Improving Patient Experience in Hospital Settings: Assessing the Role of Toolkits and Action Research through a Process Evaluation of a Complex Intervention

This article presents a process evaluation of the implementation and refinement of a patient experience toolkit (PET) by action researchers in six hospital wards in the English National Health Service (NHS). An initial assumption that health care professionals (HCPs) would use PET to improve patient experience proved unrealistic due to staff and service pressures. However, the action researchers' facilitation of PET and their support during the implementation of quality improvement efforts filled in for HCPs' lack of time. The findings suggest that the PET can be a successful guide for skilled facilitators working with HCPs, although excessive staff pressures should be avoided. Toolkits designed for implementation by HCPs should, therefore, be used sparingly; a more appropriate target audience may be facilitators. Furthermore, while the potential of action research is confirmed by this evaluation, HCPs' time to engage in service improvement is found to moderate the success of this increasingly prominent methodology

Advancing Complexity Theory in Health Services Research: The Logic of Logic Models

Background: Logic models are commonly used in evaluations to represent the causal processes through which interventions produce outcomes, yet significant debate is currently taking place over whether they can describe complex interventions which adapt to context. This paper assesses the logic models used in healthcare research from a complexity perspective. A typology of existing logic models is proposed, as well as a formal methodology for deriving more flexible and dynamic logic models. Analysis: Various logic model types were tested as part of an evaluation of a complex Patient Experience Toolkit (PET) intervention, developed and implemented through action research across six hospital wards/departments in the English NHS. Three dominant types of logic model were identified, each with certain strengths but ultimately unable to accurately capture the dynamics of PET. Hence, a fourth logic model type was developed to express how success hinges on the adaption of PET to its delivery settings. Aspects of the Promoting Action on Research Implementation in Health Services (PARIHS) model were incorporated into a traditional logic model structure to create a dynamic “type 4” logic model that can accommodate complex interventions taking on a different form in different settings. Conclusion: Logic models can be used to model complex interventions that adapt to context but more flexible and dynamic models are required. An implication of this is that how logic models are used in healthcare research may have to change. Using logic models to forge consensus among stakeholders and/or provide precise guidance across different settings will be inappropriate in the case of complex interventions that adapt to context. Instead, logic models for complex interventions may be targeted at facilitators to enable them to prospectively assess the settings they will be working in and to develop context-sensitive facilitation strategies. Researchers should be clearas to why they are using a logic model and experiment with different models to ensure they have the correct type

The Association Between Health Care Staff Engagement and Patient Safety Outcomes: A Systematic Review and Meta-Analysis

Objectives: Despite decades of research, improving health care safety remains a global priority. Individual studies have demonstrated links between staff engagement and care quality, but until now, any relationship between engagement and patient safety outcomes has been more speculative. This systematic review and meta-analysis therefore assessed this relationship and explored if the way these variables were defined and measured had any differential effect. Methods: After systematic searches of Medline, CINAHL, PsycInfo, Embase, Cochrane Library, and National Institute for Health Research Journals databases, narrative and random-effects meta-analyses were completed, with pooled effect sizes expressed as Pearson r. Results: Fourteen studies met the inclusion criteria, 11 of which were suitable for meta-analysis. Meta-analyses indicated a small but consistent, statistically significant relationship between staff engagement and patient safety (all outcomes; 11 studies; r = 0.22; 95% confidence interval [CI], 0.07 to 0.36; n = 30,490) and 2 patient safety outcome categories: patient safety culture (7 studies;r = 0.22; 95% CI, 0.01 to 0.41; n = 27,857) and errors/adverse events (4 studies;r = −0.20; 95% CI, −0.26 to −0.13; n = 2633). The specific approach to conceptualizing engagement did not affect the strength of the findings. Conclusions: This is the first review to demonstrate a significant relationship between engagement and both safety culture scores and errors/adverse events. Despite a limited and evolving evidence base, we cautiously conclude that increasing staff engagement could be an effective means of enhancing patient safety. Further research is needed to determine causality and clarify the nature of the staff engagement/patient safety relationship at individual and unit/workgroup levels

Multiple meanings of resilience: Health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error

Rationale, aims and objectives: Consistent data demonstrates negative psychological effects of caregiving on front-line health professionals. Evidence that psychological resilience factors can help minimize distress and the potential for low-cost interventions have created interest in resilience-based development programmes; yet evidence of perceived value amongst health professionals is lacking. This study explored health professionals' experiences and perceptions of a novel, resilience-based intervention designed to pro-actively prepare staff for coping with error; to investigate their perceptions of what resilience meant to them, the relevance of the intervention, and impact of participation on ability to cope with error. Methods: Semi-structured interviews 4-6 weeks post intervention with 23 randomly selected participants from seven cohorts (midwives, paediatricians, obstetricians/gynaecologists, paramedics) and trainees (physician associates, mammographers, sonographers). Thematic analysis of interview data. Findings: Participants reported various interpretations of, and a shift in perception regarding what the concept of psychological resilience meant to them and their practice. These included for example, resilience as a positive or negative concept and their awareness and response to a range of personal, organizational and system factors influencing personal resilience. They valued the prophylactic, clinically relevant, interactive and applied nature of the intervention; having developed and applied valuable skills beyond the context of involvement in error, noting that individuals needed to be willing to explore their own coping mechanisms and human fallibility to gain maximum benefit. There was also consensus that whilst proactively developing individual levelpsychological resilience is important, so too is addressing the organizational and system factors that affect staff resilience which are outside individual staff control. Conclusion: Enhancing resilience appears to be considered useful in supporting staff to prepare for coping with error and the wider emotional burden of clinical work, but such interventions require integration into wider system approaches to reduce the burden of clinical work for health professionals

Conductance quantization and snake states in graphene magnetic waveguides

We consider electron waveguides (quantum wires) in graphene created by suitable inhomogeneous magnetic fields. The properties of uni-directional snake states are discussed. For a certain magnetic field profile, two spatially separated counter-propagating snake states are formed, leading to conductance quantization insensitive to backscattering by impurities or irregularities of the magnetic field.Comment: 5 pages, 4 figures, final version accepted as Rapid Comm. in PR

A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home

Background The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient‐friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post‐discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention. Methods This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi‐structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims. Results Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness. Conclusion Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness

Using patient experience data to develop a patient experience toolkit to improve hospital care: a mixed-methods study

Background Patients are increasingly being asked to provide feedback about their experience of health-care services. Within the NHS, a significant level of resource is now allocated to the collection of this feedback. However, it is not well understood whether or not, or how, health-care staff are able to use these data to make improvements to future care delivery. Objective To understand and enhance how hospital staff learn from and act on patient experience (PE) feedback in order to co-design, test, refine and evaluate a Patient Experience Toolkit (PET). Design A predominantly qualitative study with four interlinking work packages. Setting Three NHS trusts in the north of England, focusing on six ward-based clinical teams (two at each trust). Methods A scoping review and qualitative exploratory study were conducted between November 2015 and August 2016. The findings of this work fed into a participatory co-design process with ward staff and patient representatives, which led to the production of the PET. This was primarily based on activities undertaken in three workshops (over the winter of 2016/17). Then, the facilitated use of the PET took place across the six wards over a 12-month period (February 2017 to February 2018). This involved testing and refinement through an action research (AR) methodology. A large, mixed-methods, independent process evaluation was conducted over the same 12-month period. Findings The testing and refinement of the PET during the AR phase, with the mixed-methods evaluation running alongside it, produced noteworthy findings. The idea that current PE data can be effectively triangulated for the purpose of improvement is largely a fallacy. Rather, additional but more relational feedback had to be collected by patient representatives, an unanticipated element of the study, to provide health-care staff with data that they could work with more easily. Multidisciplinary involvement in PE initiatives is difficult to establish unless teams already work in this way. Regardless, there is merit in involving different levels of the nursing hierarchy. Consideration of patient feedback by health-care staff can be an emotive process that may be difficult initially and that needs dedicated time and sensitive management. The six ward teams engaged variably with the AR process over a 12-month period. Some teams implemented far-reaching plans, whereas other teams focused on time-minimising ‘quick wins’. The evaluation found that facilitation of the toolkit was central to its implementation. The most important factors here were the development of relationships between people and the facilitator’s ability to navigate organisational complexity. Limitations The settings in which the PET was tested were extremely diverse, so the influence of variable context limits hard conclusions about its success. Conclusions The current manner in which PE feedback is collected and used is generally not fit for the purpose of enabling health-care staff to make meaningful local improvements. The PET was co-designed with health-care staff and patient representatives but it requires skilled facilitation to achieve successful outcomes. Funding The National Institute for Health Research Health Services and Delivery Research programme

Tomonaga-Luttinger liquid parameters of magnetic waveguides in graphene

Electronic waveguides in graphene formed by counterpropagating snake states in suitable inhomogeneous magnetic fields are shown to constitute a realization of a Tomonaga-Luttinger liquid. Due to the spatial separation of the right- and left-moving snake states, this non-Fermi liquid state induced by electron-electron interactions is essentially unaffected by disorder. We calculate the interaction parameters accounting for the absence of Galilei invariance in this system, and thereby demonstrate that non-Fermi liquid effects are significant and tunable in realistic geometries