Relational aspects of building capacity in economic evaluation in an Australian Primary Health Network using an embedded researcher approach.

BACKGROUND: Health organisations are increasingly implementing 'embedded researcher' models to translate research into practice. This paper examines the impact of an embedded researcher model known as the embedded Economist (eE) Program that was implemented in an Australian Primary Health Network (PHN) located in regional New South Wales, Australia. The site, participants, program aims and design are described. Insights into the facilitators, challenges and barriers to the integration of economic evaluation perspectives into the work of the PHN are provided. METHODS: The eE Program consisted of embedding a lead health economist on site, supported by offsite economists, part-time, for fifteen weeks to collaborate with PHN staff. Evaluation of the eE at the PHN included qualitative data collection via semi-structured interviews (N= 34), observations (N=8) and a field diary kept by the embedded economists. A thematic analysis was undertaken through the triangulation of this data. RESULTS: The eE Program successfully met its aims of increasing PHN staff awareness of the value of economic evaluation principles in decision-making and their capacity to access and apply these principles. There was also evidence that the program resulted in PHN staff applying economic evaluations when commissioning service providers. Evaluation of the eE identified two key facilitators for achieving these results. First, a highly receptive organisational context characterised by a work ethic, and site processes and procedures that were dedicated to improvement. Second was the development of trusted relationships between the embedded economist and PHN staff that was enabled through: the commitment of the economist to bi-directional learning; facilitating access to economic tools and techniques; personality traits (likeable and enthusiastic); and because the eE provided ongoing support for PHN projects beyond the fifteen-week embedding period. CONCLUSIONS: This study provides the first detailed case description of an embedded health economics program. The results demonstrate how the process, context and relational factors of engaging and embedding the support of a health economist works and why. The findings reinforce international evidence in this area and are of practical utility to the future deployment of such programs.

When Health Systems Consider Research to Be Beyond the Scope of Healthcare Delivery, Research Translation Is Crippled Comment on "Academic Health Science Centres as Vehicles for Knowledge Mobilisation in Australia? A Qualitative Study".

Edelman and colleagues' analysis of the views of Board members of Australian Research Translation Centres (RTCs) is well timed. There has been little study of Australian RTCs to date. We focus on their recommendations regarding knowledge mobilisation (KM) to open broader debate on the wisdom of regarding UK practices as a blueprint. We go further and ask whether successful RTCs might, as a result of responding to local context, create idiosyncratic structures and solutions, making generalisable learning less likely? There has been much invested in Australian RTCs and implications of government's formative evaluation of their work is discussed. Five recommendations are made that could help RTCs: allowing system end-users a greater say in funding decisions, taking a broader, more democratic approach to kinds of knowledge that are valued; investing in methodologies derived from the innovation space; and, a creative attention to governance to support these ideas.

"Slow science" for 21st century healthcare: reinventing health service research that serves fast-paced, high-complexity care organisations.

PURPOSE: The purpose of this paper is to argue for an improved conceptualisation of health service research, using Stengers' (2018) metaphor of "slow science" as a critical yardstick. DESIGN/METHODOLOGY/APPROACH: The paper is structured in three parts. It first reviews the field of health services research and the approaches that dominate it. It then considers the healthcare research approaches whose principles and methodologies are more aligned with "slow science" before presenting a description of a "slow science" project in which the authors are currently engaged. FINDINGS: Current approaches to health service research struggle to offer adequate resources for resolving frontline complexity, principally because they set more store by knowledge generalisation, disciplinary continuity and integrity and the consolidation of expertise, than by engaging with frontline complexity on its terms, negotiating issues with frontline staff and patients on their terms and framing findings and solutions in ways that key in to the in situ dynamics and complexities that define health service delivery. ORIGINALITY/VALUE: There is a need to engage in a paradigm shift that engages health services as co-researchers, prioritising practical change and local involvement over knowledge production. Economics is a research field where the products are of natural appeal to powerful health service managers. A "slow science" approach adopted by the embedded Economist Program with its emphasis on pre-implementation, knowledge mobilisation and parallel site capacity development sets out how research can be flexibly produced to improve health services.

Embedding an economist in regional and rural health services to add value and reduce waste by improving local-level decision-making: protocol for the 'embedded Economist' program and evaluation.

BACKGROUND: Systematic approaches to the inclusion of economic evaluation in national healthcare decision-making are usual. It is less common for economic evaluation to be routinely undertaken at the 'local-level' (e.g. in a health service or hospital) despite the largest proportion of health care expenditure being determined at this service level and recognition by local health service decision makers of the need for capacity building in economic evaluation skills. This paper describes a novel program - the embedded Economist (eE) Program. The eE Program aims to increase local health service staff awareness of, and develop their capacity to access and apply, economic evaluation principles in decision making. The eE program evaluation is also described. The aim of the evaluation is to capture the contextual, procedural and relational aspects that assist and detract from the eE program aims; as well as the outcomes and impact from the specific eE projects. METHODS: The eE Program consists of a embedding a health economist in six health services and the provision of supported education in applied economic evaluation, provided via a community of practice and a university course. The embedded approach is grounded in co-production, embedded researchers and 'slow science'. The sites, participants, and program design are described. The program evaluation includes qualitative data collection via surveys, semi-structured interviews, observations and field diaries. In order to share interim findings, data are collected and analysed prior, during and after implementation of the eE program, at each of the six health service sites. The surveys will be analysed by calculating frequencies and descriptive statistics. A thematic analysis will be conducted on interview, observation and filed diary data. The Framework to Assess the Impact from Translational health research (FAIT) is utilised to assess the overall impact of the eE Program. DISCUSSION: This program and evaluation will contribute to knowledge about how best to build capacity and skills in economic evaluation amongst decision-makers working in local-level health services. It will examine the extent to which participants are able to improve their ability to utilise evidence to inform decisions, avoid waste and improve the value of care delivery.

Nurses' knowledge of law at the end of life and implications for practice: A qualitative study.

BACKGROUND: Some patients do not receive adequate pain and symptom relief at the end of life, causing distress to patients, families and healthcare professionals. It is unclear whether undertreatment of symptoms occurs, in part, because of nurses' concerns about legal and/or disciplinary repercussions if the patient dies after medication is administered. AIM: The aim was to explore nurses' experiences and knowledge of the law relating to the provision of end-of-life pain and symptom relief. DESIGN: Semi-structured interviews with nurses were assessed using a six-stage hybrid thematic analysis technique. SETTING/PARTICIPANTS: Four face-to-face and 21 telephone interviews were conducted with nurses who routinely prescribed and/or administered pain and symptom relief to patients approaching the end of their lives in Queensland and New South Wales, Australia. RESULTS: While many nurses had no personal experiences with legal or professional repercussions after a patient had died, the fear of hastening death and being held accountable was frequently discussed and regarded as relevant to the provision of inadequate pain and symptom relief. Concerns included potential civil or criminal liability and losing one's job, registration or reputation. Two-thirds of participants believed that pain relief was sometimes withheld because of these legal concerns. Less than half of the interviewed nurses demonstrated knowledge of the doctrine of double effect, the legal protection for health professionals who provide end-of-life pain and symptom relief. CONCLUSION: Education is urgently required to strengthen nurses' knowledge of the legal protections supporting the provision of appropriate palliative medication, thereby improving their clinical practice with end-of-life patients.

The Participatory Zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement.

Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist-the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an 'explanatory theoretical model of change' that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities-narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome. TRIAL REGISTRATION NUMBER: The Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results).

The impact of patient safety culture on handover in rural health facilities.

BACKGROUND: Effective handover is crucial for patient safety. Rural health care organisations have particular challenges in relation to handover of information, placing them at higher risk of adverse events. Few studies have examined the relationship between handover and patient safety in rural contexts, particularly in Australia. This study aimed to explore the effect of handover on overall perceptions of patient safety and the effect of other patient safety dimensions on handover in a rural Australian setting. METHODS: A cross-sectional online survey using The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was implemented across six rural Local Health Districts in NSW, Australia and resulted in 1587 respondents. Hierarchical multiple linear regression analysis was conducted to account for the nested nature of the data. Models were developed to assess the effect of handover on patient safety perceptions, and the effect of other patient safety culture composites on handover variables. Open-ended questions about patient safety were inductively analyzed for themes. Quotes from the handover theme are presented. RESULTS: All models were significant overall (p < .001), with explanatory powers ranging from 29 to 48%. Within rural health settings, effective handover is significantly related to patient safety perceptions (R2 = .29). A strong teamwork culture and management support culture was found to enhance effective handover of patient information (R2 = .47), and effective handover of personal responsibility (R2 = .37). A strong teamwork, management support, and open communication culture enhances handover of department accountability (R2 = .41). Despite the implementation of standardised communication tools and frameworks for handover, patient safety is compromised by inadequate coordination, poor or absent documentation between departments, between other health care agencies and in transfer of care from acute facilities to primary/community care. CONCLUSION: Approaches to handover need to consider the particular challenges associated with rurality and strengthening elements found to be associated with increased safety, such as a strong teamwork and management culture and good reporting practices. Research is required to examine how communication at transition of care, particularly between facilities, is conducted and ways in which to enhance patients' and families' participation.

Providing Palliative Care at the End of Life: Should Health Professionals Fear Regulation?

Anecdotal evidence from Australia and abroad suggests that health professionals may fear potential legal and/or professional repercussions if their patient dies after receiving pain relieving medication at the end of life. As a result, patients may be under-medicated and their pain and other symptoms not adequately relieved. The regulatory repercussions from inappropriate administration of medications are potentially broad and include criminal charges, civil negligence claims, coronial investigations and disciplinary proceedings. But despite these potentially serious repercussions, a review of publicly available cases in Australia reveals there has been comparatively little judicial or quasi-judicial scrutiny where over-medication is alleged to have resulted in a patient's death. In this article, we describe the regulatory framework that governs this field of medical practice and analyse the extent to which the actions of health professionals have been scrutinised, and the consequences of that scrutiny. We identify a number of themes arising from this analysis and conclude that fears of legal or professional repercussions are largely unfounded, and that existing laws and other forms of regulation should not inhibit the prescription and administration of adequate pain and other symptom relief to people at the end of life.

Advancing engagement methods for trials: the CORE study relational model of engagement for a stepped wedge cluster randomised controlled trial of experience-based co-design for people living with severe mental illnesses.

BACKGROUND: Engagement is essential in trials research but is rarely embedded across all stages of the research continuum. The development, use, effectiveness and value of engagement in trials research is poorly researched and understood, and models of engagement are rarely informed by theory. This article describes an innovative methodological approach for the development and application of a relational model of engagement in a stepped wedge designed cluster randomised controlled trial (RCT), the CORE study. The purpose of the model is to embed engagement across the continuum of the trial which will test if an experience-based co-design intervention improves psychosocial recovery for people affected by severe mental illness. METHODS: The model was developed in three stages and used a structured iterative approach. A context mapping assessment of trial sites was followed by a literature review on recruitment and retention of hard-to-reach groups in complex interventions and RCTs. Relevant theoretical and philosophical underpinnings were identified by an additional review of literature to inform model development and enactment of engagement activities. RESULTS: Policy, organisational and service user data combined with evidence from the literature on barriers to recruitment provided contextual information. Four perspectives support the theoretical framework of the relational model of engagement and this is organised around two facets: the relational and continuous. The relational facet is underpinned by relational ethical theories and participatory action research principles. The continuous facet is supported by systems thinking and translation theories. These combine to enact an ethics of engagement and evoke knowledge mobilisation to reach the higher order goals of the model. CONCLUSIONS: Engagement models are invaluable for trials research, but there are opportunities to advance their theoretical development and application, particularly within stepped wedge designed studies where there may be a significant waiting period between enrolment in a study and receipt of an intervention.

Towards international consensus on patient harm: perspectives on pressure injury policy.

AIMS: To analyse influential policies that inform practice related to pressure injury management in Australia, England, Hong Kong, New Zealand, Scotland and the United States of America. BACKGROUND: Pressure injuries are associated with significant harm to patients, and carry economic consequences for the health sector. Internationally, preventing and managing pressure injuries is a key nursing activity and quality indicator. EVALUATION: Comparative review and synthesis of pressure injury policies that inform practice. KEY ISSUES: The predominant focus of policy is on patient risk assessment, compliance with documentation and pressure relief. Financial penalty for institutions is emerging as a strategy where pressure injuries occur. Comparisons of prevalence rates are hampered by the lack of consensus on data collection and reporting. To date there has been little evaluation of policy implementation and implemented policy strategies, associated guidelines remain founded upon expert opinion and low-level evidence. IMPLICATIONS FOR NURSING MANAGEMENT: The pressure injury policy agenda has fostered a discourse of attention to incidents, compliance and penalty (sanctions). Prevention and intervention strategies are informed by technical and biomedical interpretations of patient risk and harm, with little attention given to the nature or design of nursing work. Considerable challenges remain if this policy agenda is successfully to eliminate pressure injury as a source of patient harm.

The CORE study protocol: a stepped wedge cluster randomised controlled trial to test a co-design technique to optimise psychosocial recovery outcomes for people affected by mental illness in the community mental health setting.

INTRODUCTION: User engagement in mental health service design is heralded as integral to health systems quality and performance, but does engagement improve health outcomes? This article describes the CORE study protocol, a novel stepped wedge cluster randomised controlled trial (SWCRCT) to improve psychosocial recovery outcomes for people with severe mental illness. METHODS: An SWCRCT with a nested process evaluation will be conducted over nearly 4 years in Victoria, Australia. 11 teams from four mental health service providers will be randomly allocated to one of three dates 9 months apart to start the intervention. The intervention, a modified version of Mental Health Experience Co-Design (MH ECO), will be delivered to 30 service users, 30 carers and 10 staff in each cluster. Outcome data will be collected at baseline (6 months) and at completion of each intervention wave. The primary outcome is improvement in recovery score using the 24-item Revised Recovery Assessment Scale for service users. Secondary outcomes are improvements to user and carer mental health and well-being using the shortened 8-item version of the WHOQOL Quality of Life scale (EUROHIS), changes to staff attitudes using the 19-item Staff Attitudes to Recovery Scale and recovery orientation of services using the 36-item Recovery Self Assessment Scale (provider version). Intervention and usual care periods will be compared using a linear mixed effects model for continuous outcomes and a generalised linear mixed effects model for binary outcomes. Participants will be analysed in the group that the cluster was assigned to at each time point. ETHICS AND DISSEMINATION: The University of Melbourne, Human Research Ethics Committee (1340299.3) and the Federal and State Departments of Health Committees (Project 20/2014) granted ethics approval. Baseline data results will be reported in 2015 and outcomes data in 2017. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry ACTRN12614000457640.

The development and evaluation of online stories to enhance clinical learning experiences across health professions in rural Australia.

Clinical placement learning experiences are integral to all health and medical curricula as a means of integrating theory into practice and preparing graduates to deliver safe, high-quality care to health consumers. A growing challenge for education providers is to access sufficient clinical placements with experienced supervisors who are skilled at maximising learning opportunities for students. This paper reports on the development and evaluation of an innovative online learning program aimed at enhancing student and clinical supervisors' preparedness for effective workplace-based learning. The evidence-based learning program used 'story-telling' as the learning framework. The stories, which were supported by a range of resources, aimed to engage the learners in understanding student and supervisor responsibilities, as well as the expectations and competencies needed to support effective learning in the clinical environment. Evaluation of this program by the learners and stakeholders clearly indicated that they felt authentically 'connected' with the characters in the stories and developed insights that suggested effective learning had occurred.

Rural patients' experiences of the open disclosure of adverse events.

OBJECTIVE: To analyse rural patients' and their families' experiences of open disclosure and offer recommendations to improve disclosure in rural areas. DESIGN: Retrospective qualitative study based on a subset of 13 semistructured, in-depth interviews with rural patients from a larger dataset. The larger data set form a nationwide, multisite, retrospective-qualitative study that included 100 semistructured, in-depth interviews with 119 patients and family members who were involved in high-severity health care incidents and incident disclosure. The larger study is known as the '100 Patient Stories' study. Interviews were transcribed verbatim and analysed by one analyst (D.P.) for recurrent experiences and concerns. SETTING: Acute care. PARTICIPANTS: A sub-set of 13 of the 100 participants from the '100 Patient Stories' study who identified as experiencing an adverse incident in a rural or regional area. MAIN OUTCOME MEASURES: Patients' and family members' perceptions and experiences of health care incident disclosure, as expressed in interviews. RESULTS: Rural patients and clinicians experience additional challenges to metropolitan patients and clinicians in their experiences of health care incidents. These additional barriers include: a lack of resources at small hospitals; delays in diagnosis and transfer; distance between services; and a lack of communication between providers. These challenges impact not only upon how patients and their families experience incidents, but also how open disclosure is implemented. CONCLUSIONS: This analysis of 13 of the 100 Patient Stories interviews provides guidance to rural health services on how to conduct open disclosure.

Utilizing experience-based co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: an evaluation study.

BACKGROUND: This paper presents the findings of three multisite evaluations of Experience-Based Co-design (EBCD) programmes conducted in Emergency Departments (EDs) and associated departments in seven public hospitals in New South Wales, Australia. METHOD: Data for the evaluations were derived from: EBCD documentation provided by the participating sites; interviews with 117 key informants; performance data and the policy and academic literature on EBCD. RESULTS: Respondents described EBCD as a successful and sustainable method of improving the individual patient experience and the overall quality of a health service. Demonstrated successes were reported to lead to aspects of the EBCD approach spreading within services. However, like any quality improvement activity, EBCD was not without its challenges. The principal challenge particular to the EBCD projects outlined here was their deployment in ED settings. Because of their ambulant patient populations, these settings made sustaining consumer engagement for the duration of the project problematic and required tailoring EBCD to accommodate consumers' involvement preferences and constraints. CONCLUSION: The primary strength of EBCD over and above other service development methodologies was reported to be its ability to bring about improvements simultaneously in both the operational efficiency and the inter-personal dynamics of care. However, careful consideration must be given to the constraints inherent in transient patient specialties and what needs to be done to tailor EBCD to suit the particular setting in which it is deployed.

Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study.

OBJECTIVES: To investigate patients' and family members' perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure. DESIGN: Retrospective qualitative study based on 100 semi-structured, in depth interviews with patients and family members. SETTING: Nationwide multisite survey across Australia. PARTICIPANTS: 39 patients and 80 family members who were involved in high severity healthcare incidents (leading to death, permanent disability, or long term harm) and incident disclosure. Recruitment was via national newspapers (43%), health services where the incidents occurred (28%), two internet marketing companies (27%), and consumer organisations (2%). MAIN OUTCOME MEASURES: Participants' recurrent experiences and concerns expressed in interviews. RESULTS: Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process. This analysis provided the basis for the formulation of a set of principles of effective incident disclosure. CONCLUSIONS: Despite growing prominence of open disclosure, discussion about healthcare incidents still falls short of patient and family member expectations. Healthcare organisations and providers should strengthen their efforts to meet patients' (and family members') needs and expectations.

Legal aspects of open disclosure II: attitudes of health professionals - findings from a national survey.

OBJECTIVE: To assess the attitudes of health care professionals engaged in open disclosure (OD) to the legal risks and protections that surround this activity. DESIGN AND PARTICIPANTS: National cross-sectional survey of 51 experienced OD practitioners conducted in mid 2009. MAIN OUTCOME MEASURES: Perceived barriers to OD; awareness of and attitudes towards medicolegal protections; recommendations for reform. RESULTS: The vast majority of participants rated fears about the medicolegal risks (45/51) and inadequate education and training in OD skills (43/51) as major or moderate barriers to OD. A majority (30/51) of participants viewed qualified privilege laws as having limited or no effect on health professionals' willingness to conduct OD, whereas opinion was divided about the effect of apology laws (state laws protecting expressions of regret from subsequent use in legal proceedings). In four states and territories (Western Australia, South Australia, Tasmania and the Northern Territory), a majority of participants were unaware that their own jurisdiction had apology laws that applied to OD. The most frequent recommendations for legal reform to improve OD were strengthening existing protections (23), improving education and awareness of applicable laws (11), fundamental reform of the medical negligence system (8), and better alignment of the activities of certain legal actors (eg, coroners) with OD practice (6). CONCLUSIONS: Concerns about both the medicolegal implications of OD and the skills needed to conduct it effectively are prevalent among health professionals at the leading edge of the OD movement in Australia. The ability of current laws to protect against use of this information in legal proceedings is perceived as inadequate.

Disclosing clinical adverse events to patients: can practice inform policy?

OBJECTIVES: To understand patients' and health professionals' experience of Open Disclosure and how practice can inform policy. BACKGROUND: Open Disclosure procedures are being implemented in health services worldwide yet empirical evidence on which to base models of patient-clinician communication and policy development is scant. DESIGN, SETTING AND PARTICIPANTS: A qualitative method was employed using semi-structured open-ended interviews with 154 respondents (20 nursing, 49 medical, 59 clinical/administrative managerial, 3 policy coordinators, 15 patients and 8 family members) in 21 hospitals and health services in four Australian states. RESULTS: Both patients and health professionals were positive about Open Disclosure, although each differed in their assessments of practice effectiveness. We found that five major elements influenced patients' and professionals' experience of openly disclosing adverse events namely: initiating the disclosure, apologizing for the adverse event, taking the patient's perspective, communicating the adverse event and being culturally aware. CONCLUSIONS: Evaluating the impact of Open Disclosure refines policy implementation because it provides an evidence base to inform policy. Health services can use specific properties relating to each of the five Open Disclosure elements identified in this study as training standards and to assess the progress of policy implementation. However, health services must surmount their sensitivity to revealing the extent of error so that research into patient experiences can inform practice and policy development.