Symposium nine: Facilitated action research: is it an effective methodology for improving clinical practice?

Symposium lead: Antonia Beringer, Research fellow, Faculty of Health and Social Care, University of the West of England, Bristol, Bristol, United Kingdom antonia.beringer@uwe.ac.uk

Symposium chair: Dr. Margaret Fletcher, Reader in Children's Nursing, The University of the West of England, Bristol

Symposia focus

In this symposium we will present the findings of a year long action research study funded by an acute National Health Service trust. As well as describing the study and its outcomes, we will share with you what we have learned from the experience of being engaged in this process. The study took place in a children’s hospital in the West of England but as the papers presented here focus on the process being involved in action research we hope they will be of interest and use to those working in other clinical settings.

The objectives of the symposium are to:

Describe how action research has been used to improve practice in a range of children’s inpatient settings.
Critically examine this application of an action research methodology.
Identify factors that influence the effectiveness of the approach.
Recommend ways of supporting action research in an organisational context, based on our empirical and experiential findings.

Aim

The overall aim of the study was to improve the coordination of care for child patients and their families and was developed from findings of a doctoral research study carried out at the hospital.

The first three papers of the symposium are presented by clinical staff who were directly involved in the study. Each describes their own project to improve a specific aspect of care coordination in their clinical area. The final paper, presented by the researcher who facilitated the study, draws together what these projects can tell us about using a facilitated action research methodology and how this approach can be sustained in an organisational context.

Source of Funding: United Bristol Hospitals Trust

Level of funding: £12,000

Abstract one: Improving communication around the discharge of child cancer patients

Kate Pye, Ward Manager, Oncology Ward, Bristol Royal Children’s Hospital. Charlotte Higby, Senior Staff Nurse, Oncology Ward, Bristol Royal Children’s Hospital

Background

This paper presents the experience of a multi-disciplinary team in a regional paediatric oncology service in a facilitated action research project. The focus of the project was prompted by concern about gaps in the process of discharging children to the local community.

Aim

To improve communication around the discharge of child cancer patients.

Method

The action research cycle began by identifying issues of concern. These included inconsistencies in the provision of information to families and staff in other centres, delays in producing discharge summaries, the absence of a key worker system and poorly utilised discharge documentation. A plan for addressing these issues was agreed upon. This included the establishment of a multi-disciplinary group to work on the project, the mapping of current discharge processes, the clarification and agreement of roles in that process and the production of new discharge documents to support the newly agreed process. Data on the time taken to complete discharge summaries and the accurate completion of documents were collected as outcome indicators.

Results

Achievements thus far have included the production of a mapped discharge process with associated role allocation and the implementation of an agreed discharge summary standard. The documents will be disseminated throughout the South West via the Paediatric Oncology Nurses Group. A newly established monthly audit of time taken to complete discharge summaries has already established that there has been an increase in the percentage of summaries completed before the child leaves the ward.

Discussion and conclusions

The development of agreed processes, supported by new documentation have begun to have measurable effects on improving communication around the complex process of discharge. However, the most valuable outcome for us has been the establishment of the multi-disciplinary group which is working, evolving and meeting on a regular basis to continue the dialogue.

Abstract two: Addressing the issue of nursing time spent off the ward accompanying children to x-ray

Heather Julier, Senior Staff Nurse (Clinical Practice Development), Medical Ward, Bristol Royal Children’s Hospital.

Background

As a group of staff on a busy medical ward we were concerned about the length of time spent off the ward accompanying children to x-ray and for other radiological investigations. When this project began we chose this as the aspect of care we would most like to improve.

Aim

To reduce the amount of time spent off the ward by nursing staff when accompanying children to x-ray.

Method

An audit was carried out which measured time spent off the ward by nurses accompanying children for investigations during one month. We also mapped the process of a child going to x-ray to identify where there were gaps and delays. Ways of improving our clinical interaction with the x-ray department were discussed and planned.

Results

The audit allowed us to quantify the amount of time nurses were spending off the ward accompanying children to x-ray. We were able to use this data to demonstrate that it was an issue to other colleagues. Our plan to engage the x-ray department in direct dialogue proved to be challenging to implement. We therefore found ways of increasing our contact with the department in other ways. For example, by establishing a link nurse and including the x-ray department in our orientation plan for new staff. A repeat of the audit to measure time spent off the ward will be carried out in October 2007 to see if there has been a change.

Discussion and conclusions

We have found that it can be difficult to effect change in clinical processes when this involves more than one department. By scrutinising our own practice we were able to identify changes that could be made ‘unilaterally’ that we hope will be shown to have been effective when repeat the audit.

Abstract three: Reducing delays for children with orthopaedic trauma

Liz Hagan, Ward Manager, Surgical Ward, Bristol Royal Children’s Hospital Hannah Goodman, Senior Staff Nurse, Surgical Ward, Bristol Royal Children’s Hospital

Background

Our project began with a care co-ordination forum for ward managers at the children’s hospital. The forum promoted discussion about care coordination issues we were facing on our wards and presented an opportunity to make a difference to patient care using an action research approach. I selected orthopaedic trauma patients as the focus; a group which had historically been affected by delays and extended length of stay.

Aim

To reduce delays experienced by a group of child trauma patients through examining and understanding the factors which impact on their process of care. Method: A range of qualitative and quantitative baseline data were collected. These included mapping the current care process, collating patient activity spreadsheets, drawing on complaints and incident forms, keeping a log of orthopaedic patient admissions and identifying case studies. Progress against each measure was monitored during regular meetings with the facilitator. Other ward based staff were included from the outset to share the learning about the role of data collection and how this could be used to bring about change.

Results

Through systematically gathering information about the experience of this group of patients we were able to demonstrate actual delays over a period of three months, to compare this with our perception of delays and to identify changes in practice that had an impact on these patients.

Discussion and conclusions

By being involved in an action research study we gained practical skills in analysing spreadsheets, keeping logs of activity, mapping care processes. These were new skills for the staff, which we have since applied to other areas of our practice. Although successfully balancing the clinical needs of the patient and the project has been challenging in terms of time management, it has been a positive experience which has supported the professional development of those involved.

Abstract four: What are the important factors to consider when using an action research approach to improve clinical practice in a hospital setting?

Antonia Beringer, Research Fellow, Centre for Child & Adolescent Health, University of the West of England, Bristol.

Background

This paper draws together what has been learned, through the projects presented by the previous three speakers, about how a facilitated action research approach can best be used to provide a sustainable means of supporting improvement in clinical practice.

Aim

To explore factors that influence the application of action research to improve clinical practice in an organisational context.

Method

Workshops were held to introduce the approach to ward managers. Six groups of staff from different clinical areas were recruited (three of which are represented above). Groups met individually with the facilitator over one year (ending Oct 2007). The action research cycle was used as a basis on which to improve their chosen aspect of care. A range of qualitative and quantitative data were collected by each project group. An activity log and field notes were recorded by the facilitator after each session.

Results

The action research projects were found to be influenced by a complex interplay of factors relating to the ward, the organisation and the process of facilitation. An important feature of the projects presented here was that the staff developed a range of skills during the process of being involved in their particular project. These skills ranged from collecting and analysing data to running away days for their teams.

Discussion and conclusions

Our experience from this study suggests that it is this learning aspect of the approach that makes it valuable because this supports its' sustainability – an important consideration when external facilitation is time-limited. We conclude that facilitated action research is an effective way of building the competence and confidence of front line clinical staff so they feel equipped and ready to take on the task of improving clinical practice in the complex organisational context in which they operate.