Engaging Pediatric Intensive Care Unit (PICU) clinical staff to lead practice improvement: the PICU Participatory Action Research Project (PICU-PAR)

Implementation Science

William H McKellin⁴  Niranjan Kissoon²  Ronald Lindstrom⁵  Garth Hunte³  Bubli Chakraborty¹  Alexander Pitfield⁶  Mir Kaber Mosavianpour²  Peter W Skippen⁶  Jean-Paul Collet² 

[1] Provincial Health Services Authority, 1380 Burrard Street, Vancouver, British Columbia, Canada;Child and Family Research Institute, 950 West 28th Avenue, Vancouver, British Columbia, Canada;Emergency Department, Saint Paul’s Hospital and Department of Emergency Medicine, University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, Canada;Department of Anthropology, University of British Columbia, 6303 NW Marine Drive, Vancouver, BC, Canada;School of Leadership Studies, Royal Roads University, 2005 Sooke Road, Victoria, British Columbia, Canada;Pediatric Intensive Care Unit, BC Children’s Hospital, 4480 Oak Street, Vancouver, British Columbia, Canada

关键词: Children;    Reflective practice;    Learning community;    Engagement;    Distributed leadership;    Participatory action research;    Community of practice;    Quality improvement;    ICU;    PICU;   

Others  :  810582
DOI  :  10.1186/1748-5908-9-6

 received in 2013-10-02, accepted in 2013-12-27,  发布年份 2014

【 摘 要 】

Background

Despite considerable efforts, engaging staff to lead quality improvement activities in practice settings is a persistent challenge. At British Columbia Children’s Hospital (BCCH), the pediatric intensive care unit (PICU) undertook a new phase of quality improvement actions based on the Community of Practice (CoP) model with Participatory Action Research (PAR). This approach aims to mobilize the PICU ‘community’ as a whole with a focus on practice; namely, to create a ‘community of practice’ to support reflection, learning, and innovation in everyday work.

Methodology

An iterative two-stage PAR process using mixed methods has been developed among the PICU CoP to describe the environment (stage 1) and implement specific interventions (stage 2). Stage 1 is ethnographic description of the unit’s care practice. Surveys, interviews, focus groups, and direct observations describe the clinical staff’s experiences and perspectives around bedside care and quality endeavors in the PICU. Contrasts and comparisons across participants, time and activities help understanding the PICU culture and experience. Stage 2 is a succession of PAR spirals, using results from phase 1 to set up specific interventions aimed at building the staff’s capability to conduct QI projects while acquiring appropriate technical skills and leadership capacity (primary outcome). Team communication, information, and interaction will be enhanced through a knowledge exchange (KE) and a wireless network of iPADs.

Relevance

Lack of leadership at the staff level in order to improve daily practice is a recognized challenge that faces many hospitals. We believe that the PAR approach within a highly motivated CoP is a sound method to create the social dynamic and cultural context within which clinical teams can grow, reflect, innovate and feel proud to better serve patients.

【 授权许可】

   
2014 Collet et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Baker GR, Norton PG, Flintoft V, et al.: The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004, 170(11):1678-1686.
• [2]Brennan TA, Leape LL, Laird NM, et al.: Incidence of adverse events and negligence in hospitalized. Qual Saf Health Care 2004, 324:145-152.
• [3]Leape LL, Brennan TA, Laird NAN, et al.: The nature of adverse events in hospitalized patients results of the Harvard medical practice study II. N Engl J Med 1991, 324(6):377-384.
• [4]Vincent C, Neale Graham WM: Adverse events in British hospitals: preliminary retrospective. BMJ 2012, 322(7285):517-519.
• [5]Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby LHJ: The quality in Australian health care study. Med J Aust 1995, 163(9):458-471.
• [6]Institute of Medicine: Crossing the quality Chasm a new health system for the 21st Century. Washington, DC: National Academy Press; 2001.
• [7]Grol R, Berwick DM, Wensing M: On the trail of quality and safety in health care. BMJ 2008, 336(7635):74-76.
• [8]Grimshaw J, Eccles M, Thomas R, et al.: Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med 2006, 21(2):S14-S20.
• [9]Freeman C, Todd C, Camilleri-Ferrante C, et al.: Quality improvement for patients with hip fracture: experience from a multi-site audit. Qual Saf Health Care 2002, 11(3):239-245.
• [10]Ring N, Malcolm C, Coull A, Murphy-Black T, Watterson A: Nursing best practice statements: an exploration of their implementation in clinical practice. J Clin Nurs 2005, 14(9):1048-1058.
• [11]Barwick MA, Peters J, Boydell K: Getting to uptake: do communities of practice support the implementation of evidence-based practice? J Am Acad Child Adolesc Psychiatry 2009, 18(1):16-29.
• [12]BC Ministry of Health: Lean in British Columbia’ s health sector: annual report 2010-11]. 2011. [http://www.llbc.leg.bc.ca/public/pubdocs/bcdocs2012/517937/2010_2011.pdf webcite]
• [13]McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K: Effect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ 2010, 341(1):c5469-c5469.
• [14]Johnson JE, Smith AL, Mastro KA: From Toyota to the bedside: nurses can lead the lean way in health care reform. Nurs Adm Q 2012, 36(3):234-242.
• [15]Poksinska B: The current state of lean implementation in health care: literature review. Qual Manag Health Care 2010, 19(4):319-329.
• [16]Vats A, Goin KH, Villarreal MC, Yilmaz T, Fortenberry JD, Keskinocak P: The impact of a lean rounding process in a pediatric intensive care unit. Crit Care Med 2012, 40(2):608-617.
• [17]Toussaint JS, Berry LL: The promise of lean in health care 2013. Mayo Clin Proc 2013, 88(1):74-82.
• [18]Powell AE, Rushmer RK, Davies HTO: A systematic narrative review of quality improvement models in health care. 2008. [http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=ba9d888b-8837-4d57-8842-b0493b80a2a5&version=-1 webcite]
• [19]Cornwall A, Jewkes R: What is participatory research? Soc Sci Med 1995, 41(12):1667-1676.
• [20]Greenwood DJ, Levin M: Introduction to action research: social research for social change. Thousand Oaks, CA: Sage; 1998.
• [21]Herr K, Anderson GL: The Action Research Dissertation: a guide for students and faculty. Thousand Oaks, CA: Sage; 2005.
• [22]Reason P, Bradbury H: Editorial. Action Res 2008, 6(1):5-6.
• [23]Wenger E: Communities of practice and social learning systems. Organization 2000, 7(2):225-246.
• [24]Wenger E, McDermott RA, Snyder WC: Cultivating communities of practice: a guide to managing knowledge. Cambridge, MA: Harvard Business School Press; 2002.
• [25]Robin M: Principles for participatory action research. Adult Educ Q 1991, 4((3):168-187.
• [26]Riel M: Understanding action research. In Center for collaborative action research. Pepperdine University; 2010. [http://www.actionlearning.com.au/Classes/ActionResearch/Articles/Pepperdine-UnderstandingActionResearch.doc webcite]
• [27]Ellis B, Herbert SI: Complex adaptive systems (CAS): an overview of key elements, characteristics and application to management theory. Inform Prim Care 2011, 19(1):33-37.
• [28]Ellis B: Complexity in practice: understanding primary care as a complex adaptive system. Inform Prim Care 2010, 18(2):135-140.
• [29]Plsek PE, Greenhalgh T: Complexity science: the challenge of complexity in health care. BMJ 2001, 323(7313):625-628.
• [30]Plsek PE, Wilson T: Complexity science Complexity, leadership, and management in healthcare organisations four articles. BMJ 2001, 323(7315):746-749.
• [31]Glouberman S, Zimmerman B: Complicated and complex systems: What would successful reform of medicare look like?. Toronto: Commission on the Future of Health Care in Canada; 2002. [http://publications.gc.ca/collections/Collection/CP32-79-8-2002E.pdf webcite]
• [32]Tan J, Wen HJ, Awad N: Health care and services delivery systems as complex adaptive systems: commun ACM. 2005, 48(5):36-44.
• [33]Zimmerman B, Lindberg C, Plsek P: Edgeware: insights from complexity science for health care leader. Irving TX: VHA Publishing; 1998.
• [34]Begun JW, Zimmerman B, Dooley K: Health care organizations as complex adaptive systems. In Advances in health care organization theory. Edited by Mick SM, Wyttenbach M. San Francisco: Jossey-Bass; 2003:253-288.
• [35]Zimmerman B, Reason P, Rykert L, Gitterman L, Christian J, Gardam M: Front-line ownership: generating a cure mindset for patient safety. Healthc Pap 2013, 13(1):6-22.
• [36]Orlikowski WJ: Knowing In practice: enacting a collective capability in distributed organizing. Organ Sci 2002, 13(3):249-273.
• [37]Lindstrom R: Leadership needs to shift in the health system: three emerging perspectives to inform our way forward. Healthc Pap 2013, 13(1):48-54.
• [38]Baker GR, Denis J-L: Medical leadership in health care systems: from professional authority to organizational leadership. Public Money Manag 2011, 31(5):355-362.
• [39]Van de Ven A: Engaged scholarship: a guide for organizational and social research. New York: Oxford University Press; 2007.
• [40]Wallerstein N, Duran B: The conceptual, historical, and practice roots of community based participatory research and related participatory traditions. In Community-based participatory research for health. Edited by Minkler M, Wallerstein N. San Francisco, CA: Jossey-Bass; 2003:27-52.
• [41]Greewood DJ, Levin M: Reform of the social sciences and of universities through action research. In The Sage handbook of qualitative research. 3rd edition. Edited by Denzin NK, Lincoln YS. Thousand Oaks, CA: Sage; 2005:43-64.
• [42]Cicourel AV: Cognitive overload and communication in two healthcare settings. Commun Med 2004, 1(1):35-43.
• [43]Iedema R, Mesman JCK: Visualizing health care practice improvement: innovation from within. Oxford: Radcliffe Publishing Ltd; 2013.
• [44]Carroll K, Iedema R, Kerridge R: Reshaping ICU ward round practices using video-reflexive ethnography. Qual Health Res 2008, 18(3):380-390.
• [45]Norcross JC, Krebs PM, Prochaska JO: Stages of change. J Clin Psychol 2011, 67(2):143-154.
• [46]Di Noia J, Prochaska JO: Dietary stages of change and decisional balance: a meta-analytic review. Am J Health Behav 2010, 34(5):618-632.
• [47]Lam CS, Wiley AH, Siu A, Emmett J: Assessing readiness to work from a stages of change perspective: implications for return to work. Work J Prev Assess Rehabil 2010, 37(3):321-329.
• [48]Dickson G, Lindstrom R, Black C, Van der Gucht D: Evidence-informed change management in Canadian healthcare organizations. Ottawa, ON: Canadian Health Services Research Foundation; 2012.
• [49]Carrington PJ, Scott J, Wasserman SM: Models and methods in social network analysis. Cambridge: Cambridge University Press; 2005.
• [50]Hogan B, Carrasco JA, Wellman B: Visualizing personal networks: working with participant-aided sociograms. Field Methods 2007, 19(2):116-144.
• [51]Scott J: The Sage handbook of social network analysis. Thousand Oaks: Calif. Sage Publications; 2011.
• [52]Walker ME, Wasserman S, Wellman B: Statistical models for social support networks. Sociol Methods Res 1993, 22(1):71-98.
• [53]Barry W, Janet S, Dimitrina D, Laura G, Gulia Milena HC: Computer networks as social networks: collaborative work, telework, and virtual community. Annu Rev Sociol 1996, 22:213-238.
• [54]Harter JK, Ph D, Schmidt FL, Killham EA, Asplund JW: Q 12® Meta-Analysis. Gallup Inc: Omaha NB; 2006.
• [55]Upenieks VV, Lee EA, Flanagan ME, Doebbeling BN: Healthcare Team Vitality Instrument (HTVI): developing a tool assessing healthcare team functioning. J Adv Nurs 2010, 66(1):168-176.
• [56]CCHL: Canadian college of health leaders. 2013. [http://www.cchl-ccls.ca webcite]
• [57]Thomas WV: Social networks and health: models, methods and application. New York: Oxford University Press; 2010.
• [58]Cross R, Laseter T, Parker A, Velasquez G: Assessing and improving communities of practice with organizational network analysis. The Network Roundtable at the University of Virginia; 2004. [http://www.robcross.org/pdf/roundtable/formalizing_communities_of_practice.pdf webcite]
• [59]McKellin WH, Shahin K, Hodgson M, Jamieson J, Pichora-Fuller K: Pragmatics of conversation and communication in noisy settings. J Pragmat 2007, 39(12):2159-2184.
• [60]Hutchins E: The distributed cognition perspective on human interaction. In In roots of human sociality: culture, cognition and interaction. Edited by Enfield NJ, Levinson SC. Berg: Oxford; 2006:375-398.
• [61]Henry SG, Fetters MD: Video elicitation interviews: a qualitative research method for investigating physician-patient interactions. Ann Fam Med 2012, 10(2):118-125.
• [62]Iedema R, Long D, Forsyth R: Visibilising clinical work: video ethnography in the contemporary hospital. Health Sociol Rev 2006, 15(2):156-168.
• [63]Iedema R, Merrick T, Rajbhandari D, Gardo ASA: Viewing the taken-for-granted from under a different aspect: a video-based method in pursuit of patient safety. Int J Multiple Res Approaches 2009, 3(3):290-301.
• [64]Heritage J: Conversation analysis and institutional talk. In Handbook of language and social interaction. Edited by Fitch KL, Sanders RE. Mahwah, NJ: Lawrence Erlbaum Associates; 2005:103-47.
• [65]Waugh LR, Fonseca-Greber B, Vickers C, Eröz B: Multiple empirical approaches to a complex analysis of discourse. In Methods in cognitive linguistics. Edited by Gonzalez-Marquez M, Mittelberg M, Coulson S, Spivey M. Amsterdam: John Benjamins; 2007:120-148.
• [66]Agar M, Hobbs J: How to grow schemata out of interviews. In Directions in cognitive anthropology. Edited by Dougherty J. Urbana: University of Illinois Press; 1985:413-431.
• [67]Hofstede SN, Marang-van de Mheen PJ, Assendelft WJJ, et al.: Designing an implementation strategy to improve interprofessional shared decision making in sciatica: study protocol of the DISC study. Implementation Sci 2012, 7(1):55. BioMed Central Full Text
• [68]Francis JJ, Johnston M, Robertson C, et al.: What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health 2010, 25(10):1229-1245.
• [69]Guest G: How many interviews are enough?: an experiment with data saturation and variability. Field Methods 2006, 18(1):59-82.
• [70]Borgatti SP, Everett MG, Freeman LC: UCINET Software. In Ucinet for windows: software for social network analysis. Cambridge, MA: Harvard-Analytic Technologies; 2002.
• [71]Wenger E, White N, Smith J: A review of digital habitats: stewarding technologies for communities. Portland OR: CPsquare; 2009.
• [72]McGill I, Beaty L: Action learning. A practitioner’s guide. 2nd edition. London: Routledge; 2013.
• [73]Lavis JN, Lomas J, Hamid M, Sewankambo NK: Assessing country-level efforts to link research to action. Bull World Health Organ 2006, 84(8):620-628.
• [74]Mann KV: Theoretical perspectives in medical education: past experience and future possibilities. Med Educ 2011, 45(1):60-68.
• [75]Bleakley A: Broadening conceptions of learning in medical education: the message from teamworking. Med Educ 2006, 40(2):150-157.
• [76]Soubhi H, Bayliss EA, Fortin M, et al.: Learning and caring in communities of practice: Using relationships and collective learning to improve primary care for patients with multimorbidity. Ann Fam Med 2010, 8(2):170-177.
• [77]Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC, Graham ID: Use of communities of practice in business and health care sectors: a systematic review. Implementation Sci 2009, 4:27. BioMed Central Full Text
• [78]Ranmuthugala G, Plumb JJ, Cunningham CF, Georgiou A, Westbrook J, Braithwaite B: Communities of practice in the health sector: a systematic review of the peer-reviewed literature. Sydney: University of New South Wales, Australian Institute of Health Innovation; 2010.
• [79]Lave J: Situating learning in communities of practice. In Perspectives on socially shared cognition. Edited by Resnick LB, Levine JM, Teasley SD. Washington, DC: American Psychological Association; 1991:63-82.
• [80]Engestrom Y: Developmental studies of work as a testbench of activity theory: the case of primary care medical practice. In Understanding practice: perspectives on activity in context. Edited by Lave J. Cambridge: Cambridge University Press; 1993:64-103.
• [81]Nardi BA: Studying context: a comparison of activity theory, situated action models, and distributed cognition. In Context and consciousness: activity theory and human-computer interaction. Edited by Nardi B. Cambridge: Mass:MIT; 1996:69-102.
• [82]Engeström Y, Sannino A: Whatever happened to process theories of learning? Learning. Cult Social Interact 2012, 1(1):45-56.
• [83]Mercer N, Howe C: Explaining the dialogic processes of teaching and learning: the value and potential of sociocultural theory. Learn Cult Social Interac 2012, 1(1):12-21.
• [84]Engeström Y, Sannino A: Studies of expansive learning: foundations, findings and future challenges. Educ Res Rev 2010, 5(1):1-24.
• [85]Nicolini D: Practice theory, and organization: an introduction. Oxford: Oxford University Press; 2013.
• [86]McTaggart R: Participatory action research: issues in theory and practice. Educ Action Res 1994, 2(3):313-37.
• [87]Rains JW, Ray DW: Participatory action research for community health promotion. Public Health Nurs 1995, 12(4):256-261.
• [88]Dickens L, Watkins K: Action research: rethinking Lewin. Manag Learn 1999, 30(2):127-140.