A narrative inquiry into healthcare staff resilience and the sustainability of Quality Improvement implementation efforts during Covid-19.

BACKGROUND: Recent research, which explored the use of Quality Improvement (QI) methods in the Covid-19 pandemic response, found that Quality Improvement principles were utilised during the crisis management period, albeit without direct intention. Following on from this work, the aim of this paper extends that study by investigating the sustainability and resilience of not only the changes implemented by healthcare staff during Covid-19 in Ireland, but the resilience of the wellbeing of healthcare staff themselves through the various waves of Covid-19. METHODS: To explore healthcare staffs experience of Quality Improvement and the sustainability and resilience of both Quality Improvement initiatives and healthcare staff, a qualitative design was implemented. Semi-structured interviews took place online over Zoom with 11 healthcare staff members from the Irish healthcare service in the Spring of 2022. An analysis of the narratives was conducted using thematic analysis supported by NVivo12. RESULTS: Four key themes were evident from the data: (i) From fear to exhaustion; (ii) maintaining person-centred approaches to care; (iii) Covid-19 as a medium for change, and; (iv) staff resilience and appetite for Quality Improvement. DISCUSSION: The results of this work identified three key learnings; (i) integrating learning into policies and practice: (ii) the role of collective leadership and devolving/sharing power; and (iii) key drivers/factors that promote sustainability of QI interventions. Despite the challenges in recruitment of research participants experienced during the pandemic, a narrative approach supported the collation of rich and nuanced insights into the experiences of healthcare staff during this time. CONCLUSION: A growing body of literature currently exists on how healthcare staff felt during the Covid-19 pandemic. However, as the waves of Covid-19 have declined, it is vital to examine how the feelings of burnout and disillusionment will affect engagement with Quality Improvement in the future. It is also worth noting and examining the feeling of purpose and pride participants expressed from working through the Covid-19 pandemic. This study has helped to address this gap.

A resilient workforce: patient safety and the workforce response to a cyber-attack on the ICT systems of the national health service in Ireland.

BACKGROUND: In May 2021, the Irish public health service was the target of a cyber-attack. The response by the health service resulted in the widespread removal of access to ICT systems. While services including radiology, diagnostics, maternity, and oncology were prioritised for reinstatement, recovery efforts continued for over four months. This study describes the response of health service staff to the loss of ICT systems, and the risk mitigation measures introduced to safely continue health services. The resilience displayed by frontline staff whose rapid and innovative response ensured continuity of safe patient care is explored. METHODS: To gain an in-depth understanding of staff experiences of the cyber-attack, eight focus groups (n = 36) were conducted. Participants from a diverse range of health services were recruited, including staff from radiology, pathology/laboratories, radiotherapy, maternity, primary care dental services, health and wellbeing, COVID testing, older person's care, and disability services. Thematic Analysis was applied to the data to identify key themes. RESULTS: The impact of the cyber-attack varied across services depending on the type of care being offered, the reliance on IT systems, and the extent of local IT support. Staff stepped-up to the challenges and quickly developed and implemented innovative solutions, exhibiting great resilience, teamwork and adaptability, with a sharp focus on ensuring patient safety. The cyber-attack resulted in a flattening of the healthcare hierarchy, with shared decision-making at local levels leading to an empowered frontline workforce. However, participants in this study felt the stress placed on staff by the attack was more severe than the cumulative effect of the COVID-19 pandemic. CONCLUSIONS: Limited contingencies within the health system IT infrastructure - what we call a lack of system resilience - was compensated for by a resilient workforce. Within the context of the prevailing COVID-19 pandemic, this was an enormous burden on a dedicated workforce. The adverse impact of this attack may have long-term and far-reaching consequences for staff wellbeing. Design and investment in a resilient health system must be prioritised.

Factors influencing measurement for improvement skills in healthcare staff: trainee, and trainer perspectives.

BACKGROUND: Measurement for improvement is an integral component of quality improvement (QI) trainings and demonstrates whether a change resulted in an improvement. Despite its critical role, the development of measurement for improvement skills for QI is relatively under-explored. PURPOSE: To explore the training, curricular and contextual factors that influence the development of measurement for improvement skills in healthcare professionals. METHODS: This is a retrospective, qualitative, multiple case study design, based on two QI collaboratives. Trainees and trainers from these programmes participated in semi-structured interviews. A framework drawing on the Kirkpatrick's evaluation model and the Model for Understanding Success in Quality (MUSIQ) model was developed. The interviews were analysed based on a three-step qualitative thematic analysis method. RESULTS: A total of 21 participants were interviewed (15 trainees and 6 trainers). Six themes emerged in the analysis of trainee interviewees: impact of differences in job role and hierarchical levels, narrow conception of QI, knowledge disparity between trained and untrained staff, balancing the benefits and burdens of measurement, early adopters of QI driving change and supportive and engaged leadership. Themes in trainer perspectives were knowledge and understanding of measurement, application of PDSA approach to programme design, balancing consistency with adaptation to context, and attributes of sites receptive to change as predictors of development of measurement for improvement skills in staff. CONCLUSION: Training alone does not determine the development, sustainability and spread of measurement and QI skills. Instead, it is influenced by a combination of curricular, training, and contextual support structures. Training programmes should be aware of the impact of job role and hierarchy, increased knowledge disparity between trained and untrained staff and trainees equating QI to bundle implementation while designing programmes. Similarly, organisational support through leaders, encouraging staff who have an interest in measurement and a culture receptive to QI also supports development of measurement skills. The study highlights the need for trainees, trainers, and organisations to work together in balancing the benefits and burdens of measurement, leading to sustainable skill development in line with international best practices.

Exploring healthcare staff narratives to understand the role of quality improvement methods in innovative practices during COVID-19.

BACKGROUND: COVID-19 has impacted the context in which healthcare staff and teams operate and this has implications for quality improvement (QI) work. Contrary to the usual ambivalent relationship staff have with QI work, there have been examples of unprecedented staff engagement in implementing rapid changes during the pandemic indicating a change in important underlying factors that impact staff involvement in QI. The purpose of this study is to explore staff perspectives about how experience and skills of QI methods supported them in implementing innovative practices during COVID-19. METHODS: This is a qualitative narrative study based on narrative interviews to collect healthcare staff stories of implementing rapid change. The stories were identified through social media (Twitter) and a national health magazine issued by the Irish health service. Twenty staff members participated in the interviews. Interviews were audio recorded, transcribed, and anonymised. A four-step thematic analysis was conducted. RESULTS: The analysis revealed the transformational journey of healthcare staff from the initial shock and anxiety caused by COVID-19 to making sense of the situation, implementing rapid changes, and acknowledging COVID as a learning experience. Six themes were evident from the analysis: COVID anxiety and fear, emotional supports and coping mechanisms, person-centric changes, COVID as a 'forcing function' for change, a collective way of working and looking back and thinking ahead. CONCLUSIONS: While most rapid changes during COVID-19 did not represent a systematic and explicit QI application, QI principles were evident throughout the stories and actions taken, including making small changes, testing changes, learning, reflecting as a team, and improving. Many staff members were able to retrospectively identify the relevance of QI principles. COVID-19 eliminated some traditional barriers to change leading to efficient solutions, thus highlighting a need to sustain these positive changes into routine practice to develop an adaptive healthcare system receptive to QI.

A systematic review exploring the impact of focal leader behaviours on health care team performance.

AIM: The aim of this study is to understand how the behaviour of focal leaders impacts health care team performance and effectiveness. BACKGROUND: Despite recent shifts towards more collectivistic leadership approaches, hierarchical structures that emphasize the role of an individual focal leader (i.e., the formal appointed leader) are still the norm in health care. Our understanding of the effect of focal leader behaviours on health care team performance remains unclear. EVALUATION: A systematic review was conducted. Five electronic databases were searched using key terms. One thousand forty-seven records were retrieved. Data extraction, quality appraisal and narrative synthesis were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. KEY ISSUES: Fifty papers met the criteria for inclusion, were reviewed and synthesized under the following categories: task-focused leadership, directive leadership, empowering leadership and relational focused leadership. CONCLUSIONS: Categories are discussed in relation to team performance outcomes, safety specific outcomes, individual-level outcomes and outcomes related to interpersonal dynamics. Emerging themes are explored to examine and reflect on how leadership is enacted in health care, to catalogue best practices and to cascade these leadership practices broadly. IMPLICATIONS FOR NURSING MANAGEMENT: Empowering and relational leadership styles were associated with positive outcomes for nursing team performance. This underscores the importance of training and encouraging nursing leaders to engage in more collaborative leadership behaviours.

Virtual adaptation of traditional healthcare quality improvement training in response to COVID-19: a rapid narrative review.

BACKGROUND: Information and communication technology are playing a major role in ensuring continuity of healthcare services during the COVID-19 pandemic. The pandemic has also disrupted healthcare quality improvement (QI) training and education for healthcare professionals and there is a need to rethink the way QI training and education is delivered. The purpose of this rapid evidence review is to quickly, but comprehensively collate studies to identify what works and what does not in delivering QI training and education using distance learning modalities. METHODS: Three healthcare databases were searched along with grey literature sources for studies published between 2015 and 2020. Studies with QI training programmes or courses targeting healthcare professionals and students with at least one component of the programme being delivered online were included. RESULTS: A total of 19 studies were included in the review. Most studies had a mixed methods design and used blended learning methods, combining online and in-person delivery modes. Most of the included studies reported achieving desired outcomes, including improved QI knowledge, skills and attitudes of participants and improved clinical outcomes for patients. Some benefits of online QI training delivery include fewer required resources, reduced need for on-site instructors, increased programme reach, and more control and flexibility over learning time for participants. Some limitations of online delivery modes include limited learning and networking opportunities, functional and technical problems and long lead time for content adaptation and customisation. DISCUSSION: The review highlights that distance learning approaches to QI help in overcoming barriers to traditional QI training. Some important considerations for those looking to adapt traditional programmes to virtual environments include balancing virtual and non-virtual methods, using suitable technological solutions, customising coaching support, and using multiple criteria for programme evaluation. CONCLUSION: Virtual QI and training of healthcare professionals and students is a viable, efficient, and effective alternative to traditional QI education that will play a vital role in building their competence and confidence to improve the healthcare system in post-COVID environment.

Protocol for an integrated evaluation framework to study training, curricular and contextual factors impacting the success of a measurement for improvement training programme for healthcare staff in Ireland.

INTRODUCTION: Measurement for improvement is the process of collecting, analysing and presenting data to demonstrate whether a change has resulted in an improvement. It is also important in demonstrating sustainability of improvements through continuous measurement. This makes measurement for improvement a core element in quality improvement (QI) efforts. However, there is little to no research investigating factors that influence measurement for improvement skills in healthcare staff. This protocol paper presents an integrated evaluation framework to understand the training, curricular and contextual factors that influence the success of measurement for improvement training by using the experiences of trainees, trainers, programme and site coordinators. METHODS AND ANALYSIS: This research will adopt a qualitative retrospective case study design based on constructivist-pragmatic philosophy. The Pressure Ulcers to Zero collaborative and the Clinical Microsystems collaborative from the Irish health system which included a measurement for improvement component have been selected for this study. This paper presents an integrated approach proposing a novel application of two pre-existing frameworks: the Model for Understanding Success in Quality framework and the Kirkpatrick Evaluation Model to evaluate an unexplored QI context and programme. A thematic analysis of the qualitative interview data and the documents collected will be conducted. The thematic analysis is based on a four-step coding framework adapted for this research study. The coding process will be conducted using NVivo V.12 software and Microsoft Excel. A cross-case comparison between the two cases will be performed. ETHICS AND DISSEMINATION: The study has received an exemption from full ethical review from the Human Research Ethics Committee of University College Dublin, Ireland (LS-E-19-108). Informed consent will be obtained from all participants and the data will be anonymised and stored securely. The results of the study will be disseminated in peer-reviewed journals.

A Systematic Review and Narrative Synthesis: Determinants of the Effectiveness and Sustainability of Measurement-Focused Quality Improvement Trainings.

INTRODUCTION: The ability of health care professionals to measure change is critical for successful quality improvement (QI) efforts. Currently, there are no systematic reviews focusing on continuing education for health care professionals in data skills for QI. The purpose of this systematic review is to define effectiveness and sustainability of QI programs for health care professionals containing a measurement skills component and to identify barriers and facilitators to effectiveness and sustainability. METHODS: The systematic review involved study identification, screening, full text review, and data extraction. Four electronics databases and grey literature sources were searched to identify studies published between 2009 and 2019 (11 years). A customized data extraction form was developed. Mixed methods appraisal tool was used for quality assessment and a thematic analysis was conducted for narrative synthesis. RESULTS: Fifty-three studies from 11 countries were included. Most study designs were quantitative descriptive (17/53) and used a blended learning approach (25/53) combining face-to face and distance learning modes. The programs included basic, intermediate, and advanced data skills concepts. Overall, studies reported positive outcomes for participant reaction, learning, and behavior, but reported variable success in sustainability and spread of QI. DISCUSSION: Studies discussed measurement as a key competency for clinical QI. Effectiveness definitions focused on the short-term impact of the programs, whereas sustainability definitions emphasized maintenance of outcomes and skills in the long-term. Factors that influenced effectiveness and sustainability of the included studies were strategic approach to QI, organizational support, intervention design, communication, accountability, leadership support, and learning networks.

The Collective Leadership for Safety Culture (Co-Lead) Team Intervention to Promote Teamwork and Patient Safety.

Traditional hierarchical leadership has been implicated in patient safety failings internationally. Given that healthcare is almost wholly delivered by multidisciplinary teams, there have been calls for a more collective and team-based approach to the sharing of leadership and responsibility for patient safety. Although encouraging a collective approach to accountability can improve the provision of high quality and safe care, there is a lack of knowledge of how to train teams to adopt collective leadership. The Collective Leadership for Safety Cultures (Co-Lead) programme is a co-designed intervention for multidisciplinary healthcare teams. It is an open-source resource that offers teams a systematic approach to the development of collective leadership behaviours to promote effective teamworking and enhance patient safety cultures. This paper provides an overview of the co-design, pilot testing, and refining of this novel intervention prior to its implementation and discusses key early findings from the evaluation. The Co-Lead intervention is grounded in the real-world experiences and identified needs and priorities of frontline healthcare staff and management and was co-designed based on the evidence for collective leadership and teamwork in healthcare. It has proven feasible to implement and effective in supporting teams to lead collectively to enhance safety culture. This intervention overview will be of value to healthcare teams and practitioners seeking to promote safety culture and effective teamworking by supporting teams to lead collectively.