- To develop and evaluate evidenced interventions to support improved person-centredness.
- To contribute to improving and embedding patient-reported outcomes and experience across NHS Scotland as stated within the Quality Strategy.
The project was split into two studies: Improving Patients Experience of Care Study (IPEC) & Neuro-rehabilitation Outcomes Measurement System (NROMS).
IPEC: This mixed methods study ran parallel evaluations of Releasing Time to Care (NHS Tayside) (RTC™plus) and the Caring Behaviours Assurance System (CBAS™) with an embedded realist process evaluation. It sought to test the impact of these two interventions upon staff and patient outcomes, through quasi-experimental stepped wedge designs involving 30 wards (15 each intervention) over six three month phases. The study was not designed to compare the interventions. RTC™plus was delivered by the local NHS practice development team. The “plus” aspect involved a locally developed readiness for change and team feedback element delivered before RTC™. The three month implementation phase, covered implementation of the three core RTC™ units (further units were available). For RTC™plus this indicated that:
- The key aims and objectives, and core messages were understood by staff on the wards.
- There was a mixed response to the facilitation provided with mixed views being expressed about the credibility, knowledge, and supportiveness of the facilitators.
- RTC-Plus was perceived by staff as successful in 4 wards, had a mixed response in 4 wards, and was perceived unsuccessful in 2 further wards.
- Most interviewees perceived that their ward was not staffed to a level that makes full engagement in the initiatives possible.
The CBAS™ model involved training of three quality champions (across nursing grades) on each ward. Wards selected target outcomes from across the 7 “C”s of caring and quality champions then led each ward team to achieve those outcomes. For CBAS™ this indicated that:
- The key aims and objectives, and core messages of CBAS™ were well received by the people who received the facilitator training.
- Training was extremely well received by all participants.
- Facilitators perceived as knowledgeable, credible and highly supportive.
- CBAS™ was perceived by staff as successful in 2 wards, as having a mixed response in 9 wards, and as unsuccessful in 2 further wards. Staff’s perception of success was not supported by the quantitative data. However, in the wards where the realist evaluation predicted a poor response we found a statistically significant worsening in two of the three primary outcomes.
- Despite the perceived quality and credibility of the training, the ability of CBAS™, to penetrate and change ward culture in its current form appears limited at best.
There were several shared lessons from the evaluation of both interventions. Consideration should be given to targeting of these interventions to ward settings where it addresses the needs of a particular ward at that given moment in time. We propose three key mechanism of action: Fit; Mode of Delivery; and Mechanisms of Action. The support and influence of the senior charge nurse was integral to successful change. And the relationship with the ward based agents of implementation (either practice development staff or local champions) was key in terms of engagement, communication and respect.
NROMS: This mixed methods formative project worked collaboratively with NHS Fife to develop and evaluate of a person-centred outcomes system for neuro-rehabilitation. Rehabilitation of patients is a crucial component of effective healthcare delivery, particularly within a context of an aging population and associated multi-morbidities. Given the impact that rehabilitation can have on people’s lives, and the scale of rehabilitation services being delivered, it is essential that the interventions being delivered are appropriately evaluated. Patient-reported outcome measurements should enable the impact of rehabilitation on patients’ lives to be monitored and maintained, which in turn could inform future service provision. This is essential to achieve and maintain effective, safe and person-centred care in accordance with the Scottish Government’s quality strategy. To ensure such high quality evaluation and monitoring, key outcomes to be monitored must be decided upon. These must be: meaningful and important to both service users and the multi-disciplinary team; valid; reliable; sensitive to change; and useful to inform practice. However, the reality is that selecting which area of rehabilitation to evaluate, and which outcome measures to use to achieve this is challenging and can act as a barrier to routine outcome measurement in practice. The NROMS project began by consulting with local patients and Scottish neuro-rehabilitation staff to identify their outcome priorities. A multi-disciplinary, clinical working group then rationalised that list of priorities (protecting patient choices) to form a list of key targets. The research team conducted a systematic review to identify validated outcomes which mapped against these targets and the working group used this map to identify a list of core outcome measures which could be used across the patient rehabilitation journey. In collaboration with NHS eHealth, an intranet data system was developed and implemented in steps on 2 organisationally different, neuro-rehabilitation, in-patient wards. A realist evaluation used longitudinal, brief interviews with staff across a range of disciplines and seniority to understand the implementation process.