Communities of practice in Alberta Health Services: advancing a learning organisation.

BACKGROUND: In 2009, Alberta Health Services (AHS) became Canada's first and largest fully integrated healthcare system, involving the amalgamation of nine regional health authorities and three provincial services. Within AHS, communities of practice (CoPs) meet regularly to learn from one another and to find ways to improve service quality. This qualitative study examined CoPs as an applied practice of a learning organisation along with their potential influence in a healthcare system by exploring the perspectives of CoP participants. METHODS: A collective case study method was used to enable the examination of a cross-section of cases in the study organisation. Semi-structured interviews were conducted with 31 participants representing 28 distinct CoPs. Using Senge's framework of a learning organisation, CoP influences associated with team learning and organisational change were explored. RESULTS: CoPs in AHS were described as diverse in practice domains, focus, membership boundaries, attendance and sphere of influence. Using small-scale resource investments, CoPs provided members with opportunities for meaningful interactions, the capacity to build information pathways, and enhanced abilities to address needs at the point of care and service delivery. Overall, CoPs delivered a sophisticated array of engagement and knowledge-sharing activities perceived as supportive of organisational change, systems thinking, and the team learning practice critical to a learning organisation. CONCLUSION: CoPs enable the diverse wealth of knowledge embedded in people, local conditions and special circumstances to flow from practice domain groups to programme and service areas, and into the larger system where it can effect organisational change. This research highlights the potential of CoPs to influence practice and broad-scale change more directly than previously understood or reported in the literature. As such, this study suggests that CoPs have the potential to influence and advance widespread systems change in Canadian healthcare.

Description of the development and validation of the Canadian Paediatric Trigger Tool.

OBJECTIVE: To describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT). METHODS: Five existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger. RESULTS: Nurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT. CONCLUSIONS: The CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.

Developing nurse/parent relationships in the NICU through negotiated partnership.

OBJECTIVE: To explore parents' experience and satisfaction with care in the Neonatal Intensive Care Unit (NICU). DESIGN: Qualitative design using an interpretive description method. SETTING: A tertiary-level care 69-bed NICU. PARTICIPANTS: Ten parents (nine mothers and one father) were interviewed. METHOD: Parents were interviewed in person or via telephone, either following or close to discharge. Interviews were recorded, transcribed, and then analyzed using an evolving coding guide. RESULTS: All parents indicated that the relationship they developed with the bedside nurse was the most significant factor affecting their satisfaction with their NICU experience. All parents described nursing actions of perceptive engagement, cautious guidance, and subtle presence, which facilitated the development of this relationship. Further analysis of the data revealed that parents portrayed nurses in ideal nurse/parent interactions as fulfilling the roles of teacher, guardian, and facilitator. CONCLUSION: Developing a collaborative and effective nurse/parent relationship is the most significant factor affecting parents' satisfaction with their NICU experience. Providing nursing care in a manner that optimizes consistency and continuity of care facilitates the ability of both parties to develop this relationship.

Strangulation with intravenous tubing: a previously undescribed adverse advent in children.

Nonintentional strangulation in children is a widely recognized risk as a result of the vulnerability of their airway to occlusion by relatively low pressures. We describe 2 cases of strangulation by intravenous (IV) tubing in infants, 1 of which was fatal. This is the first documentation in the health science literature of this as a potential adverse consequence of IV therapy in young children. It is important that hospitals that care for such children recognize this potential risk and implement the appropriate strategies to minimize or eliminate it. Preventive interventions may include ongoing assessment of the need for continuous rather than intermittent IV infusions (saline or heparin locked IV sites), individualized level of supervision according to the child's age and behavior, and engineering modifications to the IV equipment.