Promoting a Patient-Centered Understanding of Safety in Acute Mental Health Wards: A User-Centered Design Approach to Develop a Real-Time Digital Monitoring Tool

BACKGROUND

Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need.

OBJECTIVE

This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory.

METHODS

The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool.

RESULTS

We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, "getting worse" or "getting better"; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code.

CONCLUSIONS

Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively.

Implementing and evaluating patient-focused safety technology on adult acute mental health wards

WHAT IS KNOWN ON THE SUBJECT

Mental health wards can feel unsafe. We know that patients and staff have different ideas about what makes a hospital ward safe or unsafe. Patients are often the first to know when the atmosphere on a ward becomes tense, but often, no one asks them for their views. Patients and staff are experts and should be included in discussions about how to make wards safer.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

We got together with some service users and staff, and made an app that helps patients to tell staff when they are not feeling safe on a mental health ward. We tried it out on six wards and we asked patients and staff what they thought. The app was easy to use and most people liked the look of it. Patients said staff did not talk with them enough and so they liked using the app. However, some staff said they could tell how patients were feeling without an app and so they did not need it. Ward managers told us that staff were often very busy and did not always have time to use the app.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This app could help staff know straightaway when patients do not feel safe on the ward, so that they can act quickly to calm things down. To make the most of the app, staff need to get used to it and bring it into ward routines.

ABSTRACT

INTRODUCTION: Safety improvement on mental health wards is of international concern. It should incorporate patient perspectives.

AIM

Implementation and evaluation of 'WardSonar', a digital safety-monitoring tool for adult acute mental health wards, developed with stakeholders to communicate patients' real-time safety perceptions to staff.

METHOD

Six acute adult mental health wards in England implemented the tool in 2022. Evaluation over 10 weeks involved qualitative interviews (34 patients, 33 staff), 39 focused ethnographic observations, and analysis of pen portraits.

RESULTS

Implementation and evaluation of the WardSonar tool was feasible despite challenging conditions. Most patients valued the opportunity to communicate their immediate safety concerns, stating that staff had a poor understanding of them. Some staff said the WardSonar tool could help enhanced ward safety but recognised a need to incorporate its use into daily routines. Others said they did not need the tool to understand patients' safety concerns.

DISCUSSION

Foreseeable challenges, including staff ambivalence and practical issues, appeared intensified by the post-COVID-19 context.

IMPLICATIONS FOR PRACTICE

The WardSonar tool could improve ward safety, especially from patients' perspectives. Future implementation could support staff to use the real-time data to inform proactive safety interventions.

What do primary care staff think about patients accessing electronic health records? A focus group study

BACKGROUND

Patients have expressed a growing interest in having easy access to their personal health information, and internationally there has been increasing policy focus on patient and care records being more accessible. Limited research from the UK has qualitatively explored this topic from the primary care staff perspective. This study aimed to understand what primary care staff think about patients accessing electronic health records, highlighting errors in electronic health records, and providing feedback via online patient portals.

METHODS

A focus group study involving 19 clinical and non-clinical primary care staff. Primary care practices were purposively sampled based on practice size and the percentage of patients using online services. Data were analysed inductively using reflexive thematic analysis.

RESULTS

Three themes were generated: (1) Information - what, why and when? (2) Changing behaviours and protecting relationships, and (3) Secure access and safeguarding. The emotional considerations and consequences for staff and patients featured prominently in the data as an overarching theme.

CONCLUSIONS

Primary care staff described being invested and supportive of patients accessing their electronic health records, and acknowledged the numerous potential benefits for safety. Uncertainty around the parameters of access, the information available and what this might look like in the future, processes for patients highlighting errors in records, relational issues, security and safeguarding and equitable access, were key areas warranting examination in future research.

Exploring nurses' experiences of value congruence and the perceived relationship with wellbeing and patient care and safety: a qualitative study

Background

Values are of high importance to the nursing profession. Value congruence is the extent to which an individual's values align with the values of their organisation. Value congruence has important implications for job satisfaction.

Aim

This study explored nurse values, value congruence and potential implications for individual nurses and organisations in terms of wellbeing and patient care and safety.

Method

Fifteen nurses who worked in acute hospital settings within the UK participated in semi-structured telephone interviews. Thematic analysis was utilised to analyse the data.

Results

Four themes were identified: organisational values incongruent with the work environment; personal and professional value alignment; nurse and supervisor values in conflict; nurses' values at odds with the work environment. Perceived value incongruence was related to poorer wellbeing, increased burnout and poorer perceived patient care and safety. The barriers identified for nurses being able to work in line with their values are described.

Conclusions

Value congruence is important for nurse wellbeing and patient care and safety. Improving the alignment between the values that organisations state they hold, and the values implied by the work environment may help improve patient care and safety and support nurses in practice.

Systemic safety inequities for people with learning disabilities: a qualitative integrative analysis of the experiences of English health and social care for people with learning disabilities, their families and carers

BACKGROUND

Failures in care for people with learning disabilities have been repeatedly highlighted and remain an international issue, exemplified by a disparity in premature death due to poor quality and unsafe care. This needs urgent attention. Therefore, the aim of the study was to understand the care experiences of people with learning disabilities, and explore the potential patient safety issues they, their carers and families raised.

METHODS

Two data sources exploring the lived experience of care for people with learning disabilities were synthesised using an integrative approach, and explored using reflexive thematic analysis. This comprised two focus groups with a total of 13 people with learning disabilities and supportive staff, and 377 narratives posted publicly via the feedback platform Care Opinion.

RESULTS

The qualitative exploration highlighted three key themes. Firstly, health and social care systems operated with varying levels of rigidity. This contributed to an inability to effectively cater to; complex and individualised care needs, written and verbal communication needs and needs for adequate time and space. Secondly, there were various gaps and traps within systems for this population. This highlighted the importance of care continuity, interoperability and attending to the variation in support provision from professionals. Finally, essential 'dependency work' was reliant upon social capital and fulfilled by paid and unpaid caring roles to divergent extents, however, advocacy provided an additional supportive safety net.

CONCLUSIONS

A series of safety inequities have been identified for people with learning disabilities, alongside potential protective buffers. These include; access to social support and advocacy, a malleable system able to accommodate for individualised care and communication needs, adequate staffing levels, sufficient learning disabilities expertise within and between care settings, and the interoperability of safety initiatives. In order to attend to the safety inequities for this population, these factors need to be considered at a policy and organisational level, spanning across health and social care systems. Findings have wide ranging implications for those with learning disabilities, their carers and families and health and social care providers, with the potential for international learning more widely.

Health professionals' perspectives of safety issues in mental health services: A qualitative study

The study aimed to explore mental health professionals' perceptions of patient safety issues across community and inpatient mental health services. Fourteen mental health professionals across community and inpatient settings participated in qualitative interviews. Framework analysis, guided by the Yorkshire Contributory Factors Framework - Mental Health, was used to analyse the data. Safety issues identified by mental health professionals mapped on to 19 of the 21 factors in the Yorkshire Contributory Factors Framework - Mental Health. The factors most frequently mentioned by participants were 'safety culture' which focused on raising concerns, learning from incidents and the influence of targets; 'communication systems' to support effective communication between staff; 'service user factors' including a perceived increase in illness acuity; 'service process' including how patients access and interact with services; and 'staff workload' perceived being as unmanageable. Mental health professionals consider there to be a broad range of safety issues associated with mental health services. Future research should aim to develop interventions to improve safety focused across the factors raised by professionals.

Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review

OBJECTIVES

To produce a narrative synthesis of published academic and grey literature focusing on patient safety outcomes for people with learning disabilities in an acute hospital setting.

DESIGN

Scoping review with narrative synthesis.

METHODS

The review followed the six stages of the Arksey and O'Malley framework. We searched four research databases from January 2000 to March 2021, in addition to handsearching and backwards searching using terms relating to our eligibility criteria-patient safety and adverse events, learning disability and hospital setting. Following stakeholder input, we searched grey literature databases and specific websites of known organisations until March 2020. Potentially relevant articles and grey literature materials were screened against the eligibility criteria. Findings were extracted and collated in data charting forms.

RESULTS

45 academic articles and 33 grey literature materials were included, and we organised the findings around six concepts: (1) adverse events, patient safety and quality of care; (2) maternal and infant outcomes; (3) postoperative outcomes; (4) role of family and carers; (5) understanding needs in hospital and (6) supporting initiatives, recommendations and good practice examples. The findings suggest inequalities and inequities for a range of specific patient safety outcomes including adverse events, quality of care, maternal and infant outcomes and postoperative outcomes, in addition to potential protective factors, such as the roles of family and carers and the extent to which health professionals are able to understand the needs of people with learning disabilities.

CONCLUSION

People with learning disabilities appear to experience poorer patient safety outcomes in hospital. The involvement of family and carers, and understanding and effectively meeting the needs of people with learning disabilities may play a protective role. Promising interventions and examples of good practice exist, however many of these have not been implemented consistently and warrant further robust evaluation.

Developing and evaluating packages to support implementation of quality indicators in general practice: the ASPIRE research programme, including two cluster RCTs

Background

Dissemination of clinical guidelines is necessary but seldom sufficient by itself to ensure the reliable uptake of evidence-based practice. There are further challenges in implementing multiple clinical guidelines and clinical practice recommendations in the pressurised environment of general practice.

Objectives

We aimed to develop and evaluate an implementation package that could be adapted to support the uptake of a range of clinical guideline recommendations and be sustainably integrated within general practice systems and resources. Over five linked work packages, we developed ‘high-impact’ quality indicators to show where a measurable change in clinical practice can improve patient outcomes (work package 1), analysed adherence to selected indicators (work package 2), developed an adaptable implementation package (work package 3), evaluated the effects and cost-effectiveness of adapted implementation packages targeting four indicators (work package 4) and examined intervention fidelity and mechanisms of action (work package 5).

Setting and participants

Health-care professionals and patients from general practices in West Yorkshire, UK.

Design

We reviewed recommendations from existing National Institute for Health and Care Excellence clinical guidance and used a multistage consensus process, including 11 professionals and patients, to derive a set of ‘high-impact’ evidence-based indicators that could be measured using routinely collected data (work package 1). In 89 general practices that shared data, we found marked variations and scope for improvement in adherence to several indicators (work package 2). Interviews with 60 general practitioners, practice nurses and practice managers explored perceived determinants of adherence to selected indicators and suggested the feasibility of adapting an implementation package to target different indicators (work package 3). We worked with professional and patient panels to develop four adapted implementation packages. These targeted risky prescribing involving non-steroidal anti-inflammatory and antiplatelet drugs, type 2 diabetes control, blood pressure control and anticoagulation for atrial fibrillation. The implementation packages embedded behaviour change techniques within audit and feedback, educational outreach and (for risky prescribing) computerised prompts. We randomised 178 practices to implementation packages targeting either diabetes control or risky prescribing (trial 1), or blood pressure control or anticoagulation (trial 2), or to a further control (non-intervention) group, and undertook economic modelling (work package 4). In trials 1 and 2, practices randomised to the implementation package for one indicator acted as control practices for the other package, and vice versa. A parallel process evaluation included a further eight practices (work package 5).

Main outcome measures

Trial primary end points at 11 months comprised achievement of all recommended levels of glycated haemoglobin, blood pressure and cholesterol; risky prescribing levels; achievement of recommended blood pressure; and anticoagulation prescribing.

Results

We recruited 178 (73%) out of 243 eligible general practices. We randomised 80 practices to trial 1 (40 per arm) and 64 to trial 2 (32 per arm), with 34 non-intervention controls. The risky prescribing implementation package reduced risky prescribing (odds ratio 0.82, 97.5% confidence interval 0.67 to 0.99; p = 0.017) with an incremental cost-effectiveness ratio of £2337 per quality-adjusted life-year. The other three packages had no effect on primary end points. The process evaluation suggested that trial outcomes were influenced by losses in fidelity throughout intervention delivery and enactment, and by the nature of the targeted clinical and patient behaviours.

Limitations

Our programme was conducted in one geographical area; however, practice and patient population characteristics are otherwise likely to be sufficiently diverse and typical to enhance generalisability to the UK. We used an ‘opt-out’ approach to recruit general practices to the randomised trials. Subsequently, our trial practices may have engaged with the implementation package less than if they had actively volunteered. However, this approach increases confidence in the wider applicability of trial findings as it replicates guideline implementation activities under standard conditions.

Conclusions

This pragmatic, rigorous evaluation indicates the value of an implementation package targeting risky prescribing. In broad terms, an adapted ‘one-size-fits-all’ approach did not consistently work, with no improvement for other targeted indicators.

Future work

There are challenges in designing ‘one-size-fits-all’ implementation strategies that are sufficiently robust to bring about change in the face of difficult clinical contexts and fidelity losses. We recommend maximising feasibility and ‘stress testing’ prior to rolling out interventions within a definitive evaluation. Our programme has led on to other work, adapting audit and feedback for other priorities and evaluating different ways of delivering feedback to improve patient care.

Trial registration

Current Controlled Trials ISRCTN91989345.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services

BACKGROUND

Service user and carer perspectives on safety issues in mental health services are not well known and may be important in preventing and reducing harm. The development of the Yorkshire Contributory Factors Framework-Mental Health (YCFF-MH) provides a broad structure within which to explore these perspectives.

OBJECTIVE

To explore what service users of mental health services and their carers consider to be safety issues.

DESIGN, SETTING AND PARTICIPANTS

Qualitative interviews with 13 service users and 7 carers in the UK. Participants were asked about their experiences and perceptions of safety within mental health services. Perceived safety issues were identified using framework analysis, guided by the YCFF-MH.

RESULTS

Service users and carers identified a broad range of safety issues. These were categorized under 'safety culture' and included psychological concepts of safety and raising concerns; 'social environment' involved threatened violence and sexual abuse; 'individual service user and staff factors' dominated by not being listened to; 'management of staff and staffing levels' resulting in poor continuity of care; and 'service process' typified by difficulty accessing services during a crisis. Several examples of 'active failures' were also described.

DISCUSSION AND CONCLUSIONS

Safety issues appear broader than those recorded and reported by health services and inspectorates. Many safety issues have also been identified in other care settings supporting the notion that there are overlaps between service users and carers' perspectives of safety in mental health services and those of users in other settings. Areas for further research are suggested.

An investigation into the relationships between bullying, discrimination, burnout and patient safety in nurses and midwives: is burnout a mediator?

Background

Bullying and discrimination may be indirectly associated with patient safety via their contribution to burnout, but research has yet to establish this.

Aims

The aims of this study were to investigate the relationships between workplace bullying, perceived discrimination, levels of burnout and patient safety perceptions in nurses and midwives and to assess whether bullying and discrimination were more frequently experienced by Black, Asian and minority ethnic than White nurses and midwives.

Methods

In total, 528 nurses and midwives were recruited from four hospitals in the United Kingdom to complete a cross-sectional survey between February and March 2017. The survey included items on bullying, discrimination, burnout and individual level and ward level patient safety perceptions. Data were analysed using path analysis.

Results

The results were reported according to the STROBE checklist. Bullying and discrimination were significantly associated with higher burnout. Higher burnout was in turn associated with poorer individual- and ward-level patient safety perceptions. Experiences of discrimination were three times more common among Black, Asian and minority ethnic than White nurses and midwives, but there was no significant difference in experiences of bullying.

Conclusions

Bullying and discrimination are indirectly associated with patient safety perceptions via their influence on burnout. Healthcare organisations seeking to improve patient care should implement strategies to reduce workplace bullying and discrimination.

Validation of revised patient measures of safety: PMOS-30 and PMOS-10

OBJECTIVES

There is growing evidence that patients can provide feedback on the safety of their care. The 44-item Patient Measure of Safety (PMOS) was developed for this purpose. While valid and reliable, the length of this questionnaire makes it potentially challenging for routine use. Our study aimed to produce revised, shortened versions of PMOS (PMOS-30 and PMOS-10), which retained the psychometric properties of the longer version.

PARTICIPANTS

To produce a shortened diagnostic measure, we analysed data from 2002 patients who completed PMOS-44, and examined the reliability of the revised measure (PMOS-30) in a sample of 751 patients. To produce a brief standalone measure, we again analysed data from 2002 patients who completed PMOS-44, and tested the reliability and validity of the brief standalone measure (PMOS-10) in a sample of 165 patients.

METHODS

The process of shortening the questionnaire involved a combination of secondary data analysis (eg, Standard Deviation and inter-item correlations) and a consensus group exercise to produce PMOS-30 and examine face validity. Analysis of PMOS-30 data examined reliability (eg, Cronbach's alpha). Further secondary data analysis (ie, corrected item-total correlations) produced PMOS-10, and primary data collection assessed its reliability and validity (eg, Cronbach's alpha, analysis of variance).

RESULTS

Fourteen items were removed to produce PMOS-30 and the percentage of negatively worded items was reduced from 57% to 33%. PMOS-30 demonstrated good internal reliability (α=0.89). The 10 items with the highest corrected item-total correlations across both PMOS-44 and PMOS-30 composed PMOS-10. PMOS-10 had good internal reliability (α=0.79), demonstrated convergent validity; however, discriminant validity was not established.

CONCLUSIONS

Two revised, shortened versions of the original PMOS-44 (PMOS-30 and PMOS-10) were produced to capture patient feedback about safety in hospital. The measures demonstrated good reliability and validity, and preserved the psychometric properties of the original measure.

"Change is what can actually make the tough times better": A patient-centred patient safety intervention delivered in collaboration with hospital volunteers

Background

The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect patient feedback to support service improvement. To provide a sustainable mechanism for the PRASE intervention, a 2‐year improvement project explored the potential for hospital volunteers to facilitate the collection of PRASE feedback.

Objective

To explore the implementation of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders.

Design

A qualitative case study design was utilized across three acute NHS trusts in the United Kingdom between March 2016 and October 2016. Ward level data (staff interviews; action planning meeting recordings; implementation fidelity information) were analysed taking a pen portrait approach. We also carried out focus groups with hospital volunteers and interviews with voluntary services/patient experience staff, which were analysed thematically.

Results

Whilst most ward staff reported feeling engaged with the intervention, there were discordant views on its use and usefulness. The hospital volunteers were positive about their involvement, and on some wards, worked with staff to produce actions to improve services. The voluntary services/patient experience staff participants emphasised the need for PRASE to sit within an organisations’ wider governance structure.

Conclusion

From the perspective of key stakeholders, hospital volunteers facilitating the collection of PRASE feedback is a feasible means of implementing the PRASE intervention. However, the variability around ward staff being able to use the feedback to make changes to services demonstrates that it is this latter part of the PRASE intervention cycle that is more problematic.

Service user and carer involvement in mental health care safety: raising concerns and improving the safety of services

BACKGROUND

Previous research into improving patient safety has emphasised the importance of responding to and learning from concerns raised by service users and carers. Expertise gained by the experiences of service users and their carers has also been seen as a potential resource to improve patient safety. We know little about the ease of raising concerns within mental health services, and the potential benefits of involving service users and carers in safety interventions. This study aimed to explore service user and carer perceptions of raising safety concerns, and service user, carer and health professional views on the potential for service user and carer involvement in safety interventions.

METHODS

UK service users, carers and health professionals ( n= 185) were recruited via social media to a cross-sectional survey focussed on raising concerns about safety issues and views on potential service user and carer participation in safety interventions. Data were analysed using descriptive statistics, and free text responses were coded into categories.

RESULTS

The sample of 185 participants included 90 health professionals, 77 service users and 18 carers. Seventy seven percent of service users and carers reported finding it very difficult or difficult to raise concerns. Their most frequently cited barriers to raising concerns were: services did not listen; concerns about repercussions; and the process of raising concerns, especially while experiencing mental ill health. There was universal support from health professionals for service user and carer involvement in safety interventions and over half the service users and carers supported involvement, primarily due to their expertise from experience.

CONCLUSIONS

Mental health service users and carers experience difficulties in raising safety concerns meaning that potentially useful information is being missed. All the health professionals and the majority of service users and carers saw potential for service users and carer involvement in interventions to improve safety, to ensure their experiences are taken into consideration. The results provide guidance for future research about the most effective ways of ensuring that concerns about safety can be both raised and responded to, and how service user and carer involvement in improving safety in mental health care can be further developed.

A Daily Diary Approach to the Examination of Chronic Stress, Daily Hassles and Safety Perceptions in Hospital Nursing

PURPOSE

Stress is a significant concern for individuals and organisations. Few studies have explored stress, burnout and patient safety in hospital nursing on a daily basis at the individual level. This study aimed to examine the effects of chronic stress and daily hassles on safety perceptions, the effect of chronic stress on daily hassles experienced and chronic stress as a potential moderator.

METHOD

Utilising a daily diary design, 83 UK hospital nurses completed three end-of-shift diaries, yielding 324 person days. Hassles, safety perceptions and workplace cognitive failure were measured daily, and a baseline questionnaire included a measure of chronic stress. Hierarchical multivariate linear modelling was used to analyse the data.

RESULTS

Higher chronic stress was associated with more daily hassles, poorer perceptions of safety and being less able to practise safely, but not more workplace cognitive failure. Reporting more daily hassles was associated with poorer perceptions of safety, being less able to practise safely and more workplace cognitive failure. Chronic stress did not moderate daily associations. The hassles reported illustrate the wide-ranging hassles nurses experienced.

CONCLUSION

The findings demonstrate, in addition to chronic stress, the importance of daily hassles for nurses' perceptions of safety and the hassles experienced by hospital nurses on a daily basis. Nurses perceive chronic stress and daily hassles to contribute to their perceptions of safety. Measuring the number of daily hassles experienced could proactively highlight when patient safety threats may arise, and as a result, interventions could usefully focus on the management of daily hassles.

A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers

Background

Evidence suggests that patients can meaningfully feed back to healthcare providers about the safety of their care. The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect feedback from patients to support service improvement. The intervention is being implemented in acute care settings with patient feedback collected by hospital volunteers for the first time.

Objective

To undertake a formative evaluation which explores the feasibility and acceptability of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders.

Design

A qualitative evaluation design was adopted across two acute NHS trusts in the UK between July 2014 and November 2015. We conducted five focus groups with hospital volunteers (n=15), voluntary services and patient experience staff (n=3) and semi‐structured interviews with ward staff (n=5). Data were interpreted using framework analysis.

Results

All stakeholders were positive about the PRASE intervention as a way to support service improvement, and the benefits of involving volunteers. Volunteers felt adequate training and support would be essential for retention. Staff concentrated on the infrastructure needed for implementation and raised concerns around sustainability. Findings were fed back to the implementation team to support revisions to the intervention moving into the subsequent summative evaluation phase.

Conclusion

Although there are concerns regarding sustainability in practice, the PRASE intervention delivered in collaboration with hospital volunteers is a promising approach to collect patient feedback for service improvement.

Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses

AIMS

The aim of this study was to investigate the relationships between depressive symptoms, burnout and perceptions of patient safety. A mediation model was proposed whereby the association between symptoms of depression and patient safety perceptions was mediated by burnout.

BACKGROUND

There is growing interest in the relationships between depressive symptoms and burnout in healthcare staff and the safety of patient care. Depressive symptoms are higher in healthcare staff than the general population and overlap conceptually with burnout. However, minimal research has investigated these variables in nurses. Given the conceptual overlap between depressive symptoms and burnout, there is also a need for an explanatory model outlining the relative contributions of these factors to patient safety.

DESIGN

A cross-sectional questionnaire was distributed at three acute NHS Trusts.

METHOD

Three-hundred and twenty-three hospital nursing staff completed measures of depressive symptoms, burnout and patient safety perceptions (including measures at the level of the individual and the work area/unit) between December 2015 - February 2016.

RESULTS

When tested in separate analyses, depressive symptoms and burnout facets were each associated with both patient safety measures. Furthermore, the proposed mediation model was supported, with associations between depressive symptoms and patient safety perceptions fully mediated by burnout.

CONCLUSION

These results suggest that symptoms of depression and burnout in hospital nurses may have implications for patient safety. However, interventions to improve patient safety may be best targeted at improving burnout in particular, with burnout interventions known to be most effective when focused at both the individual and the organisational level.

Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study

Background

There are recognised gaps between evidence and practice in general practice, a setting posing particular implementation challenges. We earlier screened clinical guideline recommendations to derive a set of ‘high-impact’ indicators based upon criteria including potential for significant patient benefit, scope for improved practice and amenability to measurement using routinely collected data. Here, we explore health professionals’ perceived determinants of adherence to these indicators, examining the degree to which determinants were indicator-specific or potentially generalisable across indicators.

Methods

We interviewed 60 general practitioners, practice nurses and practice managers in West Yorkshire, the UK, about adherence to four indicators: avoidance of risky prescribing; treatment targets in type 2 diabetes; blood pressure targets in treated hypertension; and anticoagulation in atrial fibrillation. Interview questions drew upon the Theoretical Domains Framework (TDF). Data were analysed using framework analysis.

Results

Professional role and identity and environmental context and resources featured prominently across all indicators whilst the importance of other domains, for example, beliefs about consequences, social influences and knowledge varied across indicators. We identified five meta-themes representing more general organisational and contextual factors common to all indicators.

Conclusions

The TDF helped elicit a wide range of reported determinants of adherence to ‘high-impact’ indicators in primary care. It was more difficult to pinpoint which determinants, if targeted by an implementation strategy, would maximise change. The meta-themes broadly underline the need to align the design of interventions targeting general practices with higher level supports and broader contextual considerations. However, our findings suggest that it is feasible to develop interventions to promote the uptake of different evidence-based indicators which share common features whilst also including content-specific adaptations.

Using intervention mapping to develop a culturally appropriate intervention to prevent childhood obesity: the HAPPY (Healthy and Active Parenting Programme for Early Years) study

Introduction

Interventions that make extensive use of theory tend to have larger effects on behaviour. The Intervention Mapping (IM) framework incorporates theory into intervention design, implementation and evaluation, and was applied to the development of a community-based childhood obesity prevention intervention for a multi-ethnic population.

Methods

IM was applied as follows: 1) Needs assessment of the community and culture; consideration of evidence-base, policy and practice; 2) Identification of desired outcomes and change objectives following identification of barriers to behaviour change mapped alongside psychological determinants (e.g. knowledge, self-efficacy, intention); 3) Selection of theory-based methods and practical applications to address barriers to behaviour change (e.g., strategies for responsive feeding); 4) Design of the intervention by developing evidence-based interactive activities and resources (e.g., visual aids to show babies stomach size). The activities were integrated into an existing parenting programme; 5) Adoption and implementation: parenting practitioners were trained by healthcare professionals to deliver the programme within Children Centres.

Results

HAPPY (Healthy and Active Parenting Programme for Early Years) is aimed at overweight and obese pregnant women (BMI > 25); consists of 12 × 2.5 hr. sessions (6 ante-natal from 24 weeks; 6 postnatal up to 9 months); it addresses mother’s diet and physical activity, breast or bottle feeding, infant diet and parental feeding practices, and infant physical activity.

Conclusion

We have demonstrated that IM is a feasible and helpful method for providing an evidence based and theoretical structure to a complex health behaviour change intervention. The next stage will be to assess the impact of the intervention on behaviour change and clinical factors associated with childhood obesity. The HAPPY programme is currently being tested as part of a randomised controlled feasibility trial.

An exploratory randomised controlled trial using short messaging service to facilitate insulin administration in young adults with type 1 diabetes

This exploratory randomised controlled trial examined the effectiveness of a novel short messaging service intervention underpinned by the theory of planned behaviour (TPB) in improving insulin administration in young adults with type 1 diabetes and the role of moderating variables. Those in the intervention condition (N = 8) received one daily text message underpinned by TPB constructs: Attitudes, subjective norms, perceived behavioural control and intention. Those in the control condition (N = 10) received weekly general health messages. Self-reported insulin administration was the main outcome measure; conscientiousness and consideration of future consequences (CFC) were measured as potential moderators. Analyses of covariance revealed no main effects of condition for morning and afternoon injections but a marginally significant effect for evening injections (p = .08). This main effect was qualified by significant interactions of condition with conscientiousness (p = .001), CFC (p = .007) and a three-way interaction among condition, conscientiousness and CFC (p = .009). Exploration of the interactions indicated the intervention significantly improved evening injection rates only in the low conscientiousness and low CFC groups. This effect was particularly strong among those low in both conscientiousness and CFC. Further investigation is warranted, using more objective measures of insulin adherence in a larger sample.