Safer clinical systems : interim report, August 2010

Safer Clinical Systems is the Health Foundation’s new five year programme of work to test and demonstrate ways to improve healthcare systems and processes, to develop safer systems that improve patient safety. It builds on learning from the Safer Patients Initiative (SPI) and models of system improvement from both healthcare and other industries. Learning from the SPI highlighted the need to take a clinical systems approach to improving safety. SPI highlighted that many hospitals struggle to implement improvement in clinical areas due to inherent problems with support mechanisms. Clinical processes and systems, rather than individuals, are often the contributors to breakdown in patient safety. The Safer Clinical Systems programme aimed to measure the reliability of clinical processes, identify defects within those processes, and identify the systems that result in those defects. Methods to improve system reliability were then to be tested and re-developed in order to reduce the risk of harm being caused to patients. Such system-level awareness should lead to improvements in other patient care pathways. The relationship between system reliability and actual harm is challenging to identify and measure. Specific, well-defined, small-scale processes have been used in other programmes, and system reliability has been shown to have a direct causal relationship with harm (e.g. care bundle compliance in an intensive care unit can reduce the incidence of ventilator-associated pneumonia). However, it has become evident that harm can be caused by a variety of factors over time; when working in broader, more complex and dynamic systems, change in outcome can be difficult to attribute to specific improvements and difficulties are also associated with relating evidence to resulting harm. The overall aim of Phase 1 of the Safer Clinical Systems programme was to demonstrate proof-of-concept that using a systems-based approach could contribute to improved patient safety. In Phase 1, experienced NHS teams from four locations worked together with expert advisers to co-design the Safer Clinical Systems programme

The Dutch Individualised Care Scale for patients and nurses : a psychometric validation study

Aims and objectives: Translating and psychometrically assessing the Individualised Care Scale (ICS) for patients and nurses for the Flemish and Dutch healthcare context. Background: Individualised care interventions have positive effects on health outcomes. However, there are no valid and reliable instruments for evaluating individualised care for the Flemish and Dutch healthcare context. Design: Psychometric validation study. Setting and participants: In Flemish hospitals, data were collected between February and June 2016, and in Dutch hospitals, data were collected between December 2014 and May 2015. Nurses with direct patient contact and a working experience of minimum 6 months on the wards could participate. Patient inclusion criteria were being an adult, being mentally competent, having an expected hospital stay of minimum 1 day, and being able to speak and read the Dutch language. In total, 845 patients and 569 nurses were included. Methods: The ICS was translated into Dutch using a forward–backward translation process. Minimal linguistic adaptations to the Dutch ICS were made to use the scale as a Flemish equivalent. Omega, Cronbach’s Alpha, mean inter-item correlations and standardised subscale correlations established the reliability and confirmatory factor analysis the construct validity of the ICS. Results: Internal consistency using Omega (Cronbach’s Alpha) ranged from 0.83 to 0.96 (0.82–0.95) for the ICSNurse and from 0.88 to 0.96 (0.87–0.96) for the ICSPatient. Fit indices of the confirmatory factor analysis indicated a good model fit, except for the root mean square error of approximation, which indicated only moderate model fit. Conclusion: The Dutch version of the ICS showed acceptable psychometric performance, supporting its use for the Dutch and Flemish healthcare context. Relevance to clinical practice: Knowledge of nurses’ and patients’ perceptions on individualised care will aid to target areas in the Dutch and Flemish healthcare context in which work needs to be undertaken to provide individualised nursing care

Study protocol: Delayed intervention randomised controlled trial within the Medical Research Council (MRC) Framework to assess the effectiveness of a new palliative care service

Background: Palliative care has been proposed to help meet the needs of patients who suffer progressive non-cancer conditions but there have been few evaluations of service development initiatives. We report here a novel protocol for the evaluation of a new palliative care service in this context. Methods/Design: Using the MRC Framework for the Evaluation of Complex Interventions we modelled a new palliative care and neurology service for patients severely affected by Multiple Sclerosis (MS). We conducted qualitative interviews with patients, families and staff, plus a literature review to model and pilot the service. Then we designed a delayed intervention randomised controlled trial to test its effectiveness as part of phase II of the MRC framework. Inclusion criteria for the trial were patients identified by referring clinicians as having unresolved symptoms or psychological concerns. Referrers were advised to use a score of greater than 8 on the Expanded Disability Scale was a benchmark. Consenting patients newly referred to the new service were randomised to either receive the palliative care service immediately (fast-track) or after a 12-week wait (standard best practice). Face to face interviews were conducted at baseline (before intervention), and at 4–6, 10–12 (before intervention for the standard-practice group), 16– 18 and 22–24 weeks with patients and their carers using standard questionnaires to assess symptoms, palliative care outcomes, function, service use and open comments. Ethics committee approval was granted separately for the qualitative phase and then for the trial. Discussion: We publish the protocol trial here, to allow methods to be reviewed in advance of publication of the results. The MRC Framework for the Evaluation of Complex Interventions was helpful in both the design of the service, methods for evaluation in convincing staff and the ethics committee to accept the trial. The research will provide valuable information on the effects of palliative care among non-cancer patients and a method to evaluate palliative care in this context

Managing ongoing swallow safety through information‐sharing: An ethnography of speech and language therapists and nurses at work on stroke units

© 2022 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists. This is an open access article under the terms of the Creative Commons Attribution License, https://creativecommons.org/licenses/by/4.0/Background: Speech and language therapists and nurses need to work together to keep patients with swallowing difficulties safe throughout their acute stroke admission. Speech and language therapists make recommendations for safe swallowing following assessment and nurses put recommendations into practice and monitor how patients cope. There has been little research into the everyday realities of ongoing swallow safety management by these two disciplines. Patient safety research in other fields of healthcare indicates that safety can be enhanced through understanding the cultural context in which risk decisions are made. Aims: To generate new understanding for how speech and language therapists (SLTs) and nurses share information for ongoing management of swallows safety on stroke units. Methods & Procedures: An ethnographic methodology involving 40 weeks of fieldwork on three stroke wards in England between 2015 and 2017. Fieldwork observation (357 h) and interviews with 43 members of SLT and nursing staff. Observational and interview data were analysed iteratively using techniques from the constant comparative method to create a thematically organized explanation. Outcomes & Results: An explanation for how disciplinary differences in time and space influenced how SLT and nursing staff shared information for ongoing management of swallow safety, based around three themes: (1) SLTs and nurses were aligned in concern for swallow safety across all information‐sharing routes; however, (2) ambiguity was introduced by the need for the information contained in swallowing recommendations to travel across time, creating dilemmas for nurses. Patients could improve or deteriorate after recommendations were made and nurses had competing demands on their time. Ambiguity had consequences for (3) critical incident reporting and relationships. SLTs experienced dilemmas over how to act when recommendations were not followed. Conclusions & Implications: This study provides new understanding for patient safety dilemmas associated with the enactment and oversight of swallowing recommendations in context, on stroke wards. Findings can support SLTs and nurses to explore together how information for ongoing dysphagia management can be safely implemented within ward realities and kept up to date. This could include considering nursing capacity to act when SLTs are not there, mealtime staffing and SLT 7‐day working. Together they can review their understanding of risk and preferred local and formal routes for learning from it. What this paper adds: What is already known on the subject: It is known that information to keep swallowing safe is shared through swallowing recommendations, which are understood to involve a balance of risks between optimizing the safety of the swallow mechanism and maintaining physiological and emotional health. There is increasing appreciation from patient safety research, of the importance of understanding the context in which hospital staff make decisions about risk and patient safety. What this paper adds to existing knowledge: The paper provides new empirical understanding for the complexities of risk management associated with SLT and nursing interactions and roles with respect to ongoing swallow safety. What are the potential or actual clinical implications of this work?: Findings can underpin SLT and nurse discussion about how swallow safety could be improved in their own settings.Peer reviewedFinal Published versio

Managing ongoing swallow safety through information‐sharing: An ethnography of speech and language therapists and nurses at work on stroke units

© 2022 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists. This is an open access article under the terms of the Creative Commons Attribution License, https://creativecommons.org/licenses/by/4.0/Background: Speech and language therapists and nurses need to work together to keep patients with swallowing difficulties safe throughout their acute stroke admission. Speech and language therapists make recommendations for safe swallowing following assessment and nurses put recommendations into practice and monitor how patients cope. There has been little research into the everyday realities of ongoing swallow safety management by these two disciplines. Patient safety research in other fields of healthcare indicates that safety can be enhanced through understanding the cultural context in which risk decisions are made. Aims: To generate new understanding for how speech and language therapists (SLTs) and nurses share information for ongoing management of swallows safety on stroke units. Methods & Procedures: An ethnographic methodology involving 40 weeks of fieldwork on three stroke wards in England between 2015 and 2017. Fieldwork observation (357 h) and interviews with 43 members of SLT and nursing staff. Observational and interview data were analysed iteratively using techniques from the constant comparative method to create a thematically organized explanation. Outcomes & Results: An explanation for how disciplinary differences in time and space influenced how SLT and nursing staff shared information for ongoing management of swallow safety, based around three themes: (1) SLTs and nurses were aligned in concern for swallow safety across all information‐sharing routes; however, (2) ambiguity was introduced by the need for the information contained in swallowing recommendations to travel across time, creating dilemmas for nurses. Patients could improve or deteriorate after recommendations were made and nurses had competing demands on their time. Ambiguity had consequences for (3) critical incident reporting and relationships. SLTs experienced dilemmas over how to act when recommendations were not followed. Conclusions & Implications: This study provides new understanding for patient safety dilemmas associated with the enactment and oversight of swallowing recommendations in context, on stroke wards. Findings can support SLTs and nurses to explore together how information for ongoing dysphagia management can be safely implemented within ward realities and kept up to date. This could include considering nursing capacity to act when SLTs are not there, mealtime staffing and SLT 7‐day working. Together they can review their understanding of risk and preferred local and formal routes for learning from it. What this paper adds: What is already known on the subject: It is known that information to keep swallowing safe is shared through swallowing recommendations, which are understood to involve a balance of risks between optimizing the safety of the swallow mechanism and maintaining physiological and emotional health. There is increasing appreciation from patient safety research, of the importance of understanding the context in which hospital staff make decisions about risk and patient safety. What this paper adds to existing knowledge: The paper provides new empirical understanding for the complexities of risk management associated with SLT and nursing interactions and roles with respect to ongoing swallow safety. What are the potential or actual clinical implications of this work?: Findings can underpin SLT and nurse discussion about how swallow safety could be improved in their own settings.Peer reviewedFinal Published versio

Udział pielęgniarki w leczeniu udaru niedokrwiennego mózgu — wiedza pielęgniarek oddziału udarowego

Introduction. Stroke units are wards created to provide specialized care after stroke. Comprehensiveness of actions taken according to the latest recommendation is a priority. A nurse plays an important role at every stage of therapeutic activities. The actions taken by her should be based on the EBNP (Evidence Based Nursing Practice) and cover all aspects of care of the patient after stroke. By using up-to-date results of scientific studies in practice, the patient has been guaranteed the highest quality of care and safety.Aim. In this study there has been discussed the issue of knowledge of the nursing staff from the Stroke Unit in the context of theoretical and practical information related to stroke.Material and Methods. The research was conducted among 26 nurses from the Neurology and Stroke Unit. The diagnostic survey method was used. The research tool was an authorial questionnaire.Results. Non-modifiable risk factors of stroke were indicated by 77% of people. The set of tests used to diagnose stroke was indicated by 15.4% of the respondents. A physical examination was often omitted. The recombinant plasminogen activator (rt-PA), as a medicine was marked by 52% participants, whereas as a medicine used for treatment was indicated by 32% of them. The meaning of the term thrombolysis is known by 100% of individuals, however, the possibility of performing intra-arterial thrombolysis was indicated by 30% of respondents. The recombinant plasminogen activator (rt-PA), as a medicine used in the thrombolysis was chosen by 43.5% respondents, and streptokinase by 39% of them. The sources of knowledge include professional work (54%), education (27%), trainings (19%). Conducting education among the patients is declared by 96% of the respondents.Conclusions. 1) Knowledge of the nurses from the Stroke Unit on the basic matters regarding stroke is at a good level. 2) Knowledge of the nurses is mainly based on their personal experience. 3) Theoretical basics regarding new treatment techniques should be strengthened. 4) There is a need to organize courses to update the gained knowledge on new guidelines and information regarding the new scientific research. (JNNN 2017;6(4):150–156)Wstęp. Oddziały udarowe to jednostki stworzone do zapewnienia specjalistycznej opieki w udarze mózgu. Priorytetem jest kompleksowość działań zgodnie z najnowszymi zaleceniami. Pielęgniarka pełni istotną rolę na każdym etapie działań terapeutycznych. Działania przez nią podejmowane powinny być oparte o EBNP (Evidence Based Nursing Practice) i obejmować zakresem wszystkie aspekty opieki nad pacjentem udarowym. Dzięki zastosowaniu aktualnych wyników badań naukowych w praktyce pacjent ma zagwarantowaną najwyższą jakość opieki i bezpieczeństwo.Cel. W badaniu podjęto problematykę wiedzy personelu pielęgniarskiego zatrudnionego w oddziale udarowym w kontekście informacji teoretycznych i praktycznych związanych z udarem.Materiał i metody. Badanie przeprowadzono wśród 26 pielęgniarek Oddziału Neurologii i Udarowego. Zastosowano metodę sondażu diagnostycznego. Użytym narzędziem badawczym był autorski kwestionariusz ankiety.Wyniki. Niemodyfikowalne czynniki ryzyka udaru mózgu wskazało 77% badanych. Komplet badań wykonywanych w diagnostyce udaru wskazało 15,4% respondentek. Najczęściej pomijano badanie fizykalne. Rekombinowany aktywator plazminogenu (rt-Pa) jako lek określiło 56% badanych, a jako lek stosowany w leczeniu 32%. Ankietowane znają znaczenie słowa tromboliza w 100%, ale możliwość podania jej dotętniczo wskazało 30% badanych. Rekombinowany aktywator plazminogenu (rt-Pa) jako lek stosowany w trombolizie wybrało 43,5%, a streptokinazę 39%. Źródłami wiedzy są praca zawodowa (54%), wykształcenie (27%), szkolenia (19%). Prowadzenie edukacji pacjentów deklaruje 96% ankietowanych.Wnioski. 1) Znajomość podstawowej tematyki udaru mózgu przez pielęgniarki oddziału udarowego jest na dobrym poziomie. 2) Wiedza pielęgniarek opiera się głównie na doświadczeniu własnym. 3) W zakresie nowych technik leczenia, należy wzmocnić podstawy teoretyczne. 4) Istnieje konieczność organizowania szkoleń, aby aktualizować zdobytą wiedzę o nowe wytyczne i informacje z zakresu nowych badań naukowych. (PNN 2017;6(4):150–156

Creating Excellence in Dementia Care: A Research Review for Ireland's National Dementia Strategy

Examines the prevalence and economic and social costs of dementia; policies, practices, and data on health and social care services in community-based, acute care, and long-term residential settings; and proposed elements for a new strategy