A case study evaluation of implementation of a care pathway to support normal birth in one English birth centre: anticipated benefits and unintended consequences.

BACKGROUND: The policy drive for the UK National Health Service (NHS) has focused on the need for high quality services informed by evidence of best practice. The introduction of care pathways and protocols to standardise care and support implementation of evidence into practice has taken place across the NHS with limited evaluation of their impact. A multi-site case study evaluation was undertaken to assess the impact of use of care pathways and protocols on clinicians, service users and service delivery. One of the five sites was a midwifery-led Birth Centre, where an adapted version of the All Wales Clinical Pathway for Normal Birth had been implemented. METHODS: The overarching framework was realistic evaluation. A case study design enabled the capture of data on use of the pathway in the clinical setting, use of multiple methods of data collection and opportunity to study and understand the experiences of clinicians and service users whose care was informed by the pathway. Women attending the Birth Centre were recruited at their 36 week antenatal visit. Episodes of care during labour were observed, following which the woman and the midwife who cared for her were interviewed about use of the pathway. Interviews were also held with other key stakeholders from the study site. Qualitative data were content analysed. RESULTS: Observations were undertaken of four women during labour. Eighteen interviews were conducted with clinicians and women, including the women whose care was observed and the midwives who cared for them, senior midwifery managers and obstetricians. The implementation of the pathway resulted in a number of anticipated benefits, including increased midwifery confidence in skills to support normal birth and promotion of team working. There were also unintended consequences, including concerns about a lack of documentation of labour care and negative impact on working relationships with obstetric and other midwifery colleagues. Women were unaware their care was informed by a care pathway. CONCLUSION: Care pathways are complex interventions which generate a number of consequences for practice. Those considering introduction of pathways need to ensure all relevant stakeholders are engaged with this and develop robust evaluation strategies to accompany implementation.

Protocol-based care: the standardisation of decision-making?

AIM: To explore how protocol-based care affects clinical decision-making. BACKGROUND: In the context of evidence-based practice, protocol-based care is a mechanism for facilitating the standardisation of care and streamlining decision-making through rationalising the information with which to make judgements and ultimately decisions. However, whether protocol-based care does, in the reality of practice, standardise decision-making is unknown. This paper reports on a study that explored the impact of protocol-based care on nurses' decision-making. DESIGN: Theoretically informed by realistic evaluation and the promoting action on research implementation in health services framework, a case study design using ethnographic methods was used. Two sites were purposively sampled; a diabetic and endocrine unit and a cardiac medical unit. METHODS: Within each site, data collection included observation, postobservation semi-structured interviews with staff and patients, field notes, feedback sessions and document review. Data were inductively and thematically analysed. RESULTS: Decisions made by nurses in both sites were varied according to many different and interacting factors. While several standardised care approaches were available for use, in reality, a variety of information sources informed decision-making. The primary approach to knowledge exchange and acquisition was person-to-person; decision-making was a social activity. Rarely were standardised care approaches obviously referred to; nurses described following a mental flowchart, not necessarily linked to a particular guideline or protocol. When standardised care approaches were used, it was reported that they were used flexibly and particularised. CONCLUSIONS: While the logic of protocol-based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses' decision-making process. This has significant implications for the political goal of standardisation. RELEVANCE TO CLINICAL PRACTICE: The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses' decision-making processes in parallel to paying attention to the influence of context.

Nurses' health, age and the wish to leave the profession--findings from the European NEXT-Study.

BACKGROUND AND OBJECTIVES: In many industrialised countries the number of workers with low health is expected to increase in the nursing profession. This will have implications for occupational health work in health care. The European NEXT-Study (www. next-study. net, funded by EU) investigates working conditions of nurses in ten European countries and provides the opportunity to evaluate the role of health with respect to age and the consideration of leaving nursing. METHODS: 26,263 female registered nurses from Belgium, Germany, Finland, France, England, Italy, Netherlands, Poland and Slovakia were eligible for analysis. RESULTS: In most countries, older nurses considered leaving the profession more frequently than younger nurses. 'Health' was--next to 'professional opportunities' and 'work organisational factors'--strongly associated with the consideration of leaving nursing. However, more than half of all nurses with low health wanted to remain in the profession. This group reported rather positive psychosocial working conditions--but also the highest fear for unemployment. CONCLUSIONS: The findings indicate that 'the nurse with low health' is reality in many health care settings. Both positive supporting working conditions but also lack of occupational alternatives and fear of unemployment may contribute to this. Current economic, political and demographic trends implicate that the number of active nurses with low health will increase. Occupational health surveillance will be challenged by this. But NEXT findings implicate that prevention also will have to regard work organisational factors if the aim is to sustain nurses' health and to enable nurses to remain healthy in their profession until retirement age.

A realistic evaluation: the case of protocol-based care.

BACKGROUND: 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways. METHODS: Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances. RESULTS: In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs). CONCLUSIONS: As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice.

Protocol-based care: impact on roles and service delivery*.

OBJECTIVE: To evaluate the impact of protocol-based care on nursing roles, practice and service delivery. DESIGN: Case study evaluation informed by realistic evaluation methodology. Qualitative data collection methods were used including non-participant observation, post-observation interviews with nurses and patients, key informant interviews, tracking patient journeys and document review. PARTICIPANTS: 141 participants took part including 73 nurses, midwives and health visitors, 4 allied health professionals, 20 doctors, 5 support staff and 39 patients. SETTINGS: Five sites were purposively sampled and included acute and primary care service provision. FINDINGS: As a mechanism for standardization, the use of protocol-based care approaches such as guidelines, care pathways, protocols and algorithms was patchy and dependent on contextual, professional and individual factors. Protocol-based care approaches were commonly used as checklists and for reference; nurses and doctors expressed concern that such use could lead to a 'tick box mentality' and restricted judgement. By using standardized care approaches nurses were taking on new tasks and developing skills beyond the traditional scope of practice including prescribing, diagnosing, ordering tests and sometimes deciding on treatments. The ability to perform these roles meant that they were able to run clinics or services independently. The extension of roles to incorporate prescribing, for example, meant that nurses were able to provide a more streamlined service for patients because they did not have to refer to doctors. In turn, it was reported that this reduced doctors' workload. Protocol-based care was viewed as a 'nurses' thing'; however, some General Practitioners and junior doctors were using available standardized care approaches. CONCLUSIONS: The potential of standardization was mediated by the patchy use of protocol-based care approaches and negative perceptions about standardization. Use of protocol-based care has the potential to impact on nurses' roles, increasing their autonomy and subsequently impacting on service delivery.

Commitment to nursing: results of a qualitative interview study.

AIM: The aims of the study were to explore opportunities to undergo continuing professional education, family friendly policy and holding an innovative or traditional post on nurses' job satisfaction and professional and organizational commitment. BACKGROUND: Qualified nurses have become a scare resource in the National Health Service. Managers need to be aware of the work-related factors most likely to secure nurses' professional and organizational commitment which will contribute to the retention. Commitment is thought to be increased if opportunities for continuing professional education are good. Family friendly policy is also important. Less is known about the relationship between type of nursing work and commitment. METHODS: An in-depth, exploratory approach to data collection were taken, employing an interview guide with open-ended questions. Data were collected with 27 nurses in clinical grades in two contrasting trusts. RESULTS: Family friendly policies emerged as most important in securing nursing commitment. Those in innovative posts whose work entailed social hours and greater professional autonomy also displayed greater levels of job satisfaction. Opportunities for continuing professional education had less influence on professional and organizational commitment. CONCLUSION: Providing flexible or social working hours appears to be more influential than providing opportunities for continuing professional education in securing nursing commitment in this exploratory study.