Co-creating system-wide improvement for people with traumatic brain injury across one integrated care system in the United Kingdom to initiate a transformation journey through co-production.

BACKGROUND AND OBJECTIVE: There is a need for better integration of services across communities and sectors for people living with traumatic brain injury (TBI) to meet their complex needs. Building on insights gained from earlier pilot work, here we report the outcomes of a participatory workshop that sought to better understand the challenges, barriers and opportunities that currently exist within the care pathway for survivors of TBI. METHODS: A diverse range of stakeholders from the acute and rehabilitation care pathway and the health and social care system were invited to participate in a 3-h workshop. The participants worked in four mixed subgroups using practice development methodology, which promotes person-centred, inclusive and participatory action. RESULTS: Thematic analysis identified shared purposes and values that were used to produce a detailed implementation and impact framework for application at both the level of the care interface and the overarching integrated care system. A variety of enablers were identified that related to collective values and behaviours, case management, team leadership and integrated team working, workforce capability, evidence-based practice and resourcing. The clinical, economic, cultural and social outcomes associated with these enablers were also identified, and included patient safety, independence and well-being, reduced waiting times, re-admission rates, staff retention and professional development. CONCLUSION: The co-produced recommendations made within the implementation and impact framework described here provide a means by which the culture and delivery of health and social care services can be better tailored to meet the needs of people living with TBI. We believe that the recommendations will help shape the formation of new services as well as the development of existing ones. PATIENT OR PUBLIC CONTRIBUTION: Patient and public involvement have been established over a 10-year history of relationship building through a joint forum and events involving three charities representing people with TBI, carers, family members, clinicians, service users, researchers and commissioners, culminating in a politically supported event that identified concerns about the needs of people following TBI. These relationships formed the foundation for the interactive workshop, the focus of this publication.

Embedding research (ER) led by nurses, midwives and allied health professionals (NMAHPs): the NMAHP-ER model.

BACKGROUND: Previous embedded researcher models have focused predominantly on an individual being a temporary team member and embedded for a project-limited short-term placement. AIM: To develop an innovative research capacity building model to address the challenges of developing, embedding and sustaining, research led by Nurses, Midwives, and Allied Health Professionals (NMAHPs) in complex clinical environments. This healthcare and academic research partnership model offers an opportunity to support the 'how' of enabling NMAHP research capacity building from within the researchers' clinical area of expertise. METHOD: Collaboration between three healthcare and academic organisations and the iterative process of cocreation, development and refinement took place over 6 months during 2021. The collaboration relied on virtual meetings, emails, telephone calls and document review. RESULTS: A codesigned NMAHP embedded research (ER) model is ready for trialling with the individual being an existing clinician working collaboratively within the healthcare setting and with academia to develop the skills to become the ER. CONCLUSION: This model supports NMAHP-led research activity in clinical organisations in a visible and manageable way. As a shared, long-term vision, the model will contribute to research capacity and capability of the wider healthcare workforce. It will lead, facilitate and support research in and across clinical organisations in collaboration with higher education institutions.

A realist synthesis of effective continuing professional development (CPD): A case study of healthcare practitioners' CPD.

BACKGROUND: Continuing professional development (CPD) in healthcare is fundamental for making sure frontline staff practice safely and effectively. This requires practitioners to update knowledge and skills regularly to match the changing complexity of healthcare needs. The drive towards using limited resources effectively for service improvements and the need for a flexible workforce necessitate a review of ad hoc approaches to CPD. OBJECTIVE: To develop strategies for achieving effective CPD in healthcare. DESIGN: A case study design drawing on principles of realist synthesis was used during two phases of the study to identify and test what works and in what circumstances. SETTING: One National Health Service Trust in South East England. PARTICIPANTS: CPD stakeholders including professional regulatory bodies (n = 8), commissioners of healthcare (n = 15), facilitators of clinical skills development (n = 34), NHS staff in clinical leadership positions (n = 38), NHS staff undertaking skills development post graduate programs (n = 31), service user advocates (n = 8) and an international expert reference group (ERG) (n = 10). METHODS: Data sources included a review of scholarly and grey literature, an online survey and a consensus workshop. Thematic and content analyses were used during data processing. RESULTS: The findings present four interdependent transformation theories comprising transforming individual practice, skills for the changing healthcare contexts, knowledge translation and workplace cultures to optimize learning, development and healthcare performance. CONCLUSIONS: The transformation theories contextualize CPD drivers and identify conditions conducive for effective CPD. Practitioner driven CPD in healthcare is effective within supportive organizations, facilitated workplace learning and effective workplace cultures. Organizations and teams with shared values and purpose enable active generation of knowledge from practice and the use of different types of knowledge for service improvements.

Developing standards for an integrated approach to workplace facilitation for interprofessional teams in health and social care contexts: a Delphi study.

Integration of health and social care forms part of health and social care policy in many countries worldwide in response to changing health and social care needs. The World Health Organization's appeal for systems to manage the global epidemiologic transition advocates for provision of care that crosses boundaries between primary, community, hospital, and social care. However, the focus on structural and process changes has not yielded the full benefit of expected advances in care delivery. Facilitating practice in the workplace is a widely recognised cornerstone for developments in the delivery of health and social care as collaborative and inclusive relationships enable frontline staff to develop effective workplace cultures that influence whether transformational change is achieved and maintained. Workplace facilitation embraces a number of different purposes which may not independently lead to better quality of care or improved patient outcomes. Holistic workplace facilitation of learning, development, and improvement supports the integration remit across health and social care systems and avoids duplication of effort and waste of valuable resources. To date, no standards to guide the quality and effectiveness of integrated facilitation have been published. This study aimed to identify key elements constitute standards for an integrated approach to facilitating work-based learning, development, improvement, inquiry, knowledge translation, and innovation in health and social care contexts using a three rounds Delphi survey of facilitation experts from 10 countries. Consensus about priority elements was determined in the final round, following an iteration process that involved modifications to validate content. The findings helped to identify key qualities and skills facilitators need to support interprofessional teams to flourish and optimise performance. Further research could evaluate the impact of skilled integrated facilitation on health and social care outcomes and the well-being of frontline interprofessional teams.

Using systems thinking to identify workforce enablers for a whole systems approach to urgent and emergency care delivery: a multiple case study.

BACKGROUND: Overcrowding in emergency departments is a global issue, which places pressure on the shrinking workforce and threatens the future of high quality, safe and effective care. Healthcare reforms aimed at tackling this crisis have focused primarily on structural changes, which alone do not deliver anticipated improvements in quality and performance. The purpose of this study was to identify workforce enablers for achieving whole systems urgent and emergency care delivery. METHODS: A multiple case study design framed around systems thinking was conducted in South East England across one Trust consisting of five hospitals, one community healthcare trust and one ambulance trust. Data sources included 14 clinical settings where upstream or downstream pinch points are likely to occur including discharge planning and rapid response teams; ten regional stakeholder events (n = 102); a qualitative survey (n = 48); and a review of literature and analysis of policy documents including care pathways and protocols. RESULTS: The key workforce enablers for whole systems urgent and emergency care delivery identified were: clinical systems leadership, a single integrated career and competence framework and skilled facilitation of work based learning. CONCLUSIONS: In this study, participants agreed that whole systems urgent and emergency care allows for the design and implementation of care delivery models that meet complexity of population healthcare needs, reduce duplication and waste and improve healthcare outcomes and patients' experiences. For this to be achieved emphasis needs to be placed on holistic changes in structures, processes and patterns of the urgent and emergency care system. Often overlooked, patterns that drive the thinking and behavior in the workplace directly impact on staff recruitment and retention and the overall effectiveness of the organization. These also need to be attended to for transformational change to be achieved and sustained. Research to refine and validate a single integrated career and competence framework and to develop standards for an integrated approach to workplace facilitation to grow the capacity of facilitators that can use the workplace as a resource for learning is needed.

Exploring the perceived role and impact of the nurse consultant.

BACKGROUND: Nurse consultant roles were introduced in 1999 with defined role criteria including expert practice, research, education and leadership. The primary objective of the role is to develop nurses and nursing to provide effective patient outcomes. In 2000 the first nurse consultant in rheumatology was appointed to establish a co-ordinated service for the management of patients with chronic musculoskeletal pain. There are now ten nurse consultants within rheumatology yet little is known of their role or impact. AIM: The aim of the study was to identify the perceived role and impact of one nurse consultant (NC) in rheumatology within the context of being a practitioner-researcher. METHOD: Seven peers of the NC and five patients cared for by the NC participated in a semi-structured interview to identify their perceptions regarding the role of the NC within the rheumatology service. RESULTS: The following themes were identified from the interviews: (1) development of a new model of care for patients with chronic musculoskeletal pain; (2) holistic person-centred care experienced and valued by the patient; (3) leadership and education; and (4) feeling cared for. CONCLUSION: The NC role had impacted on service development and culture in the instigation of a chronic musculoskeletal pain service and leadership and education activities. Patients experienced the holistic nature of the role.

Re-defining nursing expertise in the United kingdom.

There is now international recognition of the importance of practice expertise in modern and effective health services. The Expertise in Practice Project in the United Kingdom began in May 1998 and continued to 2004. It included nurses working in all four countries of the United Kingdom, and it covered clinical specialists from pediatrics to palliative care. The project added to the current understanding of what nursing practice expertise is, through the identification and verification of attributes and factors which enable expert practice. The proposed framework offers a language for sharing what constitutes practice expertise and offers insight into what occurs between the expert practitioner and the people that experience their care. The Expertise in Practice Project demonstrates that nurses affect change and facilitate performance and organizational development.