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1.
J Health Serv Res Policy ; 27(3): 203-210, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35225039

RESUMO

OBJECTIVE: To understand the process of formulating, implementing and enacting national recommendations into practice, by exploring the interactions between government policymakers and national and local organisations supporting and delivering policy implementation within a Child and Adolescent Mental Health Service (CAMHS) context in Scotland. METHODS: Data collection involved 16 semi-structured individual and four focus group interviews with a purposeful sample of policymakers, national health and social care stakeholders and local outpatient and inpatient CAMHS teams representing three NHS health boards in Scotland. RESULTS: Study participants highlighted the challenges of navigating through evolving and often conflicting policy agendas, seen to not acknowledging the current evidence base or experiential learning from services and prior evaluations. Accounts of transformation fatigue often emerged from increased expectations for staff to adopt new approaches to accommodate constantly changing recommendations. Participants also reported a lack of integration and implementation support from national health and social care organisations, leading to duplication of effort and gaps in provision or waste. Policy recommendations were perceived as sometimes vague, lacking clarity about how to deliver service transformation using a whole-system approach. The collective narratives reflected increased tension between the need for local autonomy to innovate and the limitations created vertically by the relative inflexibility of policy recommendations, and horizontally by the proliferation of national organisations delivering the same transformation aims using different approaches in a resource-constrained environment. CONCLUSION: The findings contribute to the wider literature by offering an exploration of importance of evaluation and evidence uptake in policy formulation; the roles and remits in supporting the implementation of policy recommendations; and how the dynamics of central control and local autonomy might impact on the local enactment of policy recommendations.


Assuntos
Serviços de Saúde do Adolescente , Serviços de Saúde Mental , Adolescente , Criança , Política de Saúde , Humanos , Pesquisa Qualitativa , Escócia
2.
BMJ Open Qual ; 9(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33055177

RESUMO

BACKGROUND: This paper reports the results of the evaluation of the Scottish Quality and Safety Fellowship (SQSF)-a 10-month, lead-level international educational programme established in 2008 with the overarching aim of developing clinicians with advanced quality improvement knowledge, technical ability and essential leadership skills. The evaluation explores four levels of educational and practice outcomes associated with (1) the reaction of fellows to SQSF participation, (2) learning gained, (3) subsequent behaviour changes and (4) the overall impact on national and international level capability and capacity building. METHODS: A theory-informed multi-method design was applied using (1) a search and review of the SQSF organisational database to tabulate personal, professional and demographic characteristics; (2) semi-structured telephone interviews with 16 participants using purposive and self-selected sampling; and (3) a cross-sectional online evaluation survey across all 10 cohorts involving 222 fellows RESULTS: SQSF was positively perceived as a high-quality learning experience containing a well-balanced mix of theory and practice, with a majority of respondents reporting career changing benefits. Most participants reported improved social, behavioural and emotional skills, knowledge and attitudes and, with sustained support of their host organisations, were able to apply and share learning in their workplace. The impact of the SQSF on a wider national and international level capability and capacity was both mediated and moderated by a wide range of interrelated contextual factors. CONCLUSIONS: This multi-method evaluation demonstrates that SQSF has achieved significant positive outcomes for the great majority of participants. Some tentative recommendations are provided with the aim of further enhancing fellowship content, delivery, transfer and future evaluations of wider impacts at regional, national and international health system levels.


Assuntos
Bolsas de Estudo/normas , Liderança , Melhoria de Qualidade , Educação de Pós-Graduação em Medicina/métodos , Educação de Pós-Graduação em Medicina/normas , Educação de Pós-Graduação em Medicina/tendências , Bolsas de Estudo/métodos , Bolsas de Estudo/estatística & dados numéricos , Humanos , Internet , Entrevistas como Assunto/métodos , Pesquisa Qualitativa , Escócia , Desenvolvimento de Pessoal/métodos , Desenvolvimento de Pessoal/estatística & dados numéricos , Inquéritos e Questionários
3.
BMJ Open ; 10(2): e033574, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32114469

RESUMO

OBJECTIVES: The quality and safety of drug therapy in primary care are global concerns. The Pharmacist and Data-Driven Quality Improvement in Primary Care (P-DQIP) intervention aims to improve prescribing safety via an informatics tool, which facilitates proactive management of drug therapy risks (DTRs) by health-board employed pharmacists with established roles in general practices. Study objectives were (1) to identify and prioritise factors that could influence P-DQIP implementation from the perspective of practice pharmacists and (2) to identify potentially effective, acceptable and feasible strategies to support P-DQIP implementation. DESIGN: Semistructured face-to-face interviews using a Theoretical Domains Framework informed topic guide. The framework method was used for data analysis. Identified implementation factors were prioritised for intervention based on research team consensus. Candidate intervention functions, behavioural change techniques (BCTs) and policies targeting these were identified from the behavioural change wheel. The final intervention content and modes of delivery were agreed with local senior pharmacists. SETTING: General practices from three Health and Social Care Partnerships in National Health Service (NHS) Tayside. PARTICIPANTS: 14 NHS employed practice pharmacists. RESULTS: Identified implementation factors were linked to thirteen theoretical domains (all except intentions) and six (skill, memory/attention/decision making, behavioural regulation, reinforcement, environmental context/resources, social influences) were prioritised. Three intervention functions (training, enablement and environmental restructuring) were relevant and were served by two policy categories (guidelines, communication/marketing) and eight BCTs (instructions on how to perform a behaviour, problem solving, action planning, prompt/cues, goal setting, self-monitoring, feedback and restructuring the social environment). Intervention components encompass an informatics tool, written educational material, a workshop for pharmacists, promotional activities and small financial incentives. CONCLUSIONS: This study explored pharmacists' perceptions of implementation factors which could influence management of DTRs in general practices to inform implementation of P-DQIP, which will initially be implemented in one Scottish health board with parallel evaluation of effectiveness and implementation.


Assuntos
Informática Médica , Farmacêuticos , Atenção Primária à Saúde/normas , Melhoria de Qualidade , Humanos , Pesquisa Qualitativa , Medicina Estatal
4.
BMJ Open Qual ; 8(2): e000553, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31259285

RESUMO

Background: Various theories provide guidance on implementing, sustaining and evaluating innovations within healthcare. There has been less attention given, however, to personal theories drawn from practice and the expertise of managers and front-line staff is a largely untapped resource. In this paper, we share learning from experienced improvement organisations to provide a conceptual level explanation of the conditions necessary to facilitate and sustain improvement at scale. Methods: Staff (n=42) from three leading change organisations in the UK, spanning health, education and social care, took part in three consultation meetings with the aim of sharing knowledge about sustaining large-scale change. This included one government organisation, one National Health Service Board and one large charity organisation. Using a participatory grounded theory approach, the workshops resulted in a co-created theory. Results: The theory of Motivating Change describes the psychosocial-structural conditions for large-scale, sustained change from the perspectives of front-line staff. The theory posits that change is more likely to be sustained at scale if there is synergy between staff's perceived need and desire for improvement, and the extrinsic motivators for change. Witnessing effective change is motivating for staff and positive outcomes provide a convincing argument for the need to sustain improvement activity. As such, evidence of change becomes evidence for change. This is only possible when there is a flow of trust within organisations that capitalises on positive peer pressure and suppresses infectious negativity. When these conditions are in place, organisations can generate self-proliferating improvement. Conclusions: The theory of Motivating Change has been co-created with staff and offers a useful explanation and guide for others involved in change work that capitalises on front-line expertise.


Assuntos
Motivação , Inovação Organizacional , Teoria Fundamentada , Humanos , Desenvolvimento de Programas/métodos , Pesquisa Qualitativa , Medicina Estatal/tendências , Reino Unido
5.
BMJ Open ; 9(3): e023890, 2019 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-30904844

RESUMO

OBJECTIVES: Healthcare is a complex system, so quality improvement will commonly lead to unintended consequences which are rarely evaluated. In previous qualitative work, we proposed a framework for considering the range of these potential consequences, in terms of their desirability and the extent to which they were predictable or expected during planning. This paper elaborates on the previous findings, using consensus methods to examine what consequences should be identified, why and how to prioritise, evaluate and interpret all identified consequences, and what stakeholders should be involved throughout this process. DESIGN: Two-round modified Delphi consensus study. SETTING AND PARTICIPANTS: Both rounds were completed by 60 panellists from an academic, clinical or management background and experience in designing, implementing or evaluating quality improvement programmes. RESULTS: Panellists agreed that trade-offs (expected undesirable consequences) and unpleasant surprises (unexpected undesirable consequences) should be actively considered. Measurement of harmful consequences for patients, and those with high workload or financial impact was prioritised, and their evaluation could also involve the use of qualitative methods. Clinical teams were agreed as important to involve at all stages, from identifying potential consequences, prioritising which of those to systematically evaluate, undertaking appropriate evaluation and interpreting the findings. Patients were necessary in identifying consequences, managers in identifying and prioritising, and improvement advisors in interpreting the data. CONCLUSION: There was consensus that a balanced approach to considering all the consequences of improvement can be achieved by carefully considering predictable trade-offs from the outset and deliberately pausing after implementation to identify any unexpected surprises and make an informed decision as to whether quantitative or qualitative evaluation is needed and feasible. Stakeholders' roles in in the process of identifying, prioritising, evaluating and interpreting potential consequences should be explicitly addressed within planning and revisited during and after implementation.


Assuntos
Atitude do Pessoal de Saúde , Pessoal de Saúde/psicologia , Melhoria de Qualidade , Consenso , Técnica Delphi , Grupos Focais , Objetivos , Humanos , Entrevistas como Assunto , Avaliação de Processos e Resultados em Cuidados de Saúde
6.
Disabil Rehabil ; 41(1): 9-18, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-28853296

RESUMO

PURPOSE: To examine the feasibility of undertaking a pragmatic single-blind randomised controlled trial (RCT) of a visual arts participation programme to evaluate effects on survivor wellbeing within stroke rehabilitation. METHODS: Stroke survivors receiving in-patient rehabilitation were randomised to receive eight art participation sessions (n = 41) or usual care (n = 40). Recruitment, retention, preference for art participation and change in selected outcomes were evaluated at end of intervention outcome assessment and three-month follow-up. RESULTS: Of 315 potentially eligible participants 81 (29%) were recruited. 88% (n = 71) completed outcome and 77% (n = 62) follow-up assessments. Of eight intervention group non-completers, six had no preference for art participation. Outcome completion varied between 97% and 77%. Running groups was difficult because of randomisation timing. Effectiveness cannot be determined from this feasibility study but effects sizes suggested art participation may benefit emotional wellbeing, measured on the positive and negative affect schedule, and self-efficacy for Art (d = 0.24-0.42). CONCLUSIONS: Undertaking a RCT of art participation within stroke rehabilitation was feasible. Art participation may enhance self-efficacy and positively influence emotional wellbeing. These should be outcomes in a future definitive trial. A cluster RCT would ensure art groups could be reliably convened. Fewer measures, and better retention strategies are required. Implications for Rehabilitation This feasibility randomised controlled trial (RCT) showed that recruiting and retaining stroke survivors in an RCT of a visual arts participation intervention within stroke rehabilitation was feasible. Preference to participate in art activities may influence recruitment and drop-out rates, and should be addressed and evaluated fully. Art participation as part of rehabilitation may improve some aspects of post-stroke wellbeing, including positive affect and self-efficacy for art. A future definitive cluster RCT would facilitate full evaluation of the value art participation can add to rehabilitation.


Assuntos
Arteterapia/métodos , Qualidade de Vida , Autoeficácia , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/psicologia , Idoso , Emoções , Estudos de Viabilidade , Feminino , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Método Simples-Cego , Reabilitação do Acidente Vascular Cerebral/métodos , Reabilitação do Acidente Vascular Cerebral/psicologia
7.
BMJ Qual Saf ; 27(7): 547-556, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29055901

RESUMO

BACKGROUND: As quality improvement (QI) programmes have become progressively larger scale, the risks of implementation having unintended consequences are increasingly recognised. More routine use of balancing measures to monitor unintended consequences has been proposed to evaluate overall effectiveness, but in practice published improvement interventions hardly ever report identification or measurement of consequences other than intended goals of improvement. METHODS: We conducted 15 semistructured interviews and two focus groups with 24 improvement experts to explore the current understanding of balancing measures in QI and inform a more balanced accounting of the overall impact of improvement interventions. Data were analysed iteratively using the framework approach. RESULTS: Participants described the consequences of improvement in terms of desirability/undesirability and the extent to which they were expected/unexpected when planning improvement. Four types of consequences were defined: expected desirable consequences (goals); expected undesirable consequences (trade-offs); unexpected undesirable consequences (unpleasant surprises); and unexpected desirable consequences (pleasant surprises). Unexpected consequences were considered important but rarely measured in existing programmes, and an improvement pause to take stock after implementation would allow these to be more actively identified and managed. A balanced accounting of all consequences of improvement interventions can facilitate staff engagement and reduce resistance to change, but has to be offset against the cost of additional data collection. CONCLUSION: Improvement measurement is usually focused on measuring intended goals, with minimal use of balancing measures which when used, typically monitor trade-offs expected before implementation. This paper proposes that improvers and leaders should seek a balanced accounting of all consequences of improvement across the life of an improvement programme, including deliberately pausing after implementation to identify and quantitatively or qualitatively evaluate any pleasant or unpleasant surprises.


Assuntos
Atitude do Pessoal de Saúde , Pessoal de Saúde/psicologia , Melhoria de Qualidade , Grupos Focais , Objetivos , Humanos , Entrevistas como Assunto , Avaliação de Processos e Resultados em Cuidados de Saúde , Escócia , Medicina Estatal
8.
J Antimicrob Chemother ; 72(12): 3223-3231, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-28961725

RESUMO

Drawing on a Cochrane systematic review, this paper examines the relatively limited range of outcomes measured in published evaluations of antimicrobial stewardship interventions (ASIs) in hospitals. We describe a structured framework for considering the range of consequences that ASIs can have, in terms of their desirability and the extent to which they were expected when planning an ASI: expected, desirable consequences (intervention goals); expected, undesirable consequences (intervention trade-offs); unexpected, undesirable consequences (unpleasant surprises); and unexpected, desirable consequences (pleasant surprises). Of 49 randomized controlled trials identified by the Cochrane review, 28 (57%) pre-specified increased length of stay and/or mortality as potential trade-offs of ASI, with measurement intended to provide reassurance about safety. In actuality, some studies found unexpected decreases in length of stay (a pleasant surprise). In contrast, only 11 (10%) of 110 interrupted time series studies included any information about unintended consequences, with 10 examining unexpected, undesirable outcomes (unpleasant surprises) using case-control, qualitative or cohort designs. Overall, a large proportion of the ASIs reported in the literature only assess impact on their targeted process goals-antimicrobial prescribing-with limited examination of other potential outcomes, including microbial and clinical outcomes. Achieving a balanced accounting of the impact of an ASI requires careful consideration of expected undesirable effects (potential trade-offs) from the outset, and more consideration of unexpected effects after implementation (both pleasant and unpleasant surprises, although the latter will often be more important). The proposed framework supports the systematic consideration of all types of consequences of improvement before and after implementation.


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos , Infecções Bacterianas/tratamento farmacológico , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Análise de Séries Temporais Interrompida , Tempo de Internação , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Sobrevida , Resultado do Tratamento
9.
PLoS One ; 12(7): e0180902, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28700754

RESUMO

OBJECTIVES: While there is strong evidence that regular participation in physical activity (PA) brings numerous health benefits to older adults, and interventions to effectively promote PA are being developed and tested, the characteristics and components of the most effective interventions remain unclear. This systematically conducted review of systematic reviews evaluated the effects and characteristics of PA promotion interventions aimed at community dwelling people over 50 years old. METHODS: Major databases were searched for reviews from January 1990 to May 2015. TIDieR guidelines aided data extraction and the ROBIS tool was used to assess the risk of bias. Primary outcomes were objective and self-reported levels of PA. Indicators of psychological wellbeing and participation rates were secondary outcomes. RESULTS: Of 1284 records identified, 19 reviews met inclusion criteria and eight included meta-analyses. Interventions typically incorporated behaviour change techniques (BCTs) and were delivered as face-to-face, remote, group, individual or as combined interventions. Despite their heterogeneity, interventions often resulted in sustained improvements in PA over the study period, typically at 12 months, and led to improvements in general wellbeing. However, ways to ensure effective maintenance beyond one year are unclear. Certain intervention components were more clearly associated with positive effects (e.g. tailoring promotion strategy with combination of cognitive and behavioural elements, low to moderate intensity activity recommended). We found no evidence that certain other intervention characteristics were superior in achieving positive outcomes (e.g. mode of delivery, setting, professional background of the intervention provider, type of PA recommended). CONCLUSION: The evidence suggests that interventions to promote PA among older adults are generally effective but there is uncertainty around the most beneficial intervention components. There are indications that purely cognitive strategies and BCTs might be less suitable for older adults than motivators more meaningful to them, including social and environmental support, and enjoyment coming from being physically active. A whole system-oriented approach is required that is tailored to meet the needs of older adults and aligned with social, individual and environmental factors.


Assuntos
Exercício Físico/fisiologia , Promoção da Saúde , Vida Independente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
10.
Disabil Rehabil ; 38(7): 661-72, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26084571

RESUMO

PURPOSE: To explore stroke survivors' and artists' beliefs about participatory visual arts programme participation during in-patient rehabilitation to identify benefits and potential mechanisms of action. METHOD: Qualitative design using semi-structured in-depth interviews with stroke survivors (n = 11) and artists (n = 3). ANALYSIS: Data were audio-recorded and transcribed. Framework approach was used to identify themes and develop conceptual schemes. RESULTS: The non-medical, social context of art facilitated social interaction, provided enjoyment and distraction from stroke and re-established social identity thereby improving mood. The processes of art making generated confidence and self-efficacy, setting and achievement of creative, communication and physical recovery goals that provided control over survivors' situation and hope for recovery. Creative output involved completion of artwork and display for viewing. This enhanced self-esteem and improved mood, providing survivors with new identities through positive appraisal of the work by others. Self-efficacy, hope and control appeared to mediate benefits. CONCLUSION: This study provides a model of intervention components, mechanisms of action and outcome mediators to explain how art participation may work. Findings suggest that art may influence important psychosocial outcomes that other rehabilitation approaches do not typically address. The study paves the way for a future effectiveness trial. IMPLICATIONS FOR REHABILITATION: Participation in an art programme during rehabilitation appears to improve stroke survivors' mood, confidence and self-esteem and enhances perceptions of hope and control over recovery. Social interactions, the processes of art making and review and appraisal by others may be key intervention components from which benefits are derived. Benefits from art participation may enhance survivors' experiences of rehabilitation and appear to provide benefits that other rehabilitation interventions do not. Art participation should be considered as an important adjunct to traditional rehabilitation.


Assuntos
Arteterapia/métodos , Relações Interpessoais , Autoeficácia , Meio Social , Reabilitação do Acidente Vascular Cerebral , Sobreviventes/psicologia , Atividades Cotidianas , Afeto , Idoso , Idoso de 80 Anos ou mais , Feminino , Grupos Focais , Esperança , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa
11.
Trials ; 15: 380, 2014 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-25262168

RESUMO

BACKGROUND: Benefits of art participation after stroke are becoming increasingly recognized. Qualitative studies suggest that participation in visual arts creative engagement interventions (CEIs) during rehabilitation after stroke may improve mood, self-esteem, hope and some aspects of physical recovery. This study examines the feasibility of undertaking a randomized controlled trial of a CEI delivered by artists within in-patient stroke rehabilitation to test effectiveness. METHODS/DESIGN: This trial is a two arm, single-blind, randomized controlled feasibility trial within in-patient stroke rehabilitation. We will recruit 80 patients receiving stroke rehabilitation in two stroke units in a health board area of Scotland (40 patients in each arm). Intervention arm participants will receive a visual-arts based CEI facilitated by experienced artists. Artists will follow an intervention protocol with specific components that enable participants to set, achieve and review artistic goals. Participants will receive up to eight intervention sessions, four within a group and four one-to-one with the artist. Control group participants will receive usual care only.Data collection will occur at baseline, post-intervention and three-month follow-up. Stroke-related health status is the primary outcome; mood, self-esteem, self-efficacy, perceived recovery control and hope are secondary outcomes. Semi-structured interviews will be conducted with purposively selected patients, artists and healthcare staff to elicit views and experiences of the intervention and feasibility and acceptability of trial processes. Recruitment rates, retention rates and patient preference for art participation will also be collected. Data will indicate, with confidence intervals, the proportion of patients choosing or refusing participation in the CEI and will allow calculation of recruitment rates for a future definitive trial. Summary data will indicate potential variability, magnitude and direction of difference between groups. Findings will inform sample size calculations for a definitive trial. Thematic analysis of qualitative data will be managed using the Framework Approach. Framework is an analytical approach for qualitative data, commonly used in policy and medical research. DISCUSSION: If shown to demonstrate effects, this intervention has the potential to address aspects of stroke recovery previously. Not routinely addressed in rehabilitation. TRIAL REGISTRATION: Registered with Clinical Trials.Gov: NCT02085226 on 6th March 2014.


Assuntos
Arteterapia , Criatividade , Projetos de Pesquisa , Reabilitação do Acidente Vascular Cerebral , Afeto , Protocolos Clínicos , Estudos de Viabilidade , Nível de Saúde , Esperança , Humanos , Saúde Mental , Recuperação de Função Fisiológica , Escócia , Autoimagem , Autoeficácia , Método Simples-Cego , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/psicologia , Fatores de Tempo , Resultado do Tratamento
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