other local or corporate changes.
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Struggling to maintain alignment with organisational priorities has been
recognised in evaluation of similar initiatives (Davis & Adams, 2012; Lavoie-
Tremblay et al., 2014; Robert et al., 2011; Wright & McSherry, 2013b). The need
to align the goals of the improvement initiative with organisational ones is seen as
an influential characteristic to enhancing the process of implementation and
sustainability (Kotter, 2007; Massoud, Nielsen, Nolan, Schall, & Sevin, 2006;
NNRU and the NHS Institute for Innovation and Improvement, 2011). Goal
alignment may prevent the initiative being displaced or decaying. Although goal
alignment may have been hindered in the study setting by radical organisational
change, a relocation of the facility and an organisational restructure, the nurse-led
initiative appears to have continued at a unit level.
The responsibility for selecting interventions resided mainly at unit level
and was valued by participants, but some were led by the leadership team. For
example, clinical handover at the bedside was driven by these leaders. Also, many
similar interventions were introduced by the study units which may reflect the
input of the project team or influence of publications providing readily available
interventions. The ability to reinvent interventions within the local context is seen
as positive, to be expected and occurred often (NHS Institute for Innovation and
Improvement, 2007; Stirman et al., 2012). A rapid change cycle, assisted the
introduction, observation and review of interventions quickly to assess their
benefit, reflecting the ‘Plan-Do-Study-Act (PDSA)’, cycle (Institute of Healthcare
Improvement, 2014; NHS Institute for Innovation and Improvement, 2008). Such
an improvement model encourages flexibility at a local level to adapt
interventions, potentially impacting on fidelity. However, mandating certain
interventions to be implemented risks the engagement of the staff even if they are
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evidence based and valid. This could also risk the initiative becoming a
predetermined set of interventions rather than a response to local issues. A
potential strategy is to be honest about any mandated requirements and
communicate the reason they should be viewed positively (NHS Institute for
Innovation and Improvement, 2007).
Finally, time constraints appear to have challenged sustainability aspects
of the process. The loss of support perceived when the project team was
disbanded appears to have contributed to the perceived lack of time to implement
interventions. This constraint was consistent with previous reports of the negative
impact of staffing pressures (Kendall-Raynor, 2010; Robert et al., 2011) and lack
of protected time (Wright & McSherry, 2013b). Commitment by the organisation
to ongoing resources may have addressed this issue and assisted sustainment.
Product
‘Product’ refers to the outcomes of the implementation of the transforming
care process and the dissemination and promotion of those outcomes.
Measurement is integral to improvement to identity if the changes are having the
desired effect (Nolan, Schall, Erb, & Nolan, 2005). Participants appeared to feel
strongly that there was improvement despite limited objective evidence. However,
whiteboards were used to display some performance measures including nurse-
sensitive indicators such as falls and HAPU. This echoes the ‘Knowing How We
Are Doing’ boards implemented as part of The Productive Ward program
(Bloodworth, 2011). Displaying of performance in this way can act as a driver for
change, prompting staff (Wright & McSherry, 2013a). However, robust
measurement appeared to have been limited in this initiative, creating a reliance
on anecdotal self-reports and use of some existing measures. This is reflective of a
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review of 125 studies on sustainability of program or intervention effectiveness
that demonstrated only nine identified effectiveness (Stirman et al., 2012). In
addition, poor compliance with the measurement component of the PDSA cycle
has been reported (Taylor et al., 2013).
The lack of compliance may reflect the challenges of measurement rather
than a reluctance to demonstrate effectiveness. Ease of data collection of
performance measures has been identified as influential in an evaluation of
TCAB, which noted that widely used measures such as pressure ulcers and falls
were those that were routinely collected and therefore data was readily available.
(University of California Los Angeles-RAND Evaluation Team, 2009). However,
if identifying the effectiveness of the improvement is important for sustainment
and to focus further improvement, the challenge of measurement needs to be
addressed.
In addition, to assist in embedding the initiative, opportunities for
reporting progress and achievements could encourage spread and potentially
avoid ‘islands of improvement’ (NNRU and the NHS Institute for Innovation and
Improvement, 2011). This can be viewed as ‘marketing’ the product.
‘Communities of practice’ offer the opportunity for healthcare staff to come
together to learn from each other and exchange information and knowledge
(Ranmuthugala et al., 2011). Benefits of participation in a ‘Community of
practice’ have included the provision of opportunities for continuing education
and professional development and to seek advice and discuss clinical issues
(Rolls, Kowal, Elliott, & Burrell, 2008; Urquhart et al., 2013). The development
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of such a community of practice could have assisted the nurses to share their
experiences and knowledge of implementing and sustaining the initiative.
Limitations
This was a small scale study conducted at one facility and therefore
generalisability is restricted, although qualitative research aims for conceptual
understanding not generalisability. This study is of value in contributing to the
understanding of influential factors that can impact on transforming care
initiatives. Participants were nursing leaders purposively selected and agreed to be
interviewed and it may be that views were therefore not representative of all
nurses who participated in the initiative or those who were reluctant to participate.
Additionally, it had been five years since the commencement of the pilot and with
the changes that had ensued in the organisation since, participants did need to take
time to recall events that had occurred. It is always possible that if participants
had been interviewed at different time points throughout the study it may have
resulted in different understandings of the process. However, thoughtful
consideration in their responses and consistency among the participants afforded
trustworthiness.
Implications for Nursing Practice
Perceptions of nurse leaders implementing and sustaining transforming
care initiatives can be considered in relation to three domains; people, process and
product. Additional influential factors may correspond to these domains and
further examination and development is required. Nurses need to see that with the
dynamic nature of contemporary healthcare, change is inevitable and therefore
they need to be willing to embrace this. The application of a formal
implementation framework should be considered to assist in addressing the
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challenges in relation to implementation and sustainment of a transforming care
initiative.
Conclusion
Multiple factors can impact on the implementation and sustainability of
transforming care initiatives, and can be conceptualised in three domains; people,
process and product. Whilst this representation is simplistic, it may act as an
easily recalled conceptualisation for nurses participating in or leading
implementation and sustainment of new models of nursing care. Factors aligned to
these domains derived from the findings included staff engagement and culture,
flexibility for adaptation to context and measurement. Undoubtedly, additional
factors would be congruent with these domains and they warrant further
exploration. What was clear is that implementation was not a single event. It may
have had an identifiable starting point but not a clear end point. The process is
ongoing and one that needs to be continually nurtured.
5.3 Summary
This chapter has presented the findings of Phase Two of the study that
explored the perception of eight RNs who were involved in the implementation
and sustainment of the transforming care initiative. Individual semi-structured
interviews were conducted and the digital recordings were transcribed. Inductive
content analysis was used to analyse the data. The findings indicate that the
initiative had been sustained particularly at a local unit level. The six main
categories derived from participant responses on the implementation and
sustainment have been discussed in relation to some of the influential factors that
impacted on sustainment. Further examination is required to explore these and
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other factors. The findings will be further considered with those of Phase One in
the following chapter, which provides a discussion of the findings of both phases
of the study. This discussion is followed by consideration of the limitations of the
study. Finally recommendations for nursing practice, education and research are
discussed.
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CHAPTER 6
Discussion
6.1 Introduction
This study assessed the impact of a local transforming care initiative in
one Australian hospital. A review of the relevant literature identified limited
evidence to date on transforming care initiatives in the Australian context. The
findings of this study identified the impact of a local transforming care initiative
on patient outcomes and sought understanding of the implementation and
sustainment of the quality improvement initiative. A synthesis and discussion of
the findings is presented in relation to previous studies. Further, the limitations of
the study are discussed. Finally, the contributions this study makes and
recommendations that arise from it, are identified.
6.2 Summary of Findings
This study was conducted in two phases to address the two research
questions. First, the study examined the relationship between a local transforming
care initiative and two NSIs; inpatient falls and HAPU, in hospitalised medical-
surgical patients. Second, the study explored the implementation and
sustainability of the transforming care initiative. Phase One, used a non-equivalent
control group design with historical controls and an uncontrolled interrupted time
series. Phase Two, used an interpretive approach.
The findings of Phase One identified a significant improvement in one
surgical and one medical unit, in relation to the proportion of patients
experiencing an inpatient fall. Conversely, no significant improvement in
inpatient falls was seen in the remaining two units. Also, no significant
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improvement in the proportion of patients experiencing HAPU were seen in any
of the four units. Therefore consistent improvement in NSIs was lacking in the
four study units.
The findings of Phase Two demonstrated that nurse leaders perceived that
the transforming care initiative had positive benefits for patients and staff and had
been sustained, particularly at a local unit level. Six main categories were derived
from participant responses, representing factors considered to have influenced the
implementation and sustainability of the initiative. These were conceptualised
within three domains; people, process and product.
Overall, the study discovered the relationship between transforming care
and NSIs was not consistent. This was in contrast to the perceptions of nurses
involved with implementation, that transforming care had improved patient safety
and benefitted staff. Large scale evaluations of similar contemporary initiatives
have been undertaken in the UK and US. Our findings are congruent with a large
scale evaluation in the UK of The Productive Ward by the National Nursing
Research Unit (NNRU) for the National Health Service (NHS). Perceived benefits
for patient safety were reported, but consistent long term trends in clinical
outcomes or staff outcomes were not demonstrated, although a few hospitals and
units reported longer term improvements, for example related to inpatient falls
(NHS Institute for Innovation and Improvement & NNRU, 2010, p. 8-11). In the
US evaluation of TCAB, undertaken on behalf of the Robert Wood Johnson
Foundation by the University of California-RAND evaluation team (Robert Wood
Johnson Foundation, 2011), they found that following a pilot in 10 hospitals from
2004 to 2008, falls resulting in harm and deaths within 30 days of discharge, had
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been significantly reduced (Robert Wood Johnson Foundation, 2011, p. 23-24),
but other clinical outcomes showed little improvement. The reduction in falls
resulting in harm has been most consistently demonstrated internationally
(Chaboyer et al., 2010; Dearmon et al., 2013; Moore & Blick, 2013). Therefore,
whilst there appears to be consensus from evaluations of similar initiatives and
this study, that nurses involved with transforming care initiatives perceive benefits
for patients and staff, the picture concerning NSIs is less convincing. Several
explanations for this dichotomy between the objective and subjective evidence are
discussed in relation to the three domains conceptualised by the ‘3P’s model’;
people, process and product.
6.3 People
Some clarity regarding the disparity in the findings of this study could be
provided by ‘people’ related factors. Through the use of an interpretive approach,
the findings showed that promoting teamwork, collaboration and engagement of
staff when implementing and sustaining a transforming care initiative, were
perceived to be important and the initiative appeared to have some success in
achieving this. The findings demonstrated consistency with emerging evidence
from the US and UK in relation to the implementation of similar initiatives, citing
participation as an enabling factor (Needleman et al., 2009; Van Bogaert et al.,
2014; Wilson, 2009; Wright & McSherry, 2013b). Our findings therefore reflect
the importance of interdisciplinary collaboration for patient safety in general,
emphasised in the ‘To Err is Human’ report by the Institute of Medicine and the
‘National Standards for Safety and Quality in Healthcare Standards’, which also
reinforce the need to include all staff (Australian Commission on Safety and
Quality in Healthcare, 2011; Institute of Medicine, 1999).
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Ineffective communication and poor teamwork has been estimated to
account for approximately 55% to 75% of healthcare errors (Hughes, 2008;
Leonard, Graham, & Bonacum, 2004; Riley et al., 2010). Several characteristics
of teamwork have been identified: quality of collaboration, shared mental models,
coordination, open communication and shared leadership and clarity of roles
(Manser, 2009; Wheeler & Stoller, 2011). However, health professionals may be
challenged by their work conditions in regard to demonstrating these important
characteristics of teamwork. Medical teams in healthcare work under conditions
that change frequently, have a dynamic membership, work together for short
periods of time and have to integrate different professional cultures (Manser,
2009). These work conditions appear equally applicable to nurses. If teamwork is
considered inherent to positive patient outcomes it would seem appropriate that
nurses cultivate the ability to function effectively in teams.
The findings of this study also identified the nursing culture was not
conducive to change with some resistance to the initiative by nurses and difficulty
engaging some members of the interdisciplinary team. Again this has been noted
in similar initiatives and manifested as disinterest and scepticism (Armitage &
Higham, 2011; Bloodworth, 2009; Davis & Adams, 2012). Knowing that staff
need to be engaged and work collaboratively does not necessarily translate into
their actually doing so.
There is a plethora of theories and models to assist in engaging staff and
promoting teamwork, to translate knowledge to action and change associated
individual behavioural (Graham & Tetroe, 2009; Kitson, Harvey, & McCormack,
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1998; Prochaska & DiClemente, 1983). These theories and models are not always
clear on how to actually achieve engagement and some focus on individual
behaviour change rather than group behaviour. Active strategies employed in the
implementation of similar initiatives have included participation in designing
interventions (Pearson et al., 2009), involvement in testing interventions
(Armitage & Higham, 2011; Parkerton et al., 2009), devising a communication
strategy (White et al., 2013) and generally fostering a ‘bottom-up approach. In
fact, several of these active strategies were used by the leaders at this study site.
Conversely, a passive approach that tolerates disrespectful, disruptive
behaviour and defers to existing behaviour and culture, may cause poor morale
and result in a failure to challenge poor practice (Dixon-Woods, McNicol, &
Martin, 2012; Leape et al., 2009). A non-punitive approach has been advocated to
respond to individuals’ non-engagement, encouraging a systems focus when
trying to understand when errors occur and drive improvement (Berwick, 2003b;
Institute of Medicine, 1999). Interview findings, suggest the nursing leaders did
face some resistance, but developed strategies to address this resistance.
Promoting change through fear or regulation may result in ‘work arounds’ and be
unlikely to produce lasting commitment to change (Moss, 2013). Implementation
of active strategies such as audit, feedback and education are preferred (Daly,
Kermode, & Reilly, 2009; Eveillard et al., 2011; Reynolds, Dulhunty, Tower,
Taraporewalla, & Rickard, 2013). While only briefly mentioned by some
participants, the display of performance measures on whiteboards, reflects audit
and feedback, in a passive way. The ability to select and use these strategies
appropriately can be viewed as ‘processes’, however the implications for nurses
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participating and leading implementation, are that they require the leadership
commitment and style to promote staff engagement.
The perception by participants of this study that they had devolved
decision making and promoted open dialogue suggests that they may have
adopted a ‘transformational leadership’ style. Similarly, a small UK study of six
participants from a cardiothoracic unit participating in The Productive Ward
initiative, identified that the nurses had portrayed a ‘transformational’ leadership
style (Davis & Adams, 2012). If a transformational leadership style is capable of
developing followers and for promoting safety participation (Bass & Steidlmeier,
1999; Casida & Parker, 2011; Clarke, 2013), then it would seem relevant that
nurses participating in or leading transforming care initiatives aimed at improving
patient safety, should consider adopting this leadership style. In addition, they
should adopt this style in an authentic manner. Authentic leaders believe and act
in accordance with their values and beliefs, building credibility, respect and trust
through leading employees in a way that is seen as authentic (Avolio et al., 2004).
Authentic leadership has been associated with greater work engagement of nurses
and perceived decreased adverse patient outcomes (Bamford et al., 2013; Wong &
Giallonardo, 2013). Further, nurses need to be able to adapt their leadership style
to the situation. Nurse Managers have been found to use up to four leadership
styles with choice influenced by ‘significant’ people, work history, clinical
context and flow of information (Vesterinen, Isola, & Paasivaara, 2009).
Therefore nurses participating in a transforming care initiative might find it useful
to adopt an authentic transformational leadership style to engage staff varying
their style according to the context. As it is unclear from this study the extent to
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which nurses adopted a transformational leadership style throughout the study
period, if they did not, it may offer an explanation for the disparate findings.
Finally, the findings of this study showed that the process of
implementation and sustainment is complex and the nurse leaders perceived
leadership support was provided by the project and executive teams until their
disbandment. Project teams are often used to facilitate implementation of new
initiatives (Farrell & Casey, 2011; McLaughlin & Burke, 2010; Robert et al.,
2011), but, they are not always maintained. In a busy hospital environment where
nurses have competing priorities, they often struggle to find time for improvement
activities (Davis & Adams, 2012). Yet, they are required to sustain the initiative.
Sustainment of the transforming care initiative despite dissolution of the project
team suggests other nursing leaders were able to provide ongoing support to staff.
This study confirmed the importance of the engagement of staff to the
implementation and sustainment of a new model of care. This has implications for
nurses in regard to the leadership style they adopt to promote engagement.
Consequently, this study contributes insight by identifying the benefit of
strengthening nurses’ leadership capability in leading and participating in
transforming care initiatives enabling them to promote the engagement of all staff.
6.4 Process
Further clarity regarding the findings can be achieved by exploration of
‘process’ related factors. The findings provide both advances and contributions to
knowledge related to the processes of implementing and sustaining transforming
care initiatives. First, the advancement of knowledge of the process to the
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Australian context will be discussed. Second, insight regarding the process in
relation to the development of the ‘beginning model’ will be explored. Third,
insight regarding potential process related reasons for the lack of consistent
improvement will be debated.
First, in relation to the advancement of knowledge, no studies could be
sourced that explicated the process of implementing and sustaining a transforming
care initiative situated in the Australian context. Only two studies have been
published in the Australian context (one forms part of this PhD) and they focus on
the impact of transforming care through exploration of the association of
transforming care and NSIs (Burston et al., 2014; Chaboyer et al., 2010). The
findings of this study identified that multiple factors could potentially have had a
negative impact on implementation and sustainment including emergent and
planned organisational change, interventions selected, withdrawal of the executive
and project teams and time constraints. For example, with regard to intervention
selection, the majority of interventions were similar across all four units which
may suggest that selection may have been more directed than reflective of a
‘bottom up’ approach. Additionally, the leadership support provided by an
executive and project team, perceived ability to select interventions at unit level
and team engagement were potential facilitating factors, and are congruent with
factors identified from similar international reports of implementation of
transforming care initiatives (Martin et al., 2007; Moore & Blick, 2013; NHS
Institute for Innovation and Improvement & NNRU, 2010; University of
California Los Angeles-RAND Evaluation Team, 2007; Wright & McSherry,
2013a).
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Our findings also reflect the multiple factors found to be influential to the
adoption process of large and small scale innovation, generally. These include,
trialability, observability, leadership, involvement of all staff and ability for staff
to raise issues and contextualise solutions (Greenhalgh et al., 2004; Kaplan et al.,
2010; Rogers, 1995; Saladino, Pickett, Mall, & Champagne, 2013; White et al.,
2013). Trialability refers to experimentation with the intervention by the users and
observability refers to the visibility of the benefits to the users of the intervention
which makes it more easily adopted (Greenhalgh et al., 2004). Both these
concepts were evidenced in this study through the units adapting the interventions
to suit their local context and their positive perception of the benefits for patients
and staff encouraging them to continue with the interventions. Conceptualisation
of these factors initiated a ‘beginning’ model of implementing and sustaining a
transforming care initiative, the ‘3P’s Model’.
Second, insight into the process of implementing and sustaining a
transforming care initiative was provided by the development of a ‘beginning’
model of implementing and sustaining a new model of nursing care. Despite our
‘3P’s Model’ being in its embryonic stage in terms of model development,
consideration of its similarities and differences to other models helps in its
development and refinement. The domains of people, process and product are
consistent across many models of implementation and sustainment but differ in
their conceptualisation.
The ‘Promoting Action on Research Implementation in Health Services
(PARIHS) framework identifies three elements for successful implementation; the
level and nature of evidence, the context into which the evidence is implemented
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and the method by which the process is facilitated (Kitson et al., 1998). A
similarity between this model and the ‘3P’s model’ is afforded by the alignment
of our process domain and the method element of the PARIHS framework. A
notable difference is the recognition by the PARIHS framework of the strong
influence of the organisational context and that some contexts are more conducive
to implementing evidence than others, in contrast to the current ‘3P’s model’ that
had considered it within the ‘process’ domain. In addition our model considers
leadership and teamwork and engagement within a ‘people’ domain in contrast to
the PARIHS framework which incorporates this into the ‘context’ element
(Rycroft-Malone & Bucknall, 2010). Further this framework differs from the
‘3P’s model’ with regard to the third element of ‘evidence’ which the ‘3P’s
model’ considers again within the process domain in regard to the interventions.
The NHS Sustainability model also represents factors influential to
sustainment of service improvement as a triad; staff, process and organisational
factors (Doyle et al., 2013; Higuchi, Downey, Davies, Bajnok, & Waggott, 2013).
Again in the sustainability model, organisational context is strongly emphasised.
The ‘staff’ and ‘process’ domains appear to align to the ‘people’ and ‘process’
domains of our model. The weight afforded to the impact of the organisational
context in these two models is consistent with evidence provided by a systematic
review of the literature that organisational context is important to successful
implementation of innovation (Greenhalgh et al., 2004).
Third, insight regarding the transforming care process used in this study
and the lack of disparity between the findings of the two phases, could be
explained by four factors. Initially, the impact of the adaptation of the
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interventions and associated interventions fidelity are considered. The volume of
interventions implemented are then discussed. Further, the local organisational
context and associated nurse leadership is considered. Finally the activities and
strategies of the project team are discussed.
With regard to the implementation of the actual interventions, this study
discovered through an inductive approach that adopting and adapting
interventions, ‘trialability’, was perceived by the nurses as important to sustaining
change. However the adaptation of interventions may explain the lack of
consistent findings in Phase One. Each unit implemented a slightly different
‘bundle of interventions’ and adapted those interventions to their specific context.
This approach of allowing local adaptation of interventions and local innovation
was consistent with the implementation of related initiatives in the US and UK
(Robert et al., 2011; Roussel et al., 2012; White & Waldron, 2014) and reflects
the philosophy of TCAB and The Productive Ward, embedded by the use of the
Plan-Do-Study-Act cycle. Consequently, this opportunity to trial interventions and
adapt them may have generated a lack of fidelity, not to the overarching
transforming care initiative, but to the individual interventions introduced.
A variety of terms are used such as ‘fidelity’, ‘adherence’, ‘integrity’ and
‘implementation’ to describe the extent to which an intervention is delivered as
intended” (MRC Population Health Sciences Research Network, 2014). For
example, one intervention, clinical bedside handover was implemented differently
following local adaptation. Some units had an initial handover with all nurses for
the oncoming shift present, followed by a handover at the bedside. Alternatively,
other units only had handover at the bedside. Variations also existed on a shift by
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shift basis. These observations are consistent with an Australian study of bedside
handover that reported differences in the actual process and that less than half of
the handovers actually involved the patient (Chaboyer, McMurray, & Wallis,
2010). Another example of adaptation stems from the introduction of whiteboards
into four units in one facility (Chaboyer, Wallen, Wallis, & McMurray, 2009).
The whiteboards were reported to facilitate timely referrals and improved patient
flow. However, differences in the integration of the whiteboards into ward
routines were noted from multidisciplinary use and regular updating in one unit,
to only one nurse assistant updating information that no other staff observed in
another unit. The consequence of a lack of fidelity to the original intervention may
account for our findings of the inconsistent improvement in the NSIs measured.
Fidelity to the intervention has been considered a key factor in regard to
lack of implementation success, rather than the inadequacy of the actual
intervention (Carroll et al., 2007; Keith, Hopp, Subramanian, Wlitala, & Lowery,
2010). Alternatively, as is increasingly argued, if healthcare is viewed as a
complex adaptive system (Boustani et al., 2010; Matthews & Thomas, 2007), then
success is determined more by the relationships and context than the lack of
fidelity (Greenhalgh et al., 2004). Ultimately, if adaptations are permissible as has
been reported in studies of The Productive Ward (Clarke-Jones, 2007; Morrow et
al., 2012), what may be much more difficult to understand is the impact on the
outcomes of the improvement. Fidelity or the integrity of implementation is not
well understood (Carroll et al., 2007), with systematic methods to measure fidelity
such as component analysis being developed. For example, component analysis
was conducted for the implementation of a Chronic Heart Failure Nurse
Practitioner case management program and chronic musculoskeletal pain (Keith et
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al., 2010; Mars et al., 2013). Difficulty has however, been acknowledged in
identifying appropriate components that affect provider and patient outcomes and
applying measures to these (Mars et al., 2013; Nadeem, Olin, Hill, Hoagwood, &
Horwitz, 2013). Documentation of the interventions and adaptations by the project
team was undertaken in this initiative although the robustness of this was
challenged by the withdrawal of the project team. The interventions following
adaptation may have changed to the extent that the original principles were
overlooked, potentially impacting on the outcomes.
Additionally, the volume of interventions may also have impacted on the
ability of nurses to remember each intervention being implemented. The four units
implemented between 10 and 12 interventions each during the initial three month
period. A US study noted that the number of interventions implemented by 13
medical-surgical units piloting TCAB varied widely, averaging 41 interventions
per unit over a 2 year period (Needleman et al., 2009). An Australian study of two
medical units reported 13 interventions implemented in a two month period
(Chaboyer et al., 2010). It is difficult to compare directly as the time range for
implementation in the first study is broader and it is unknown how many
interventions may have been introduced in the first few months compared to the
latter months of the two year period. However the impact of implementing
multiple interventions in a short time period has consequences for the nurses
involved. It has been observed that humans can only process or retain seven plus
or minus two chunks of information in their short term memory (Miller, 1956).
This can lead to active failures of those directly involved in care, such as nurses,
as opposed to latent failures associated with healthcare system related factors
(Reason, 1990, 2000). It creates the concern that implementing 10 to 12
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interventions in a three month period may have been bordering on too many.
Therefore consideration is required with regard to the number of interventions and
associated information nurses are expected to retain.
Furthermore, the organisational context may have attributed to our
findings. Competing clinical and organisational demands can create obstacles to
engaging middle managers and frontline staff in introducing change (Dixon-
Woods et al., 2012). The influence of the organisational context on the
implementation and sustainment at the study site is congruent with findings
reported for similar initiatives such as the negative impact of operational changes
and the provision of executive level support perceived by nurses involved in
implementation (Morrow et al., 2012; Parkerton et al., 2009; Robert et al., 2011).
It has been suggested the influence of the organisational context can be to
maintain the status quo (Forbes-Thompson, Leiker, & Bleich, 2007). In contrast,
in this study the organisational context was altered by planned and emergent
change and the eventual withdrawal of the executive and project teams, disrupting
the ‘status quo’. Associated with these changes was attrition of staff in senior
influential positions. The loss of historical knowledge following retrenchment or
natural attrition can result in lessons learnt from previous failures being unknown
(Lahaie, 2005; Martins & Martins, 2011). The potential lack of attendance to
history disregards a key rule regarding elements of context that need to be
considered for transformation in healthcare (Best et al., 2012). Despite this
context, the initiative demonstrated resilience and sustainment. This may suggest
that the consistent local unit nursing leadership was responding to these
contextual changes and continuing to drive the initiative and interventions taking
on some of the roles of the defunct project team. The nurse leaders may have
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developed an attitude and perspective to champion the cause to maintain the
initiative.
Finally, the support provided by the project team may also have influenced
the findings. Initially the project team held meetings, ‘discovery workshops’, for
the units to identify areas for improvement, a strategy promoted by TCAB in the
US (Rutherford et al., 2009). It may be that differences in how these meetings
were facilitated or their duration and frequency can explain the findings. The
project team provided support through multiple strategies: facilitation of meetings
between unit staff to identify relevant areas for improvement, role modelling,
education, audit and feedback and recommendations of interventions. These
reflect well recognised strategies to influence behaviour although they all have
strengths and weaknesses as clarified in a review of systematic and narrative
reviews published between 1995 and 2006 (Robertson & Jochelson, 2007). For
example, educational material has been considered to be a passive strategy but
was more effective if the information is replicated in practice (Grimshaw et al.,
2004). Audit and feedback has been also asserted as a useful strategy but is
dependent on clinician buy-in, good quality data, timeliness of feedback and who
gives that feedback (Jamtvedt, Young, Kristoffersen, O'Brien, & Oxman, 2006;
Robertson & Jochelson, 2007). Ultimately multiple strategies need to be used
concurrently to address the different individuals involved and complexity of the
change with multiple interventions (Robertson & Jochelson, 2007). Although
multiple strategies were used, individually they may not have been used
effectively, contributing to the disparity of findings between the two phases.
Further analysis would need to be undertaken to ascertain differences in why there
was not a consistent improvement seen in the NSIs.
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This study has contributed a deeper understanding of the process of
implementing and sustaining a new model of nursing care for nurses seeking to
improve the safety and quality of nursing care in the Australian context. Our
findings have identified that the process of implementing and sustaining a
transforming care initiative incorporated three dimensions: people, process and
product. It has particularly highlighted that if the wider organisation is undergoing
change it does not need to lead to the initiative ‘decaying’.
6.5 Product
Further understanding of the findings of this study can be achieved by
exploration of ‘product’ related factors. Our findings did not demonstrate a
consistent improvement in the NSIs examined but in itself, the quantitative
findings extend understanding of the impact of a transforming care initiative in the
Australian context (i.e. it is variable). Further insight into the growing empirical
evidence on the relationship between transforming care initiatives and NSIs has
been provided. The findings will be explored in relation to prior evidence and
several explanations for the inconsistent findings discussed. These include the
NSIs examined, data source, method of data analysis and measurement.
Discussion regarding the impact of the adaptation and volume of interventions on
the NSIs has been discussed in the previous section (section 6.4).
Prior evidence regarding similar initiatives that used comparable NSIs is
limited. The available international small scale studies and larger multi-site
evaluations have reported more consistent improvement with regard to falls,
particularly falls resulting in harm in the UK and US (Bloodworth, 2011;
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Dearmon et al., 2013; Moore & Blick, 2013; Needleman et al., 2009) and in
Australia (Chaboyer et al., 2010). A downward trend in the reduction of pressure
ulcers has also been reported in the UK and US (Bloodworth, 2011; Bolton &
Aronow, 2009). This is contrasted by one study that reported the proportion of
pressure ulcers did not significantly decrease over a sustained period of time in
Australia (Chaboyer et al., 2010). There are several factors that could explain our
incongruent findings.
First, the NSIs used may explain our inconsistent findings. One of the two
NSIs used as outcome measures, HAPU, did not demonstrate a statistically
significant improvement. HAPU is generally considered to be a viable NSI
(American Nurses Association, 2014; Collaborative Alliance for Nursing
Outcomes, 2014). Because a pressure ulcer prevention working party had been
commenced at the study site prior to implementation of the initiative,
improvements in HAPU rates may already have been made and therefore the
baseline incidence was low. It is also noted that whereas in the other studies data
was collected on falls that resulted in harm, we collected data on all falls in this
study which are likely to go unreported (Haines, Massey, Varghese, Fleming, &
Gray, 2009). Additionally, some studies that reported improvements in falls
resulting in harm, implemented interventions focused specifically on falls
reduction (Chaboyer et al., 2010; Needleman et al., 2009). This may account for
our findings of a lack of consistent improvement.
Second, in understanding our outcome findings, this study used statistical
process control (SPC), to analyse the outcomes in Phase One. Through the
application of SPC, our study provides insights for those seeking to use it in
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quality improvement initiatives. This method of statistical analysis provides a
visual means of analysing performance by the application of statistical rules. It is
used increasingly in quality improvement in healthcare to demonstrate post
intervention impact (Duncan & Haigh, 2013; Richardson et al., 2012; Thor et al.,
2007). However it has had limited application in regard to implementation of
similar initiatives, having only been used in one other published study also in an
Australian setting (Chaboyer et al., 2010). That study also reported no significant
improvement in HAPU in two medical units but demonstrated consistent findings
for two other NSIs: falls resulting in harm and medication errors resulting in
harm. Instead of simply identifying trends as has been done in the past
(Bloodworth, 2011; Bolton & Aronow, 2009), by using SPC, we were able to rule
out chance as the likely cause of our findings. Our study has therefore assisted the
advancement of knowledge regarding the use of SPC to demonstrate the impact of
a transforming care initiative.
Third, our findings are congruent with studies of the relationship between
nursing structural and process variables and outcomes, in that the measurement of
NSIs remains an issue and may explain the lack of consistent improvement seen.
Studies have identified the difficulty associated with collecting data with
measures restricted to those which data can be easily collected (Morrow et al.,
2012; University of California Los Angeles-RAND Evaluation Team, 2009).
Varying definitions have also been used as the indicator such as falls resulting in
harm per 1,000 bed days and number of falls per month and this has hindered
comparison efforts (Dearmon et al., 2013; Needleman et al., 2009). However, the
potential of data to identify the focus of further improvements was demonstrated
in an evaluation of TCAB that used measurement to support the PDSA cycle and
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drive further improvement (University of California Los Angeles-RAND
Evaluation Team, 2009). To be able to demonstrate improvement, reliable
consistent data needs to be available to nurses and they need to be able to interpret
the data.
In summary, the findings provide assistance to nurses seeking to
demonstrate the impact of quality improvement initiatives. Several product related
factors could have impacted on the potential to demonstrate improvement in the
NSIs to verify the perceived benefits. Nurses are encouraged to consider what
they wish to measure as outcomes prior to commencing the quality improvement
initiative. This will provide direction for the selection of NSIs, confirmation of an
accessible data source and how results will be interpreted. Statistical process
control offers a viable option for analysis to demonstrate the impact of a
transforming care initiative.
6.6 Place
Following further consideration of our findings and synthesising the
evidence of both phases of this study, it is apparent that the organisational context
influences all three domains of the ‘3Ps model’, not just the ‘process’ domain.
Therefore a revised ‘4Ps model’ has been developed with an additional domain
‘place’ as depicted in Figure 2. ‘Place’ represents the setting both internal and
external to where the new model of nursing is being implemented, and is
conceptualised encompassing the original three domains, demonstrating its
influence on each of them. Given the discussion about organisational context, as
described under process, on reflection the data supports this fourth ‘P’.
178
Figure 2 The 4P’s’ Model of Sustained Implementation of a New Model of
Nursing Care
Note. TC= Transforming care
Further, our model also placed increased weight on the ‘product’
component of implementing and sustaining innovation. It has been noted that
without empirical observation to identify the influence of context, important
information regarding knowledge translation can be lost (Brehaut & Eva, 2012).
The Plan-Do-Study-Act model of improvement emphasises the need to measure
improvement in its ‘study’ stage (Langley et al., 2009). Also demonstrating
People • Engaging the team • Shifting culture
Product • Seeing the
change • Entrenching new
ways of working
Process • Rolling out TC • Leading the
change to TC
Place
TC
179
outcomes is important to drive further improvement and suggests performance
requires a prominent focus rather than being subsumed into the process. Only a
limited consideration of this model can be undertaken at present as the inter- and
intra-relationships between the domains remain unclarified.
6.7 Limitations of the Study
There are several limitations that could have impacted on this study. First,
with regard to a limitation that affects both phases, this study was conducted at
one facility and therefore generalisability may be limited. Although in terms of
Phase Two, qualitative research aims for conceptual understanding not
generalisability; the use of ‘thick description’ of the context aids consideration as
to the applicability or relevance of the findings to other contexts (Lincoln & Guba,
1985). In addition, sampling another facility may have contributed more depth to
our understanding, however, at the time it was not known what other
organisations may have implemented a transforming care initiative. Despite only
one site being used, the study does further enhance understanding of the impact of
implementing a new model of nursing care, particularly in the Australian
healthcare context.
Second, with regard to the robustness of the data source in Phase One,
there are potential limitations to the use of a secondary data source, coded medical
record data. The use of existing data is potentially limited by it having been
recorded for purposes other than research and it may not be standardised or
complete and prone to subjectivity (Cheng et al., 2009; Hess, 2004; Jansen et al.,
2005). The training and audit of those who perform the coding and a robust audit
process assist in mitigating this limitation.
180
Third, there are several inherent limitations of the use of statistical process
control (SPC) to demonstrate improvement following implementation of a
transforming care initiative. There was no risk adjustment of the data at hospital
or casemix level. Risk adjustment for casemix in outcome studies is complex
(Powell, Davies, & Thomson, 2003). Issues include unobserved patient attributes
not adjusted for and different methods providing different results (Lane-Hall &
Neumen, 2013). In this study, the level of analysis was the individual unit and
performance comparisons were not made between individual units or other
healthcare providers. Each outcome was analysed against the unit’s own baseline.
Additionally, when creating SPC charts in SPSS (IBM, New York, NY, US), only
one control limit line can be displayed on the chart at one time. This can make
interpretation difficult for the reader if the rules violated for ‘special cause
variation’ affect more than one of the control limits. Finally, there is debate
regarding how many data-points are required to generate a stable trend and create
the baseline exists; 12 to 25 data-points have been suggested with 20 to 25 most
commonly advised (Lee & McGreevey, 2002; Polit & Chaboyer, 2012; Wheeler,
2000). In this study there were 14 data-points pre intervention but a stable
baseline was not always achieved due to special cause variation occurring at
singular data-points. Additional data-points may have assisted in generating a
stable baseline. However, fewer than 20 data-points may increase the risk of
missing a special cause whilst more than 30 data-points may increase the risk of
attributing a false special cause (Polit & Chaboyer, 2012) as well as adding to the
potential problems of history confounding the results. This adds to the complexity
of using the charts for inexperienced users trying to establish a baseline.
181
Fourth, there was no control over the study setting or the initiative
implemented. The researchers were passive observers of the implementation. This
restricted the study to a retrospective approach and is acknowledged by a
recommendation to conduct a prospective cluster randomised trial. Further, it
means that the analysis reflects change (or stability) over time and cannot test a
cause and effect relationship.
Fifth, in Phase Two, participants were purposively selected and agreed to
be interviewed. The views of the participants may therefore not be representative
of all the nurses who participated in the initiative. In particular, they may not
reflect those who were reluctant to participate. In addition, as previously
identified, the initiative had commenced five years prior to the study and major
changes had taken place in the organisation including a relocation and restructure.
Some participants did require time to recall events that had occurred since
inception of the initiative. However consistency among the participants afforded
trustworthiness.
With due consideration to these limitations, the most robust study design
was used to provide as much strength to the findings as possible. Some of these
limitations would be addressed through the recommendations of this study. For
example, the lack of control over the implementation afforded by the retrospective
nature of the study would be moderated by undertaking a prospective study in
multiple study sites.
182
6.8 Recommendations for Nursing Practice, Education and Research
Several recommendations emanate from this study. These are proposed in
relation to nursing practice, education and research.
6.8.1 Practice
With regard to nursing practice utilising a conceptual model, such as the
‘4P’s’ Model developed in this study to guide implementation of new models of
care, is recommended. This would encourage consideration of salient factors prior
to implementation. For example, contemplation of the outcomes expected to be
seen both theoretically and empirically prior to implementing the initiative, could
guide the evaluation and sustainment strategy. A model such as the ‘4P’s Model
of Sustained Implementation of a New Model of Nursing Care’, could assist
implementation and sustainment.
To address our finding that to implement and sustain a new model of care
nurses were required to engage with interdisciplinary teams and with all staff, it is
recommended that teamwork and interdisciplinary communication be fostered.
Interprofessional rounds, meetings and externally facilitated interprofessional
audit were promising strategies to promote interprofessional practice
(Zwarenstein, Goldman, & Reeves, 2009). Interprofessional clinical learning units
have also been introduced to enhance teamwork, increasing awareness of roles
and promoting communication (Sommerfeldt, Barton, Stayko, Patterson, &
Pimlott, 2011). Organisational strategies such as aligning paperwork and IT
systems for consistency and familiarity and behavioural strategies such as training
in graded assertiveness, have also been promoted to assist teamwork and
communication (Weller, Boyd, & Cumin, 2014). Strategies are available to
183
engender teamwork and collaboration which should be employed to promote
patient safety.
The importance of the organisational context, and alignment between the
organisational philosophy, mission and priorities and those of the clinical units
and the initiative should be recognised. As a new model of care, it is
recommended that the initiative be embedded in nursing policies and new
priorities such as through the integration of existing terminology. For example, a
procedure to support and reinforce the ‘handover at the bedside’ intervention may
assist in sustainment. Aligning the initiative with formal accreditation schemes
and professional development opportunities is a potential strategy (Morrow et al.,
2012). At the study site during a recent accreditation review, the National Safety
and Quality Health Service Standards (Australian Commission on Safety and
Quality in Healthcare, 2011), were integrated into the ‘where we are at boards’
and within the TCAB pillars; safe and reliable care, value-added, patient-centred
and care team vitality. Such strategies could assist in preventing the decay of an
improvement initiative and reinforce the philosophy.
In addition the pace of implementation of the individual interventions may
require consideration. It would appear that implementing a high volume of
interventions at one time may have implications for how much new information
nurses are expected to retain. It would seem reasonable to consider the capacity of
humans to retain limited information (Miller, 1956). Therefore those tasked with
leading the implementation of similar initiatives need to consider how many
interventions are being implemented concurrently and the associated information
184
that needs to be retained. Strategies to reinforce this such as through visual aids,
tools and terminology may be helpful.
6.8.2 Education
Educational recommendations also arise from our study. It is
recommended that nurses require ‘non-technical skills’ to foster teamwork,
collaboration and leadership, to lead and participate in safety and quality
initiatives. Non-technical skills encompass both interpersonal and cognitive skills
(White, 2012). These include leadership, communication, decision making, task
management, followership and situation awareness (Flin, O'Connor, & Crichton,
2008). In a synthesis of the literature regarding team-training in healthcare,
support for teamwork and communication, as critical components of safe
healthcare systems, was asserted (Weaver, Dy, & Rosen, 2014); and teamwork is
considered critical to patient safety (Baker, Day, & Salas, 2006). Two educational
strategies demonstrating potential in promoting teamwork and collaboration are
simulation and interprofessional clinical learning units (Liaw, Zhou, Lau, Siau, &
Chan, 2014; Morphet et al., 2014).
Simulation has gained recognition as an approach to encourage teamwork.
Simulation has proved beneficial to interdisciplinary teamwork in both high
fidelity settings (Baker et al., 2006) and in the clinical setting (Guise, 2010). A
systematic review of 38 studies concluded that simulation as an education strategy
had positive benefits for the technical skills of teams during critical events and
complex procedures (Schmidt, Goldharber-Fiebert, Ho, & McDonald, 2013).
Simulation may offer potential as an educational strategy to promote teamwork
and leadership.
185
Implementing new models of nursing care such as transforming care
requires not only healthcare professionals to work together, but all staff. There is
increasing recognition of the need to promote teamwork for patient safety in pre-
and post-registration education and training of healthcare professionals through
incorporation in curriculums and interprofessional education (Bajnok, Puddesters,
Macdonald, Archibald, & Kuhl, 2012; Slater, Lawnton, Armitage, Bibby, &
Wright, 2012). A US study of nursing and hospital leaders found that they
perceived the need for nursing education programs to strengthen curricula to
include concepts and skills needed to participate in quality improvement activities
(Draper et al., 2008). This need is recognised in the WHO Framework for Action
on Interprofessional Education and Collaborative Practice, which calls for greater
focus in pre-registration programs (WHO Framework for Action on
Interprofessional Education and Collaborative Practice & Baker, 2010).
Interprofessional clinical learning units or ‘dedicated education units’, are a
concept that has been trialled internationally (Mulready-Shick, Kafel, Banister, &
Mylott, 2009; Rhodes, Meyers, & Underhill, 2012) and in various settings
including sub-acute care (Vanderzalm, Hall, McFarlane, Rutherford, & Patterson,
2013) and acute care (Sommerfeldt et al., 2011). Benefits reported have included
providing greater learning opportunities, better collaboration between the students
and registered nurses and relationship building with unit health care team
members (Moore & Nahigian, 2013; Mulready-Shick et al., 2009). Further,
promotion of professional development opportunities to promote teamwork and
collaboration are required for post-registration staff in the healthcare providers’
environment, especially to benefit staff who trained prior to interdisciplinary
education becoming more widely used at pre-registration level.
186
Bundled educational strategies may offer more effective benefits for
teamwork. A US review of studies examining team-training interventions in acute
care settings between 2000 and 2012, concluded that bundled interventions had
been implemented by the most robust studies undertaken in large care systems and
demonstrated strong quasi-experimental designs and were most effective (Weaver
et al., 2014). The bundled interventions included “preplanning, readiness
assessments, interdisciplinary learning activities and tools to support active
transfer into daily care” (Weaver et al., 2014).
In addition to improving nurses’ capability to work in teams, they would
benefit from being prepared for the leadership requirements of supporting the
implementation of new models of nursing care. The need to develop the
leadership capability in nurses to implement quality improvement has been noted
in previous studies of similar initiatives in the US and UK (Clarke & Marks-
Maran, 2014; Kliger et al., 2010; Morrow et al., 2012; NHS Scotland, 2008;
Parkerton et al., 2009; White et al., 2013). Our study concurs with these findings,
highlighting the importance of nurses’ leadership style and skills to foster the
engagement and collaboration of all staff. Therefore it is recommended that nurses
receive education in leadership and particularly for leading change for quality
improvement. Further exploration of the types of education and support for those
engaged in implementing quality initiatives is required (White et al., 2013).
With regard to the findings of this thesis which demonstrated nurses were
eager to share their experiences and learn from one another, it is recommended
that a mechanism for dissemination and sharing of innovations be included in the
implementation and sustainment strategy (Avis, 2011). This would create an
187
opportunity for nurses to learn from one another which may encourage best
practice to become standard (Wright & McSherry, 2013b). A community of
practice may address this need. Communities of practice provide an opportunity
for knowledge exchange (Ranmuthugala et al., 2011). The concept has been
defined as “Groups of people who share a concern, a set of problems, or a
passion about a topic, and who deepen their knowledge and expertise in this area
by interacting on an ongoing basis” (Wenger, McDermott, & Snyder, 2002, p.4).
As the community of practice members have a shared interest it would provide an
opportunity for the broader interdisciplinary team to participate, promoting the
involvement of all staff in a transforming care initiative, as perceived to be
beneficial by nurses in this study. Communities of practice have been explored
internationally in a variety of settings. In Canada a community of practice for
knowledge translation researchers and practitioners was implemented to support
their ongoing professional development (Urquhart et al., 2013). Improving
outdated gerontological nursing practice was the focus of a community of practice
instigated for nurses and academics in Scotland (Andrew, Ferguson, Wilkie,
Corcoran, & Simpson, 2009). Further, a community of practice was commenced
for nurses working with homeless people in Canada and provided nurses an
opportunity to share their stories, validate their practice and adapt practice to their
context (Valaitis, Danesh, Brooks, Binks, & Semogas, 2011). Various means of
communication have been used to support communities of practice such as web
based discussion boards, videoconferencing and chat rooms (Ho et al., 2010).
Online technology through the use of webinars were used for knowledge sharing
in a TCAB initiative in Canada over a two year period, providing staff an
opportunity for reflection and feedback (Lavoie-Tremblay et al., 2014). Overall
the benefits reported of assisting participants continuing education and
188
professional development and providing opportunities to seek advice and discuss
clinical issues appear congruent with a transforming care initiative (Rolls, Kowal,
Elliott, & Burrell, 2008; Urquhart et al., 2013).
Therefore education strategies at pre- and post-registration levels are
recommended in both the academic and healthcare provider levels to support
nurses to lead and participate in quality improvement initiatives. This would assist
in optimising the role of nurses in quality improvement.
6.8.3 Research
Quality improvement initiatives such as transforming care are complex
healthcare system interventions. High quality research is lacking in this area and
further research would help to secure the benefits of such programmes and
generate support. Exploring the following research foci could assist in the
achievement of this goal.
A prospective cluster trial could be undertaken, randomising units to
implementing the transforming care initiative and those that do not (Polit & Beck,
2012). This would provide an opportunity for the inclusion of prospective data
sources, broadening the evaluation that can be undertaken. Careful documentation
of other clinical practice is required, as this would be needed to assess
contamination across units.
In recognition of the need to respond to the organisational context, a
prospective environmental scan may also be beneficial. An environmental scan
can assist in describing the characteristics of the work place that are strengths or
enablers of cultural and practice change (Gibb, 2013). This could provide an
189
understanding of the context in which the initiative is being implemented and
provide direction for strategies to address relevant issues. Environmental scans
have previously been used to help researchers determine future areas for
investigation (Gillespie, Chaboyer, Nieuwenhoven, & Rickard, 2012).
Additionally, conducting a comprehensive process evaluation would assist
in providing a more detailed understanding of the transforming care initiative to
inform policy and practice (Grant, Treweek, Dreischulte, Foy, & Guthrie, 2013;
MRC Population Health Sciences Research Network, 2014). Process evaluation
can explicate the mechanisms responsible for the result of a quality intervention
by the documentation and evaluation of each step of the process (Hulscher,
Laurant, & Grol, 2003; Reelick, Faes, Esselink, Kessels, & Rikkert, 2011), which
can improve the validity of the findings (Carroll et al., 2007; Hulscher et al.,
2003). It can also assist in understanding why an intervention was effective in one
setting but not in another, exploring the context (MRC Population Health Sciences
Research Network, 2014). Methodology for process evaluation can be quantitative
and qualitative and the integration of process and outcome data maximise the
ability to interpret empirical evidence (Boon et al., 2007; MRC Population Health
Sciences Research Network, 2014; Oakley et al., 2006). Visual representations of
the process can also assist in articulating the components of the process including
the interventions and contributing factors and be adapted as the process evolves
(Reed, McNicholas, Woodcock, Issen, & Bell, 2014). A process evaluation could
include the perceptions of other professional and ancillary staff involved in
similar initiatives. This may afford a greater understanding of the challenges of
implementation, measuring of the benefits and strategies used.
190
A further research direction, is the recommendation to empirically test and
refine the conceptual model (4P’s), induced by this study. Models and theories
can be structured through the process of empiric knowledge development which
conceptualises phenomena and formulates criteria (Chinn & Kramer, 2011;
Havenga, Poggenpoel, & Myburgh, 2014). Conceptual models or frameworks are
comprised of concepts that address the phenomenon of interest and propositions
that describe both the concepts and their relationships (Fawcett & DeSanto-
Madeya, 2013). They can assist in organising thinking and act as a guide for what
to focus on and for interpretation and are continually developed as new evidence
arises (Rycroft-Malone & Bucknall, 2010). Models and theories are vital to
supporting healthcare interventions. Our study has presented a ‘beginning’ model,
which provides an understanding of key concepts that can influence the
implementation and sustainment of new models of nursing care in a medical-
surgical context. Case studies can contribute to this process. Application of the
model in several contexts, would assist further development and refinement
explicating the propositions. A proposition that could be explored is ‘There is a
relationship between leadership involvement in the transforming care process and
sustainment of transforming care initiatives’. A second proposition that could be
examined is ‘There is a relationship between the nurses’ readiness to accept
change and the sustainment of transforming care initiatives. A third proposition
that may be of benefit to explore is ‘There is a relationship between the fidelity of
the interventions and sustainment’. Conceptual models can also be used to frame
research (Benoit & Mion, 2012). The ‘4P’s’ Model could therefore assist in
directing future research regarding transforming care initiatives.
191
6.9 Conclusion
This study was set against a background of growing awareness of the need
to improve the safety and quality of nursing care. The two phases provided insight
into the impact of the initiative in regard to patient safety and the perception of the
nurses involved. Several contributions are made. First, this study did not
demonstrate a consistent relationship between transforming care and NSIs in an
acute medical-surgical setting. However, nurses perceived that there were benefits
for patients and staff from implementing and sustaining a transforming care
initiative. Additionally, a model was developed, conceptualising the sustained
implementation of a new model of care, comprised of four domains; people,
process, product and place. This ‘4P’s’ model has the potential to be of benefit to
nurses introducing new models of care, to improve both the safety and quality of
nursing care and to inform their decision making. Further, evidence of the
importance of adaptation of interventions to the local context was provided.
Finally, this study emphasised the importance of leadership, teamwork and
collaboration to implementing and sustaining new models of care. Successful
implementation and sustainment of new models of nursing care is a complex and
multifaceted process. As the 19th Century German Philosopher, Goethe observed,
‘To put your ideas into actions is one of the most difficult things in the world’.
192
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238
APPENDIX A
Participant Information Sheet
239
APPENDIX B:
Participant Consent Form
240
241
APPENDIX C
Interview Schedule
Demographics 1. Age at last birthday (yrs)
2. Gender Male Female 3. Role
Current role _____________________________________________________ Role at time of pilot ______________________________________________ 4. Years in current role (yrs) 5. Years in current organisation (yrs) Questions a) Tell me about your experience of TC:PAFF (the transforming care initiative)
b) What do you think have been the benefits of TC:PAFF since implementation?
c) Can you tell me about your thoughts regarding the sustainability of TC:PAFF
d) What do you think may have sustained TC:PAFF?
e) What do you think may not have helped sustain TC:PAFF?
f) Can you describe to me any new innovations that you have introduced recently in
your practice or that you know of that would be an example of TC:PAFF being
sustained?
240
APP
EN
DIX
D
Aud
it tr
ail-S
ubca
tego
ry A
dapt
ing
Tra
nsfo
rmin
g C
are
to C
onte
xt
Initi
al
Cod
ing
Sub-
cate
gory
C
ateg
ory
Des
crip
tion
Quo
tes
Mem
os
..we’
ve
just
fine
tu
ned
it to
su
it us
’
Ada
ptin
g
tran
sfor
min
g ca
re to
cont
ext
Rol
ling
tran
sfor
min
g
care
out
Parti
cipa
nts p
erce
ived
they
w
ere
able
to a
dapt
the
inte
rven
tions
to th
eir u
nit.
Th
ey w
ere
allo
wed
to se
lect
th
e in
terv
entio
ns th
at
addr
esse
d th
e ne
eds o
f the
ir un
its n
ot to
ld w
hich
one
s the
y ha
d to
impl
emen
t. In
dica
tion
it w
ould
be
disa
ppoi
ntin
g to
be
told
wha
t the
y ne
eded
to
do.
Als
o re
cogn
ise
that
st
anda
rdis
atio
n m
ay a
ffec
t su
stai
nabi
lity
as it
may
cre
ate
som
e re
sist
ance
.
• “i
t's u
p to
the
war
d in
how
they
bes
t use
is a
nd h
ow it
wor
ks
for t
hem
” D
•
“I'd
be
disa
ppoi
nted
if th
ey d
id a
lter i
t or c
hang
e it
or te
ll us
ho
w b
est t
o do
our
bus
ines
s whe
n I t
hink
it's
up to
eve
ry w
ard
in h
ow th
ey u
tilise
it a
nd w
hat b
enef
its th
ey g
et o
ut o
f it.”
(D)
• “I
still
thin
k ev
eryo
ne in
terp
rets
it d
iffer
ently
and
eve
ryon
e w
ill u
se it
in d
iffer
ent w
ays.”
(D)
• “S
o, a
s lon
g as
you
've
got y
our p
rinci
ples
, I th
ink
it ca
n th
en
be u
sed
how
ever
the
team
sees
fit.”
(D)
• “I
just
won
der m
aybe
that
cou
ld b
e ta
ken
into
con
sider
atio
n th
at e
ach
war
d ha
s diff
eren
t pat
ient
mak
e-up
. Yea
h, I
love
the
thou
ght o
f sta
ndar
disa
tion,
but
whe
ther
it's
- tha
t cou
ld a
ffect
su
stain
abili
ty b
ecau
se y
ou m
ight
hav
e so
me
resi
stanc
e be
caus
e ag
ain,
you
're n
ot g
ettin
g th
at fe
edba
ck a
nd a
ctin
g up
on it
or i
ncor
pora
ting
it in
to th
e ne
xt m
ove,
the
next
ch
ange
kin
d of
thin
g.”
(D)
• “I
don
’t kn
ow if
ther
e’s a
ny b
ig p
ictu
re d
irec
tion,
do
you
know
wha
t I m
ean?
It w
as in
itiat
ed a
nd w
e’ve
just
fine
tune
d it
to su
it us
.” (G
)
Pilo
t uni
ts w
ere
able
to
ada
pt th
e in
terv
entio
ns to
suit
thei
r uni
t and
feel
ing
is th
at th
is w
as v
alue
d by
the
staf
f.
Allo
win
g va
riatio
n an
d ad
apta
tion
whi
ch
may
influ
ence
su
cces
s.
241
Initi
al
Cod
ing
Sub-
cate
gory
C
ateg
ory
Des
crip
tion
Quo
tes
Mem
os
Mak
ing
choi
ces
•
“we
certa
inly
had
our
ups
and
dow
ns in
term
s of t
he w
ay w
e ap
proa
ched
it”
(C)
• “w
e w
ere
give
n a
sort
of a
bit
of a
free
-for-
all,
we
pick
ed a
nd c
hose
wha
t we
wan
ted.
Th
en I
thin
k ot
her w
ards
wer
e gi
ven
dire
ctiv
es, l
ike,
this
is w
hat y
ou n
eed
- you
nee
d to
do
this
.” (
B)
• “I
don
’t kn
ow if
ther
e’s a
ny b
ig p
ictu
re d
irec
tion,
do
you
know
wha
t I m
ean?
It w
as
initi
ated
and
we’
ve ju
st fi
ne tu
ned
it to
suit
us”
(G)
• “I
still
thin
k ev
eryo
ne in
terp
rets
it d
iffer
ently
and
eve
ryon
e w
ill u
se it
in d
iffer
ent w
ays.”
D
•
“I th
ink
also
that
som
e of
the
key
mile
stone
s tha
t we
wan
ted
to h
it w
eren
't hi
t bec
ause
of
that
, bec
ause
oth
er p
eopl
e m
ight
hav
e pr
iori
tised
thin
gs d
iffer
ently
and
wan
ted
to w
ork
on v
ario
us th
ings
inst
ead
of p
erha
ps w
hat w
e re
ally
saw
as i
mpo
rtan
t.” (C
)
Hav
ing
a fle
xibl
e ap
proa
ch
• “w
e ce
rtain
ly h
ad o
ur u
ps a
nd d
owns
in te
rms o
f the
way
we
appr
oach
ed it
” (C
) •
“we
wer
e gi
ven
a so
rt o
f a b
it of
a fr
ee-fo
r-al
l, w
e pi
cked
and
cho
se w
hat w
e w
ante
d.
Then
I th
ink
othe
r war
ds w
ere
give
n di
rect
ives
, lik
e, th
is is
wha
t you
nee
d - y
ou n
eed
to
do th
is.”
(B)
•
“I d
on’t
know
if th
ere’
s any
big
pic
ture
dir
ectio
n, d
o yo
u kn
ow w
hat I
mea
n? It
was
in
itiat
ed a
nd w
e’ve
just
fine
tune
d it
to su
it us
” (G
) •
“I st
ill th
ink
ever
yone
inte
rpre
ts it
diff
eren
tly a
nd e
very
one
will
use
it in
diff
eren
t way
s.”
D
• “w
e ga
ve th
em a
fram
ewor
k, I
supp
ose,
in te
rms o
f the
clin
ical
are
as a
nd th
en it
was
up
to th
em w
hat t
hey
deci
ded
to ta
ke u
p an
d w
hat t
hey
didn
't an
d ho
w th
ey to
ok th
at u
p” (C
) •
“I th
ink
also
that
som
e of
the
key
mile
stone
s tha
t we
wan
ted
to h
it w
eren
't hi
t bec
ause
of
that
, bec
ause
oth
er p
eopl
e m
ight
hav
e pr
iori
tised
thin
gs d
iffer
ently
and
wan
ted
to w
ork
on v
ario
us th
ings
inst
ead
of p
erha
ps w
hat w
e re
ally
saw
as i
mpo
rtan
t.” (C
)
