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Welcome to symposium 14 about protocol-based / standardised care

Welcome to symposium 14 about protocol-based / standardised care. Chair: Dr Susan Read, RCN Fellow . Programme:. Welcome: Dr Susan Read, RCN Fellow Introduction: Dr Jo Rick Presentations:

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Welcome to symposium 14 about protocol-based / standardised care

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  1. Welcometo symposium 14 about protocol-based / standardised care Chair: Dr Susan Read, RCN Fellow

  2. Programme: • Welcome: Dr Susan Read, RCN Fellow • Introduction: Dr Jo Rick • Presentations: • Development and implementation of protocol-based care. A systematic literature review. Dr Irene Ilott • Impact of protocol-based care on nurses' experience of work. National survey. Malcolm Patterson • Competing ideologies in maternity care: a discourse analysis. Rose O'Neill • Discussion about the recommendations

  3. Evaluating protocol-based care: a mixed method approach Dr Jo Rick, Malcolm Patterson, Dr Irene Ilott & Rose O'Neill RCN 2008 International Nursing Research Conference 9th April 2008, Liverpool

  4. Acknowledgement This symposium presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Programme. The views expressed in this presentation are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR SDO programme is funded by the Department of Health.

  5. Protocol-based care: policy driven 'standardised care' “By 2004 the majority of NHS will be working under agreed protocols identifying how common conditions should be handled and which staff can best handle them. The new NHS Modernisation Agency will lead a major drive to ensure that protocol-based care takes hold throughout the NHS … to develop clear protocols that make the best use of all the talents of NHS staff and which are flexible enough to take account of patients’ individual needs” (p83). Department of Health (2000). The NHS Plan. A plan for investment. A plan for reform. London: The Stationery Office.

  6. Standards: shaping or determining care? “The introduction of standards and guidelines should help reduce the gap between what people who receive the best care and treatment and those who are missing out. However, it is clear that the NHS needs to implement these standards and guidelines more consistently” (p41) “In an organisation as big as the NHS, some differences are to be expected. In fact, they should be encouraged so that services can be free to develop. But differences should not result in services for some falling below acceptable standards” (p68) Healthcare Commission (2005) State of Healthcare. London.

  7. Evaluation framework Opinion Leader Interviews Systematic Literature Reviews National Survey of Nurses, Mid-wives and Health Visitors Detailed Case Study Work at Five Sites

  8. Interviews OPINION LEADER INTERVIEWS • AIM: • Understand current thinking on standardised care from different perspectives: • Practice • Policy • Research Literature Reviews National Survey Case Studies

  9. Search for Evidence Interviews • AIM: • To establish what evidence exists on standardised care • Development & implementation • Impact • Costs SYSTEMATIC LITERATURE REVIEWS National Survey Case Studies

  10. Standardised Care in Practice Interviews • What really goes on… developing, • implementing and sustaining? • How does it impact on those delivering care? • New national guideline • Health visitor x 2 • End of Life care • MI care pathway Literature Reviews DETAILED CASE STUDY WORK National Survey

  11. User Views • Survey to explore • attitudes, • beliefs & • experience – • Job satisfaction • Mental health • Feelings of competence & autonomy Interviews Literature Reviews Case Studies National Survey of Nurses, Midwives & Health Visitors

  12. Search for Evidence Interviews • AIM: • To establish what evidence exists on standardised care • Development & implementation • Impact • Costs SYSTEMATIC LITERATURE REVIEWS National Survey Case Studies

  13. Development, implementation and impact: a systematic literature review Irene Ilott, Andrew Booth, Jo Rick, Rose O’Neill & Malcolm Patterson RCN International Nursing Research Conference April 8th 2008, Liverpool

  14. Content • Method: • Systematic literature review and qualitative analysis • Appraising practitioner and research knowledge • Key findings: • Multiple purposes of standardised care • Different approaches to development • Complex, time-consuming process • Challenge of change • Some questions and implications

  15. Systematic literature reviews "are a method of making sense of large bodies of information, and a means of contributing to the answers to questions about what works and what does not - and many other types of question too. They are a method of mapping out areas of uncertainty, and identifying where little or no relevant research has been done, but where new studies are needed" (Pettigrew & Roberts 2006, p2)

  16. Protocol-based care Search of 20 databases yielded only 56 papers heterogeneous 24 excluded as about software Standardised care Search terms: protocols, and guidelines, and pathways 6,901 studies from 5 ‘nursing’ databases and hand search of J. Integrated Care Pathways 3,872 - Ist sift using Ref. Manager 859 - 2nd sift data extraction 289 - papers about development & implementation 64 - papers appraised - data about impact on staff outcomes Two systematic literature reviews:

  17. Impact: international studies Included studies: • 64 studies published between1990-2005 • Source: 27 USA, 24 UK, 4 Netherlands, 4 Australia, 2 Ireland, 1 New Zealand, 1 Saudi Arabia, 1 Hong Kong • About: nurses (n=59), midwives (n=4) and public health nurses(n=1) Findings:few studies, poor methodological quality but consistent positive (eg. empower, expanded roles, team working) and negative outcomes (restrict decision-making and deskilling)

  18. Review: representative set UK papers about development and implementation • 33/117 papers reviewed by two people, in different ways: • inductively using Qualitative Assessment and Review Instrument (QARI) from The Joanna Briggs Institute • deductively – comparing descriptions with 12-step MA/NICE (2002) framework for developing protocols • Trustworthiness: reflexivity, data saturation and audit by an independent researcher

  19. UK perspective derived from: • 33 UK papers published between 1991-2006 • 27 in England, 3 in Scotland, 2 in Wales, 1 England and Wales • 20 in hospitals/secondary care: 5 ICU/HDU, 2 A&E, 4 nurse-led day care/clinics • 3 District Nurses, 2 Community Nurses, 1 Health visitors • 1 Midwives (as part of a md, inter-agency team)

  20. ‘Appraising’ practitioner knowledge • Everyday experience - authenticity and credibility of the source (Pawson et al 2003) • Purpose: sharing learning and positive experience about a specific standardised care, at particular time and place • 10 contained extracts of ‘standardised care’ • 7 ‘pilot studies’ about safety re changes in working practices on patient outcomes and costs • Most described development process – many different purposes, details and activities

  21. Approaches to development • Problem orientated local innovation eg District Nurses registering expected out-of-hours death (28/33) • Macro level, national to local guidance or policy-led change eg reducing waiting times (5/33) • Formalising or making current practice evidence-based eg management of constipation in critical care unit • Adopting/adapting something used elsewhere eg Liverpool end of life care pathway introduced in two Primary Care Trusts

  22. Primary and secondary purposes 26/33 gave multiple aims that included: • Policy: workforce modernisation and standardisation of procedures or service • Improving quality of patient care • Organisational reasons – increased demand • Team working – improve consistency • Staff reasons – expand scope of practice • Task related purposes – ‘unappreciated’ aspect of care eg oral care

  23. Tool-box for a spiral process rather than a 12-step linear process Varied sequence with some steps or parts: • missed (patient involvement, process mapping) • repeated and ongoing (stakeholder support) • not mentioned (using information scientists, interpreting the evidence & drafting the documents) Guidance estimated 3-6 months from start to use: • Time reported in 10/33 studies • Range 6-36 months, took an average 15 months

  24. Example: step 3 of 12 Involve patients & users 1 - instigated by patient representative support group: protocol for improving consistency of diagnosis and treatment of symphysis pubis dysfunction 6 – produced patient information leaflets 1 – questioned patients about preventative information they had received

  25. Staff perspective • Most made only ‘passing reference’ to staff and impact, eg. about empowerment and control • Nurses’ contribution was understated/difficult to identify; 10/33 re nurse-led care/role expansion • Doctor-nurse relationship: assessment of competence 4/33, challenging adherence 1/33

  26. Implementing and sustaining change “Despite the long run-in period involving staff consultation and preparation, it took nearly a year before the use of the protocol (for weaning ventilated patients) was successfully embedded into unit practice” (on an intensive care unit) Bruton & McPherson 2004: 438

  27. Thank-you Any questions or comments? • Does the UK literature reflect your experience in the UK and elsewhere? • What’s the impact of the growing number of national guidelines on local developments? • What’s the implications of policies/procedures manuals as important sources of knowledge - evidence-based practice (Gerrish et al 2008)

  28. References Bruton A & McPherson K (2004) Impact of the introduction of a multidisciplinary weaning team on a general intensive care unit. Int J Therapy and Rehabilitation, 11, 9, 435-430. Gerrish K et al (2008) Developing evidence-based practice: experiences of senior and junior nurses. Journal of Advanced Nursing, 62, 1, 62-73. NHS Modernisation Agency and National Institute for Clinical Excellence (2002) A Step-by-Step Guide to Developing Protocols. Pawson R et al (2003) Knowledge Review. Types and Quality of Knowledge in Social Care. SCIE/The Policy Press. Petticrew M & Roberts H (2006) Systematic Reviews in the Social Sciences. A Practical Guide. Blackwell Publishing.

  29. Standardised Care in Practice Interviews • What really goes on… developing, • implementing and sustaining? • How does it impact on those delivering care? • New national guideline • Health visitor x 2 • End of Life care • MI care pathway Literature Reviews DETAILED CASE STUDY WORK National Survey

  30. Competing ideologies in maternity care: A discourse analysis Rose O’Neill, Malcolm Patterson & Jo Rick RCN 2008 International Research Conference Liverpool, 9th April 2008

  31. Background • Very detailed research in five case study sites to examine standardised care in practice • Influence of clinical settings leads to considerable variation in acceptance and use of standardised care • Midwifery example to explore the impact of existing ideologies on perceptions of standardised care stringency

  32. Content • Competing ideologies in midwifery • ‘With woman’ versus ‘with institution’ • Basic principles of discourse analysis • Findings from interviews with midwives • Influence of ideological preference on midwives’ perceptions of clinical guideline stringency

  33. Definitionand types of ideologies • “shared, relatively coherently interrelated sets of emotionally charged beliefs, values, and norms that bind some people together and help them to make sense of their worlds” (Trice & Beyer, 1993, p.33) • Differing professional specialties adopt different ideologies • Individuals acquire sense of professional legitimacy by adopting ideology • Ideologies are often in conflict e.g., tension between medical intervention and more natural models (Meyerson, 1994) • Tension particularly evident in midwifery care (Hyde & Roche-Reid, 2004) • Midwifery profession founded on autonomy and independent clinical practice

  34. Ideologiesin maternity care (1) • ‘With woman’ ideology (Hunter, 2004) • ‘Mid’ = ‘with’ and ‘wif’ = ‘woman’ • Midwifery model of care • Natural, normal birth • Midwives are experts in normality • Autonomous, independent practitioners • Continuity of care • Woman-centred care

  35. Ideologiesin maternity care (2) • ‘With institution’ ideology (Hunter, 2004) • Medical model of care • Dominant model • Standardisation, medical intervention • Strict protocols – “fossilise into rules” (Kirkham, 2004, p.273) • Erosion of traditional midwifery, loss autonomy • Discrepancies between midwives’ core values and medical model of care (Curtis, Ball & Kirkham, 2006)

  36. Discourse analysis • Ideologies manifest in language • Study of midwives’ language ideal methodology • Individuals use language to construct their reality • Discourse analysis enables in-depth exploration of specific language use • Aim to understand how specific language is used to construct reality • Looking for the use of particular words, for vivid images, metaphors, or figures of speech • Important to acknowledge my own role in interpretation of the discourse • Highly subjective process • No claims made as to objectivity or generalisability of findings

  37. Research aim and question • To explore the competing ‘with woman’ and ‘with institution’ ideologies underpinning maternity care in a midwifery-led care unit and a consultant-led care unit, respectively • How do midwives use language to construct the realities of a midwifery-led care unit following a ‘with woman’ ideology and a consultant-led care unit following a ‘with institution’ ideology?

  38. Reality of woman-centred v task focused maternity care • “The difference is, I can explain it very, very simply, that in the community you worked for the woman, when she needed it, how she needed it. When you go into the hospital you really start working for the institution, so you have to do things which you know are not necessarily the best thing for the woman or the baby, it’s because you’re in a building, an institution, with its own rules and requirements so you have to do things in a certain way. And those ways are often very time consuming and take the focus away from the woman herself.” Midwife 8

  39. Reality of midwifery v obstetric nursing • “…you’re not giving sort of 100% midwifery care, you’re giving medicalised care, you’re giving obstetric nurse care, you know, you’re not doing…like when I’m down on midwifery led care, generally you’re on your hands and knees, you’re on the floor you know, you either get along with your woman or you don’t go in there, do you know what I mean? Up here they’ve not got that, that kind of connection with you, it’s not the same because they’re sat on a bed, they see the doctors coming in and out, telling you what to do, and it’s just like you’re a little handmaiden running in and out, not doing your job. I mean you do your best to make it as normal as possible for them but it’s not always easy and it does, it takes away your satisfaction as a midwife. And like I say, it’s not being a midwife up here, it’s just being an obstetric nurse because you’re just caring, you’re taking care of people’s needs from a medicalised point of view, and that’s not what I became a midwife for” Midwife 2

  40. Reality of guidelines v protocols (1) • “that’s why it’s called a guideline – the midwives should, in theory, be given the confidence to use a guideline, know the guideline, acknowledge the guideline, but also be able to justify their actions or potential delays that they might do through their clinical skills” Midwife 4 • “obviously guidelines are not gospel they are there as guidance.” Midwife 6

  41. Reality of guidelines v protocols (2) • “guidelines are guidelines, I mean you either go with them or you go with your experience and you work as an autonomous midwife” • “I mean we know it’s all for safety and patient care and one thing and another…butI think sometimes there needs to be that leeway” • “I mean we all know that we’ve got to work within the protocols but I think sometimes we just need that, that little bit of space” Midwife 2

  42. Clinical guideline stringency (1) • Midwives’ ideological preference influenced their perceptions of clinical guideline stringency • Power of ideology over attitudes and behaviours • Consensus regarding standardised care on midwifery-led care unit • Strongly evidence-based “guidelines” • Supportive towards best practice and flexibility to accommodate women’s individual needs • But discrepancy regarding standardised care on consultant-led care unit • Midwives favouring a ‘with woman’ ideology described standardised care as much more restrictive than midwives favouring a ‘with institution’ ideology

  43. Clinicalguideline stringency (2) • ‘With woman’ ideological preference • Talked about strict, inflexible “protocols” and “rules” on consultant-led care • Highly medicalised, proceduralised care • Limited abilities to practice autonomously and provide individualised care • Profound incongruence with core midwifery values • BUT, did acknowledge the importance of highly medicalised and proceduralised care for dealing with rare, life threatening emergencies

  44. Clinical guideline stringency (3) • ‘With institution’ ideological preference • Talked about “consultant-led care guidelines” • More prescriptive than midwifery-led guidelines, but still flexible “guidelines” • Still able to use clinical judgement to deviate when necessary and provide individualised care • No perceived loss of autonomy • Compatible with core midwifery values

  45. Key findings • Conflict exists between competing models of maternity care and their underpinning ideologies • Midwifery v medical models • ‘With woman’ v ‘with institution’ ideologies • Important to acknowledge strong influence of ideological preference (and core midwifery values) over perceptions of standardised care • Flexible care guidelines v strict protocols • Potential incongruence with core midwifery values • What impact does this have?

  46. Conclusion • The findings presented here are specific to midwifery, however pre-existing values and beliefs are present in any branch of nursing • Such values and beliefs need to be taken into account for the successful development and implementation of standardised care • They are equally important for understanding how standardised care can impact on the professional identity of nurses and the way they experience their work

  47. Thanks for listening… • Any questions or comments? • How do these findings fit with your experience in your speciality and country?

  48. References • Curtis, P., Ball, L. and Kirkham, M. (2006). Why do midwives leave? (Not) being the kind of midwife you want to be. British Journal of Midwifery, 14, 27-31. • Hunter, B. (2004). Conflicting ideologies as a source of emotion work in midwifery. Midwifery, 20, 261-272. • Hyde, A. and Roche-Reid, B. (2004). Midwifery practice and the crisis of modernity: Implications for the role of the midwife. Social Science and Medicine, 58, 2613-2623. • Kirkham, M. (2004). Choice and bureaucracy. In M. Kirkham (Ed.), Informed Choice in Maternity Care (pp.265-290). New York : Palgrave Macmillan. • Meyerson, D. E. (1994). Interpretations of stress in institutions: The cultural production of ambiguity and burnout. Administrative Science Quarterly, 39, 628-653. • Trice, H. and Beyer, J. (1993). The Cultures of Work Organizations. Englewood Cliffs, NJ : Prentice Hall.

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