Facilitating an accelerated experience-based co-design project Ruth Tollyfield
Abstract
This article describes an accelerated experience-based co-design (AEBCD) quality improvement project that was undertaken in an adult critical care setting and the facilitation of that process. In doing so the aim is to encourage other clinical settings to engage with their patients, carers and staff alike and undertake their own quality improvement project. Patient, carer and staff experience and its place in the quality sphere is outlined and the importance of capturing patient, carer and staff feedback established. Experience-based co-design (EBCD) is described along with the recently tested accelerated version of the process. An overview of the project and outline of the organisational tasks and activities undertaken by the facilitator are given. The facilitation of the process and key outcomes are discussed and reflected on. Recommendations for future undertakings of the accelerated process are given and conclusions drawn. Key words: Facilitation ■ Patient experience ■ Staff experience ■ Experience-based co-design ■ Quality improvement ■ Critical care
C
aring for patients is at the very heart of the NHS. Providing excellent standards of care, of the highest quality to all, is what the NHS continually aspires to achieve, at all times (Department of Health (DH), 2013). It stands to reason that the very people who encounter this service provision and those who work within it should be regularly consulted as to what their experience of the service is, in order that continual improvements can be made.
Aim The aim of this article is to recount the experience of the facilitation of a quality improvement project undertaken in a large specialist cardiothoracic intensive therapy unit (ITU) in order that other critical care units, wards, outpatient departments and many other healthcare settings may be encouraged to undertake their own similar patient, carer and staff experience project.
Ruth Tollyfield is Senior Sister, Intensive Therapy Unit, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London Accepted for publication: January 2014
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Over the last 13 years, since the publication of Patient and Public Involvement in the New NHS (DH, 1999), and in addition The NHS Plan (DH, 2000), there has been an increased drive towards engaging patients, carers and the public in their care provision and treatment choices, as well as the development of an understanding of their actual experiences (DH, 2009). High Quality Care for All: The NHS Next Stage Review (Darzi, 2008) clearly outlines patient experience as being one of three important measures of quality; the other two being safety and clinical effectiveness. The report indicates that improving the experience of those requring care is central to enhancing quality and this has led to the development of supporting guidelines from the National Institute for Health and Care Excellence (NICE) (2012). Hospital board members have been provided with ‘intelligence’ regarding the need to understand their patients’ experience and in the future patient experience will become an actual measure of quality on which a trust’s performance will be judged (Dr Foster Intelligence, 2010; DH, 2010). There is evidence to suggest that high levels of patient satisfaction with their experience are linked with enhanced health outcomes and also that patient experience is positively associated with clinical effectiveness and patient safety (NHS Confederation, 2010; Doyle et al, 2013). By contrast, raised mortality rates and evidence of poor standards of care delivery were discovered at Mid Staffordshire NHS Foundation Trust with the subsequent Francis Report (Francis, 2013) stating that management at the Trust did not have a culture of listening to patients and asking for feedback. Traditionally patient feedback has been sourced via complaints, surveys, comment cards and interviews, yet these tools tend to simply ask how people rate their experience rather than fully capturing the experience and gathering ideas for how it could be improved. More recently websites, such as Patient Opinion (www.patientopinion.org.uk), have been developed and this is a platform that is being increasingly used by patients to express their views, give an account of and rate their experiences. The evidence base on what patient experience is, what shapes it and how it can be enhanced is limited compared to other areas of development such as patient safety. However, this area is being actively explored and the evidence of what actually matters to patients is developing rapidly. Patient experience is gaining more of an equal footing in importance alongside patient safety and clinical effectiveness (Goodrich and Cornwell, 2008; Robert et al, 2011). The experiences and wellbeing of staff and the subsequent impact on the quality of care they provide, and thus patient
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Background
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ADULT CRITICAL CARE experience, is an another area of research that is limited but growing. Initial research that has been undertaken, including Raleigh et al’s (2009) and Maben et al’s (2012) multiple linear regression and mixed methods studies, strongly indicates that there is indeed a positive link between staff experience, patient experience and quality. It is believed that patient care will be enhanced if investment is made in the the welfare of front-line staff (Gasper, 2010). The government has stated its commitment to providing this through encouraging positive working environments that are open and supportive as well as engagement with decisions that affect service provision (DH, 2013).
Experienced-based co-design (EBCD) New ways that enable patients and staff to listen to each other and work together are emerging. Design-led professions such as architecture and computer graphics have long held the common aim that a product or process should be as userfriendly as possible. Bate and Robert (2006) suggest that this aim should be applied within the healthcare setting because ultimately—although a challenge—listening to patients’ experiences and designing services with them ensures that services are truly patient-centred. EBCD, an approach developed by Bate and Robert (2007), has arisen from this concept. It is a form of participatory action research where patients, carers and staff are drawn together to narrate and share their experiences of how a current service truly feels to all those who participate in it. They then work together, as equal partners, to redesign (co-design) those services in order to enhance the future experience for all. A number of important EBCD studies have been undertaken and evaluated, including work in breast and lung cancer patients services in the UK (Farr, 2011; Tsianakas et al, 2012) and emergency departments in Australia (Piper et
Stage 1 Staff interviews
al, 2012). These have demonstrated the effectiveness of the EBCD process in generating quality improvements.
The EBCD process EBCD is typically a 6-stage process (Figure 1). In previous studies the process occurred over a 12-month period and was facilitated by experienced qualitative researchers who analysed the data. Stage 1 is the exploratory phase where patients, carers and staff are interviewed and observations of the environment are made. In the original studies patients were also filmed, their responses analysed to create themes, known as ‘touch points’, and then edited to create a single 35-minute film.The staff interviews are not filmed but again their responses are analysed thematically. In previous studies the discovery phase took about 6 months. In stage 2 the staff meet and are offered the opportunity to review and discuss the themes that emerged from their interviews. The staff then choose four or five priorities they would like to take forward to their next stage. At a similar time, in order to retain the momentum of the project, stage 3 occurs, when the patients and carers meet for the first time. They are shown the film, which is used as a ‘trigger’ to prompt recall of experiences and generate discussion. The discussion is facilitated and intial issues noted. An exercise to explore and identify key moments, or ‘touch points’, along their journey is then undertaken. This is known as emotional mapping. Once the themes have been identified the patients choose their priorities to take forward to their next stage. Stage 4 is the coming together of patients, carers and staff for the first time at a joint event. At the event the staff are shown the film. The patients, carers and staff are then invited to join together in small groups to discuss any issues arising
Stage 1 Observation
Stage 1 Patient interviews
Stage 3 Patient event
Stage 2 Staff event
Stage 4 Joint staff/patient event
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Stage 5 Co-design working group
Stage 5 Co-design working group
Stage 5 Co-design working group
Stage 5 Co-design working group
Stage 6 Review and celebration
Figure 1. The experience-based co-design (EBCD) process (adapted from Bate and Robert, 2007)
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from the film and the priority themes that emerged from the previous events. The patients, carers and staff then identify four or five joint priorities they would like to work on together to improve services. Stage 5 sees small facilitated groups of patients, carers and staff (maximum 10 per group) working together on an individual theme that emerged from the previous event. Co-design group meetings occur typically on two or three occasions. Action points are agreed and taken forward by volunteers from the group and so quality improvements are made that enhance the experience for all. Stage 6 occurs at the end of the process. The co-design groups reconvene to review their work, celebrate their successes and plan for the future as necessary. Full details of the EBCD process and toolkit along with useful materials and other resources, including explanatory film recordings and ‘hints and tips’ from previous EBCD facilitators, can be found on the excellent King’s Fund website at www.kingsfund.org.uk/projects/point-care/ebcd.
films are reusable in any context and will be made available online, through the Kings Fund EBCD toolkit site and www. healthtalkonline.org, for others to use.
Accelerated EBCD
Training and support
In a variation of EBCD Locock et al (in press) have explored the potential of creating and testing a 35-minute film using patient and carer narrative from a national archive of interviews held by the Health Experiences Research Group at the University of Oxford, and disseminated on www. healthtalkonline.org. By reducing the need to interview local patients and carers, and analyse and process the film footage, they reduced the overall length of the EBCD process by 6 months. The researchers also chose to engage local facilitators to undertake the process, now termed ‘accelerated EBCD’ or ‘AEBCD’ (Table 1). The research project by Locock et al (in press) was undertaken in intensive care units and then lung cancer services in two hospital trusts, The Royal Berkshire NHS Foundation Trust and Royal Brompton and Harefield NHS Foundation Trust. Preliminary results indicate that the film, made from the national archive, was readily accepted by all participants and served its purpose as a ‘trigger’ and catalyst for discussion. Although some patients felt it was more negative than their own experience, the fact that it was not local patients in the film seemed to make staff feel less defensive or threatened by it. A total of 48 quality improvement activities occurred, across both trusts, ranging from small-scale changes to process redesign between organisations. Engaging local facilitators, not external researchers, and not interviewing and filming the patients and carers, as well as undertaking the process in 6 rather than 12 months also resulted in significant financial cost savings (Locock et al, in press). The trigger
At the beginning of the process the two ITU facilitators, one from each trust, spent half a day training with the researchers. They were then left to run the process alone, although they had email and telephone support as necessary from the researchers and met up with them on a few occasions. Both facilitators found the King’s Fund website an extremely useful resource.
EBCD
AEBCD
12-month process
6-month process
Patients and carers interviewed and filmed
Patients and carers not interviewed or filmed
35-minute film created from filmed footage
35-minute film created from archive footage
Facilitated by experienced researchers
Facilitated by internal staff
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The AEBCD project was fully supported and endorsed by the director of nursing for the Trust, the critical care service manager and an ITU consultant physician. Buy-in from senior staff and the practice education team is absolutely necessary as it helps promote the project to other staff (Robertson, 2009). A senior sister with 12 years’ experience in the environment, and with an additional role of quality improvement, was assigned the role of internal facilitator as it was felt that this person would have a comprehensive understanding of the potential needs of the patients and staff in this environment. Facilitators who have a limited insight of a unit or ward’s political organisation and history are not likely to be as effective (Routhieaux and Higgins, 1999).
Engaging staff and patients Staff engagement proved to be a key aspect of the project and it was continually promoted via posters, emails, one-toone discussions and the ITU weekly newsletter. In addition, 15 staff, representative of the whole ITU multidisciplinary team (MDT), were interviewed confidentially and as a result were more committed to the project and attended most of the events and their chosen co-design group meetings. Attendance by staff from across the MDT was encouraged with openness and flexibility. Some staff attended on a couple of occasions with others being able to attend only one event or meeting. In total 50 staff participated in the project. The recruitment of patients and carers to the project also required extra attention. A sample, that was as representative as possible of the ITU patient population, was sourced from databases and invitations were sent. Initially there was a poor positive response rate (8%). More patients and carers were recruited by resending invitations with an amended covering letter informing all that attendance at each stage of the process was flexible. This suggested that the project did not need to be seen as too much of a commitment yet interestingly nearly all of those who attended the patient/ carer event stayed throughout the project. Harefield ITU does not at the moment have a follow-up clinic, which could have been a useful resource from which to recruit. In all 19 patients and carers participated in the project.
Planning and organisation The key organisational tasks and activities of the Harefield ITU facilitator, with the associated project timescale, are
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Table 1. Key differences between EBCD and AEBCD
The Harefield experience Background
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ADULT CRITICAL CARE
Table 2. Facilitator’s key organisational tasks and activities Month 1 Stage 1
■■ Recruiting
a minimum of 15 patients and carers, as requested by the researchers, who are representative of the patient population ■■ Preparing and sending invitations and tracking responses. Invitations included all the information required, directions and parking. Further invitations sent due to poor response from the first round ■■ Interviewing 15 staff, as requested by the researchers, who are representative of the whole multidisciplinary team working or involved with the ITU environment then thematically analysing responses ■■ Promoting the project to all staff—posters, emails, one-to-one ■■ Preparing for staff event—presentation, two helpers sourced and briefed, ensuring appropriate tools available, (e.g. flip charts and stationery), organising venue and catering, attendance record
Month 2 Stages 2, 3, 4
■■ Facilitating
Months 3–5 Stage 5
■■ Preparing
Month 6 Stage 6
■■ Preparing
staff event (2 hours) for patient/carer event—contacting participants, introductory presentation, film, two helpers briefed, ensuring appropriate tools available, organising venue and catering, attendance record ■■ Facilitating patient/carer event (5 hours) ■■ Reflecting on staff event and patient/carer event ■■ Continuing to promote the project ■■ Preparing for join event—as per preparation of patient/carer event ■■ Facilitating joint event (2 hours) ■■ Preparing
for co-design group meetings—as per previous events but in addition preparation of reference materials to guide each group’s discussions ■■ Facilitating four co-design group meetings (1 hour each, two meetings per group) ■■ Writing up minutes and action points of meetings and following up action points ■■ Continuing to promote the project for final ‘celebration’ event—contacting participants, promoting to all staff, presentation, organising venue, catering and gifts ■■ Facilitating ‘celebration’ event (2 hours)
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outlined in Table 2. The first 2 months were demanding, with little time for any clinical work, and required good time management skills. During this period the facilitator was learning about the process as well as undertaking the necessary organisational tasks and activities, while also following the timeline of the research study. Future facilitators could overcome this by undertaking some earlier preplanning and preparation. Thorough preparation and planning for each event and co-design group meeting was essential. The programme for the main events was followed as per the suggestions found in the King’s Fund Toolkit. Additional help was also sourced for the first three events in order to ensure every participant’s voice and opinion could be heard as well as the smooth facilitation of any group discussions and decision making processes. The first meeting of the co-design groups commenced with a reflection upon what had been discussed on the subject area in the previous events and staff interviews along with any previously suggested action points. These reflections were supported by written evidence compiled from the aforementioned sources. The group members, having a basis upon which to start, were then able to take the facilitated discussion forward in subsequent meetings until key action points were formed and agreed.
Facilitation of events and co-design group meetings Effective facilitation of the main events and co-design meetings was essential in order to obtain the best outcomes for all participants and for the project as a whole. The overall role of the facilitator is that of catalyst or enabler; creating a positive
British Journal of Nursing, 2014, Vol 23, No 3
working environment in order to enable the participants to come together and achieve the goals of the project (Rees, 2005). While leaders visualise a process and managers plan for it, facilitators help others to understand the process and work well together (Asselin, 2001). Routhieaux and Higgins (1999) additionally assert that those facilitators who are committed and who create a ‘sincere’ and ‘collaborative environment’ are the most effective and valued as this encourages participants to feel safe and able to express themselves openly and freely. The Harefield project facilitator endeavoured to ensure that at each event and meeting the environment and atmosphere was welcoming and relaxed. Participants were encouraged to work together with mutual respect and in equal partnership. Attention was also paid to the physical environment to ensure it was clean and comfortable, with chairs appropriately arranged so participants could see each other easily. Employing key verbal and non-verbal skills of facilitation, was essential (Routhieaux and Higgins, 1999; Asselin, 2001; Rees, 2005; Kitzinger, 2013) (Table 3).
Outcomes At the joint event patients, carers and staff agreed on four key priorities: ■■ Enhancing basic care ■■ Reducing noise and sleep deprivation ■■ Improving communication ■■ Improving patient–doctor communications on ward rounds. These priorities formed the basis of each co-design group and 29 action points were generated. Examples of the action points include encouraging family involvement with simple patient-care activities, creating posters to encourage quiet and
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success of the project has led to it being rolled out to other departments within the trust.
Verbal skills
Non verbal skills ■■ Active
listening ■■ Being fully attentive ■■ Probing ■■ Understanding when to be silent ■■ Paraphrasing ■■ Using appropriate tone and inflection ■■ Redirecting questions and comments of voice ■■ Encouraging exploration and debate ■■ Maintaining appropriate eye contact ■■ Challenging ■■ Supporting the group and flow of ■■ Facial expression matching message to be conveyed, e.g. smiling discussion ■■ Including (particularly quieter group ■■ Open and relaxed body language ■■ Aware of distracting habits, e.g. members) fiddling with items, scratching nose ■■ Focusing ■■ Clarifying ■■ Enthusiasm, being energetic, positive ■■ Summarising ■■ Questioning
reduce noise, emailing the weekly newsletter to all MDT staff and ensuring doctors wore identity badges with their names easily visible. The action points, or quality improvements, were implemented by staff and the facilitator. One patient also volunteered to source new toothbrushes. One very successful implementation was changing the timing of patients’ washes. Traditionally patients were washed at around 5pm and 6am. The afternoon wash always interrupted the time patients spent with their loved ones and the morning wash always ensured they were woken very early. Instead patients are now washed once a day in the evening, and at other times as necessary, and this helps promote rest and sleep. To date most of the quality improvements have been implemented but some, e.g. reducing noise, need to be further embedded into the culture of the unit.
Patient, carer and staff perceptions of the project Undertaking a quality improvement process such as AEBCD was a new experience for all staff within the ITU, and indeed the Trust, and because of this a natural feeling of initial apprehension was felt. Some patients, carers or staff may have harboured preconceived ideas that meeting together could result in upset or conflict but this was not the case. All participants really listened to each other, as if for the first time, and got to know and understand each other as individuals as well as professionals while developing new patient, carer and staff relationships and ways of working together. Staff were given the opportunity to reconnect with their core values of caring and compassion. All participants who completed feedback forms or gave feedback verbally felt as though the project was a very positive experience (Table 4). The Table 4. Patient, carer and staff feedback Patient and carer feedback
Staff feedback
‘How grateful I am, and we are, for your invitation to this group – that everything we came up with you have responded to’
‘In twenty years of nursing I have never interacted with patients in this way before’
‘It’s great to see changes happening – it’s not just lip service’
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‘It’s really good to be able to see the patients’ perspective’
Conclusion and recommendations The importance of engaging with patients, and their relatives, and seeking their opinion and feedback has been widely publicised in the literature. It is usually undertaken via comments cards and questionnaires yet the AEBCD process and this project took the next step forward. It truly engaged with patients and their carers. ITU staff from the whole MDT also had the opportunity to express their opinions, and staff, patients and carers alike were provided with a forum in which they could work together to generate service improvements for all. Following the facilitators experience it is recommended that all critical care units, wards and departments engage proactively with their patient population, their carers and their staff by undertaking their own version of the AEBCD process. In this way they can gain a real understanding of the experiences of all those who give and receive the service and take steps to enhance the future quality and experience of BJN that service for all. Acknowledgements: The author wishes to thank all the patients, carers and staff who participated in the project; Dr Louise Locock, Professor Glenn Robert, the researchers and fellow facilitators; Dr Caroline Shuldham, Director of Nursing and Clinical Governance; Peter Doyle, Critical Care Service Manager; Dr Sharon Fleming, Head of Research in Nursing and Melanie Foody, Patient Experience & PPI Manager, all at Royal Brompton & Harefield NHS Foundation Trust, for their support. Funding Acknowledgement: This project is funded by the NIHR Health Services and Delivery Research Programme (project number 10/1009/14). The views and opinions expressed are those of the author and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health Asselin M (2001) How a work group facilitator can help units reach goals. Dimens Crit Care Nurs 20(4): 34-8 Bate P, Robert G (2006) Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Qual Saf Health Care 15(5): 307-10 Bate P, Robert G (2007) Bringing User Experience to Healthcare Improvement: the Concepts, Methods and Practices of Experience-Based Design. Radcliffe Publishing, Oxford Darzi A (2008) High Quality Care for All: NHS Next Stage Review Final Report. DH, London. Department of Health (1999) Patient and Public Involvement in the New NHS. DH, London Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. DH, London Department of Health (2009) Putting People at the Heart of Care: The Vision for Public and Patient Experience and Engagement. http://tinyurl.com/ppvsfoo (accessed 22 January 2014) Department of Health (2010) Equity and Excellence: Liberating the NHS. http:// tinyurl.com/mk4m6hd (accessed 22 January 2014) Department of Health (2013) The NHS Constitution:The NHS Belongs to us All. http://tinyurl.com/c9qmsac (accessed 22 January 2014) Doyle C, Lennox L, Bell D (2013) A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 3(1): doi: 10.1136/bmjopen-2012-001570. Dr Foster Intelligence (2010) The Intelligent Board 2010: Patient Experience. Dr Foster Intelligence. London Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://www.midstaffspublicinquiry.com/report (accessed 22 January 2014) Farr M for The Kings Fund (2011) The Patient-Centred Care Project Evaluation
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Table 3. Verbal and non verbal facilitation skills
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ADULT CRITICAL CARE Report. http://tinyurl.com/obrj2be (accessed 22 January 2014) Gasper A (2010) Does patient experience correlate to the experiences of NHS staff? Br J Nurs 19(6): 386-7 Goodrich J, Cornwell C for The King’s Fund (2008) Seeing the Person in the Patient: the Point of Care Review Paper. http://tinyurl.com/qgy4t5r (accessed 22 January 2014) Kitzinger J (2013) Using focus groups to understand experiences of health and illness. In: Ziebland S, Coulter A, Calabrese J, Locock L (eds) Understanding and Using Health Experiences. Improving Patient Care. Oxford University Press. Oxford: Chapter 6 Locock L, Robert G, Boaz A, Vougioukalou S, Shuldham C, Fielden J, Gager M, Tollyfield R, Piercey J (in press) Testing accelerated experience-based co-design: a qualitative study of using a national archive of patient experience narrative interviews to promote rapid patient-centered service improvement. Health Services and Delivery Research. National Institute for Health and Care Excellence (2012) Patient Experience in Adult NHS Services. NICE clinical guideline 138. www.nice.org.uk/ guidance/CG138 (accessed 22 January 2014) NHS Confederation (2010) Feeling better? Improving Patient Experience in Hospital. http://tinyurl.com/otpweoo (accessed 22 January 2014) Maben J, Peccei R, Adams M et al (2012) Exploring the Relationship Between Patients’ Experiences of Care and the Influence of Staff Motivation, Affect and Wellbeing. Final Report. National Institute for Health Research Service Delivery and Organisation Programme, Southampton Piper D, Iedema R, Gray J, Verma R, Holmes L, Manning N (2012) Utilizing experience-based co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: an evaluation study. Health Serv Manage Res 25: 162–72 Raleigh VS, Hussey D, Seccombe I, Qi R (2009) Do associations between staff and inpatient feedback have the potential for improving patient experience?
KEY POINTS n Understanding
patients, carers and staff experiences of a service is essential in order to make quality service improvements
n Accelerated
experience-based co-design is a process that enables service users and providers to come together, develop new ways of working together and redesign the service to ensure it better meets the needs of all
n Effective
facilitation of the process is necessary in order to obtain the best outcomes
An analysis of surveys in NHS acute trusts in England. Qual Saf Health Care 18(5): 347-54 Rees F (2005) The Facilitator Excellence Handbook. 2nd edn. Pfeiffer, San Francisco Robert G, Cornwall J, Brearley S et al (2011) What Matters to Patients: Developing the Evidence Base for Measuring and Improving the Patient Experience. http:// tinyurl.com/c8f4hsl (accessed 22 January 2014) Robertson K (2009) Becoming a facilitator: tips for the uninitiated. Can Nurse 105(8): 6-7 Routhieaux RL, Higgins SE (1999) Best-practice guidelines for utilizing facilitators. Health Care Superv 17(3) 1-10 Tsianakas V, Robert G, Maben J et al (2012) Implementing patient-centred cancer care: using experience-based co-design to improve patient experience in breast and lung cancer services. Support Care Cancer 20(11): 2639-47
Critiquing Nursing Research 2nd edition About the book
The fundamentals of the book, however, remain the same. It focuses specifically on critiquing nursing research and the increasing requirement for nurses to become conversant with research and understand its link with the use of evidence to underpin practice.
This second edition retains all the successful Having read this book, nurses should be more familiar with the approaches and techniques involved in critiquing nursing research and be able to utilise some of these skills and techniques in their own efforts to critique. Accordingly, they will be better placed to make informed judgements regarding the quality of the research paper and the value of the evidence reported.
features of the first, plus additional material on psychiatric research and critiquing nursing research when writing a dissertation. As nurse education around the world increasingly moves towards an all-graduate discipline, it is vital for nurses to have the ability to critique research in order to benefit practice. This book is the perfect tool for those seeking to gain or develop precisely that skill and is a must-have for all student nurses, teachers and academics.
About the authors
Dr John R. Cutcliffe holds the as ‘David G.students Braithwaite’ Professor ofhave Very suitable toChairundertake Nursing Endowed at the University of Texas (Tyler); he is also an Adjunct Professor of Psychiatric Nursing at Stenberg College International School of Nursing, Vancouver, Canada and a Visiting Professor at the University of Ulster, United Kingdom. He is an Associate Editor for the Journal of Psychiatric and Mental Health Nursing and an Assistant Editor for the International Journal of Nursing Studies. John’s clinical background is in psychiatric and general nursing, having worked as a clinician and then as an educator in the United Kingdom. He is an international scholar having worked in universities in four different countries: England, Northern Ireland, Canada and the United States. Martin Ward is an Independent Mental Health Nursing Consultant; he is also Co-ordinator of Mental Health Nursing Studies at the University of Malta and Chair of the Expert Panel of Horatio - European Psychiatric Nurses, based in the Netherlands. From 1995 to 2000 he held the post of Director of Mental Health for the Royal College of Nursing. Martin has been a Trustee of the English Health Advisory Service (HAS) and a member of the HAS Inspectorate and has also been involved with work with the World Health Organisation. In 1997, both authors were instrumental in designing and launching the NPNR National Journal Club.
Critiquing Nursing Research
John Cutcliffe and Martin Ward
This second edition of Critiquing Nursing Research retains the features which made the original book a best-seller while incorporating new material in order to expand its applicability. In addition to reviewing and updating the material of the original text, the authors have added two further chapters: the first focuses on how to critique research as part of the work of preparing a dissertation; and the second on mental health research agendas throughout Europe.
Critiquing Nursing Research 2nd edition
a dissertation where they critique three pieces of nursing research.
ISBN-13: 978-1-85642-316-8; 234 x 156 mm; paperback; 244 pages; publication November 2006; £25.99
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John Cutcliffe and Martin Ward
ISBN 978-1-85642-316-8
John Cutcliffe and Martin Ward
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Abstract
This article describes an accelerated experience-based co-design (AEBCD) quality improvement project that was undertaken in an adult critical care setting and the facilitation of that process. In doing so the aim is to encourage other clinical settings to engage with their patients, carers and staff alike and undertake their own quality improvement project. Patient, carer and staff experience and its place in the quality sphere is outlined and the importance of capturing patient, carer and staff feedback established. Experience-based co-design (EBCD) is described along with the recently tested accelerated version of the process. An overview of the project and outline of the organisational tasks and activities undertaken by the facilitator are given. The facilitation of the process and key outcomes are discussed and reflected on. Recommendations for future undertakings of the accelerated process are given and conclusions drawn. Key words: Facilitation ■ Patient experience ■ Staff experience ■ Experience-based co-design ■ Quality improvement ■ Critical care
C
aring for patients is at the very heart of the NHS. Providing excellent standards of care, of the highest quality to all, is what the NHS continually aspires to achieve, at all times (Department of Health (DH), 2013). It stands to reason that the very people who encounter this service provision and those who work within it should be regularly consulted as to what their experience of the service is, in order that continual improvements can be made.
Aim The aim of this article is to recount the experience of the facilitation of a quality improvement project undertaken in a large specialist cardiothoracic intensive therapy unit (ITU) in order that other critical care units, wards, outpatient departments and many other healthcare settings may be encouraged to undertake their own similar patient, carer and staff experience project.
Ruth Tollyfield is Senior Sister, Intensive Therapy Unit, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London Accepted for publication: January 2014
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Over the last 13 years, since the publication of Patient and Public Involvement in the New NHS (DH, 1999), and in addition The NHS Plan (DH, 2000), there has been an increased drive towards engaging patients, carers and the public in their care provision and treatment choices, as well as the development of an understanding of their actual experiences (DH, 2009). High Quality Care for All: The NHS Next Stage Review (Darzi, 2008) clearly outlines patient experience as being one of three important measures of quality; the other two being safety and clinical effectiveness. The report indicates that improving the experience of those requring care is central to enhancing quality and this has led to the development of supporting guidelines from the National Institute for Health and Care Excellence (NICE) (2012). Hospital board members have been provided with ‘intelligence’ regarding the need to understand their patients’ experience and in the future patient experience will become an actual measure of quality on which a trust’s performance will be judged (Dr Foster Intelligence, 2010; DH, 2010). There is evidence to suggest that high levels of patient satisfaction with their experience are linked with enhanced health outcomes and also that patient experience is positively associated with clinical effectiveness and patient safety (NHS Confederation, 2010; Doyle et al, 2013). By contrast, raised mortality rates and evidence of poor standards of care delivery were discovered at Mid Staffordshire NHS Foundation Trust with the subsequent Francis Report (Francis, 2013) stating that management at the Trust did not have a culture of listening to patients and asking for feedback. Traditionally patient feedback has been sourced via complaints, surveys, comment cards and interviews, yet these tools tend to simply ask how people rate their experience rather than fully capturing the experience and gathering ideas for how it could be improved. More recently websites, such as Patient Opinion (www.patientopinion.org.uk), have been developed and this is a platform that is being increasingly used by patients to express their views, give an account of and rate their experiences. The evidence base on what patient experience is, what shapes it and how it can be enhanced is limited compared to other areas of development such as patient safety. However, this area is being actively explored and the evidence of what actually matters to patients is developing rapidly. Patient experience is gaining more of an equal footing in importance alongside patient safety and clinical effectiveness (Goodrich and Cornwell, 2008; Robert et al, 2011). The experiences and wellbeing of staff and the subsequent impact on the quality of care they provide, and thus patient
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Background
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ADULT CRITICAL CARE experience, is an another area of research that is limited but growing. Initial research that has been undertaken, including Raleigh et al’s (2009) and Maben et al’s (2012) multiple linear regression and mixed methods studies, strongly indicates that there is indeed a positive link between staff experience, patient experience and quality. It is believed that patient care will be enhanced if investment is made in the the welfare of front-line staff (Gasper, 2010). The government has stated its commitment to providing this through encouraging positive working environments that are open and supportive as well as engagement with decisions that affect service provision (DH, 2013).
Experienced-based co-design (EBCD) New ways that enable patients and staff to listen to each other and work together are emerging. Design-led professions such as architecture and computer graphics have long held the common aim that a product or process should be as userfriendly as possible. Bate and Robert (2006) suggest that this aim should be applied within the healthcare setting because ultimately—although a challenge—listening to patients’ experiences and designing services with them ensures that services are truly patient-centred. EBCD, an approach developed by Bate and Robert (2007), has arisen from this concept. It is a form of participatory action research where patients, carers and staff are drawn together to narrate and share their experiences of how a current service truly feels to all those who participate in it. They then work together, as equal partners, to redesign (co-design) those services in order to enhance the future experience for all. A number of important EBCD studies have been undertaken and evaluated, including work in breast and lung cancer patients services in the UK (Farr, 2011; Tsianakas et al, 2012) and emergency departments in Australia (Piper et
Stage 1 Staff interviews
al, 2012). These have demonstrated the effectiveness of the EBCD process in generating quality improvements.
The EBCD process EBCD is typically a 6-stage process (Figure 1). In previous studies the process occurred over a 12-month period and was facilitated by experienced qualitative researchers who analysed the data. Stage 1 is the exploratory phase where patients, carers and staff are interviewed and observations of the environment are made. In the original studies patients were also filmed, their responses analysed to create themes, known as ‘touch points’, and then edited to create a single 35-minute film.The staff interviews are not filmed but again their responses are analysed thematically. In previous studies the discovery phase took about 6 months. In stage 2 the staff meet and are offered the opportunity to review and discuss the themes that emerged from their interviews. The staff then choose four or five priorities they would like to take forward to their next stage. At a similar time, in order to retain the momentum of the project, stage 3 occurs, when the patients and carers meet for the first time. They are shown the film, which is used as a ‘trigger’ to prompt recall of experiences and generate discussion. The discussion is facilitated and intial issues noted. An exercise to explore and identify key moments, or ‘touch points’, along their journey is then undertaken. This is known as emotional mapping. Once the themes have been identified the patients choose their priorities to take forward to their next stage. Stage 4 is the coming together of patients, carers and staff for the first time at a joint event. At the event the staff are shown the film. The patients, carers and staff are then invited to join together in small groups to discuss any issues arising
Stage 1 Observation
Stage 1 Patient interviews
Stage 3 Patient event
Stage 2 Staff event
Stage 4 Joint staff/patient event
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Stage 5 Co-design working group
Stage 5 Co-design working group
Stage 5 Co-design working group
Stage 5 Co-design working group
Stage 6 Review and celebration
Figure 1. The experience-based co-design (EBCD) process (adapted from Bate and Robert, 2007)
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from the film and the priority themes that emerged from the previous events. The patients, carers and staff then identify four or five joint priorities they would like to work on together to improve services. Stage 5 sees small facilitated groups of patients, carers and staff (maximum 10 per group) working together on an individual theme that emerged from the previous event. Co-design group meetings occur typically on two or three occasions. Action points are agreed and taken forward by volunteers from the group and so quality improvements are made that enhance the experience for all. Stage 6 occurs at the end of the process. The co-design groups reconvene to review their work, celebrate their successes and plan for the future as necessary. Full details of the EBCD process and toolkit along with useful materials and other resources, including explanatory film recordings and ‘hints and tips’ from previous EBCD facilitators, can be found on the excellent King’s Fund website at www.kingsfund.org.uk/projects/point-care/ebcd.
films are reusable in any context and will be made available online, through the Kings Fund EBCD toolkit site and www. healthtalkonline.org, for others to use.
Accelerated EBCD
Training and support
In a variation of EBCD Locock et al (in press) have explored the potential of creating and testing a 35-minute film using patient and carer narrative from a national archive of interviews held by the Health Experiences Research Group at the University of Oxford, and disseminated on www. healthtalkonline.org. By reducing the need to interview local patients and carers, and analyse and process the film footage, they reduced the overall length of the EBCD process by 6 months. The researchers also chose to engage local facilitators to undertake the process, now termed ‘accelerated EBCD’ or ‘AEBCD’ (Table 1). The research project by Locock et al (in press) was undertaken in intensive care units and then lung cancer services in two hospital trusts, The Royal Berkshire NHS Foundation Trust and Royal Brompton and Harefield NHS Foundation Trust. Preliminary results indicate that the film, made from the national archive, was readily accepted by all participants and served its purpose as a ‘trigger’ and catalyst for discussion. Although some patients felt it was more negative than their own experience, the fact that it was not local patients in the film seemed to make staff feel less defensive or threatened by it. A total of 48 quality improvement activities occurred, across both trusts, ranging from small-scale changes to process redesign between organisations. Engaging local facilitators, not external researchers, and not interviewing and filming the patients and carers, as well as undertaking the process in 6 rather than 12 months also resulted in significant financial cost savings (Locock et al, in press). The trigger
At the beginning of the process the two ITU facilitators, one from each trust, spent half a day training with the researchers. They were then left to run the process alone, although they had email and telephone support as necessary from the researchers and met up with them on a few occasions. Both facilitators found the King’s Fund website an extremely useful resource.
EBCD
AEBCD
12-month process
6-month process
Patients and carers interviewed and filmed
Patients and carers not interviewed or filmed
35-minute film created from filmed footage
35-minute film created from archive footage
Facilitated by experienced researchers
Facilitated by internal staff
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The AEBCD project was fully supported and endorsed by the director of nursing for the Trust, the critical care service manager and an ITU consultant physician. Buy-in from senior staff and the practice education team is absolutely necessary as it helps promote the project to other staff (Robertson, 2009). A senior sister with 12 years’ experience in the environment, and with an additional role of quality improvement, was assigned the role of internal facilitator as it was felt that this person would have a comprehensive understanding of the potential needs of the patients and staff in this environment. Facilitators who have a limited insight of a unit or ward’s political organisation and history are not likely to be as effective (Routhieaux and Higgins, 1999).
Engaging staff and patients Staff engagement proved to be a key aspect of the project and it was continually promoted via posters, emails, one-toone discussions and the ITU weekly newsletter. In addition, 15 staff, representative of the whole ITU multidisciplinary team (MDT), were interviewed confidentially and as a result were more committed to the project and attended most of the events and their chosen co-design group meetings. Attendance by staff from across the MDT was encouraged with openness and flexibility. Some staff attended on a couple of occasions with others being able to attend only one event or meeting. In total 50 staff participated in the project. The recruitment of patients and carers to the project also required extra attention. A sample, that was as representative as possible of the ITU patient population, was sourced from databases and invitations were sent. Initially there was a poor positive response rate (8%). More patients and carers were recruited by resending invitations with an amended covering letter informing all that attendance at each stage of the process was flexible. This suggested that the project did not need to be seen as too much of a commitment yet interestingly nearly all of those who attended the patient/ carer event stayed throughout the project. Harefield ITU does not at the moment have a follow-up clinic, which could have been a useful resource from which to recruit. In all 19 patients and carers participated in the project.
Planning and organisation The key organisational tasks and activities of the Harefield ITU facilitator, with the associated project timescale, are
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Table 1. Key differences between EBCD and AEBCD
The Harefield experience Background
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ADULT CRITICAL CARE
Table 2. Facilitator’s key organisational tasks and activities Month 1 Stage 1
■■ Recruiting
a minimum of 15 patients and carers, as requested by the researchers, who are representative of the patient population ■■ Preparing and sending invitations and tracking responses. Invitations included all the information required, directions and parking. Further invitations sent due to poor response from the first round ■■ Interviewing 15 staff, as requested by the researchers, who are representative of the whole multidisciplinary team working or involved with the ITU environment then thematically analysing responses ■■ Promoting the project to all staff—posters, emails, one-to-one ■■ Preparing for staff event—presentation, two helpers sourced and briefed, ensuring appropriate tools available, (e.g. flip charts and stationery), organising venue and catering, attendance record
Month 2 Stages 2, 3, 4
■■ Facilitating
Months 3–5 Stage 5
■■ Preparing
Month 6 Stage 6
■■ Preparing
staff event (2 hours) for patient/carer event—contacting participants, introductory presentation, film, two helpers briefed, ensuring appropriate tools available, organising venue and catering, attendance record ■■ Facilitating patient/carer event (5 hours) ■■ Reflecting on staff event and patient/carer event ■■ Continuing to promote the project ■■ Preparing for join event—as per preparation of patient/carer event ■■ Facilitating joint event (2 hours) ■■ Preparing
for co-design group meetings—as per previous events but in addition preparation of reference materials to guide each group’s discussions ■■ Facilitating four co-design group meetings (1 hour each, two meetings per group) ■■ Writing up minutes and action points of meetings and following up action points ■■ Continuing to promote the project for final ‘celebration’ event—contacting participants, promoting to all staff, presentation, organising venue, catering and gifts ■■ Facilitating ‘celebration’ event (2 hours)
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outlined in Table 2. The first 2 months were demanding, with little time for any clinical work, and required good time management skills. During this period the facilitator was learning about the process as well as undertaking the necessary organisational tasks and activities, while also following the timeline of the research study. Future facilitators could overcome this by undertaking some earlier preplanning and preparation. Thorough preparation and planning for each event and co-design group meeting was essential. The programme for the main events was followed as per the suggestions found in the King’s Fund Toolkit. Additional help was also sourced for the first three events in order to ensure every participant’s voice and opinion could be heard as well as the smooth facilitation of any group discussions and decision making processes. The first meeting of the co-design groups commenced with a reflection upon what had been discussed on the subject area in the previous events and staff interviews along with any previously suggested action points. These reflections were supported by written evidence compiled from the aforementioned sources. The group members, having a basis upon which to start, were then able to take the facilitated discussion forward in subsequent meetings until key action points were formed and agreed.
Facilitation of events and co-design group meetings Effective facilitation of the main events and co-design meetings was essential in order to obtain the best outcomes for all participants and for the project as a whole. The overall role of the facilitator is that of catalyst or enabler; creating a positive
British Journal of Nursing, 2014, Vol 23, No 3
working environment in order to enable the participants to come together and achieve the goals of the project (Rees, 2005). While leaders visualise a process and managers plan for it, facilitators help others to understand the process and work well together (Asselin, 2001). Routhieaux and Higgins (1999) additionally assert that those facilitators who are committed and who create a ‘sincere’ and ‘collaborative environment’ are the most effective and valued as this encourages participants to feel safe and able to express themselves openly and freely. The Harefield project facilitator endeavoured to ensure that at each event and meeting the environment and atmosphere was welcoming and relaxed. Participants were encouraged to work together with mutual respect and in equal partnership. Attention was also paid to the physical environment to ensure it was clean and comfortable, with chairs appropriately arranged so participants could see each other easily. Employing key verbal and non-verbal skills of facilitation, was essential (Routhieaux and Higgins, 1999; Asselin, 2001; Rees, 2005; Kitzinger, 2013) (Table 3).
Outcomes At the joint event patients, carers and staff agreed on four key priorities: ■■ Enhancing basic care ■■ Reducing noise and sleep deprivation ■■ Improving communication ■■ Improving patient–doctor communications on ward rounds. These priorities formed the basis of each co-design group and 29 action points were generated. Examples of the action points include encouraging family involvement with simple patient-care activities, creating posters to encourage quiet and
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success of the project has led to it being rolled out to other departments within the trust.
Verbal skills
Non verbal skills ■■ Active
listening ■■ Being fully attentive ■■ Probing ■■ Understanding when to be silent ■■ Paraphrasing ■■ Using appropriate tone and inflection ■■ Redirecting questions and comments of voice ■■ Encouraging exploration and debate ■■ Maintaining appropriate eye contact ■■ Challenging ■■ Supporting the group and flow of ■■ Facial expression matching message to be conveyed, e.g. smiling discussion ■■ Including (particularly quieter group ■■ Open and relaxed body language ■■ Aware of distracting habits, e.g. members) fiddling with items, scratching nose ■■ Focusing ■■ Clarifying ■■ Enthusiasm, being energetic, positive ■■ Summarising ■■ Questioning
reduce noise, emailing the weekly newsletter to all MDT staff and ensuring doctors wore identity badges with their names easily visible. The action points, or quality improvements, were implemented by staff and the facilitator. One patient also volunteered to source new toothbrushes. One very successful implementation was changing the timing of patients’ washes. Traditionally patients were washed at around 5pm and 6am. The afternoon wash always interrupted the time patients spent with their loved ones and the morning wash always ensured they were woken very early. Instead patients are now washed once a day in the evening, and at other times as necessary, and this helps promote rest and sleep. To date most of the quality improvements have been implemented but some, e.g. reducing noise, need to be further embedded into the culture of the unit.
Patient, carer and staff perceptions of the project Undertaking a quality improvement process such as AEBCD was a new experience for all staff within the ITU, and indeed the Trust, and because of this a natural feeling of initial apprehension was felt. Some patients, carers or staff may have harboured preconceived ideas that meeting together could result in upset or conflict but this was not the case. All participants really listened to each other, as if for the first time, and got to know and understand each other as individuals as well as professionals while developing new patient, carer and staff relationships and ways of working together. Staff were given the opportunity to reconnect with their core values of caring and compassion. All participants who completed feedback forms or gave feedback verbally felt as though the project was a very positive experience (Table 4). The Table 4. Patient, carer and staff feedback Patient and carer feedback
Staff feedback
‘How grateful I am, and we are, for your invitation to this group – that everything we came up with you have responded to’
‘In twenty years of nursing I have never interacted with patients in this way before’
‘It’s great to see changes happening – it’s not just lip service’
140
‘It’s really good to be able to see the patients’ perspective’
Conclusion and recommendations The importance of engaging with patients, and their relatives, and seeking their opinion and feedback has been widely publicised in the literature. It is usually undertaken via comments cards and questionnaires yet the AEBCD process and this project took the next step forward. It truly engaged with patients and their carers. ITU staff from the whole MDT also had the opportunity to express their opinions, and staff, patients and carers alike were provided with a forum in which they could work together to generate service improvements for all. Following the facilitators experience it is recommended that all critical care units, wards and departments engage proactively with their patient population, their carers and their staff by undertaking their own version of the AEBCD process. In this way they can gain a real understanding of the experiences of all those who give and receive the service and take steps to enhance the future quality and experience of BJN that service for all. Acknowledgements: The author wishes to thank all the patients, carers and staff who participated in the project; Dr Louise Locock, Professor Glenn Robert, the researchers and fellow facilitators; Dr Caroline Shuldham, Director of Nursing and Clinical Governance; Peter Doyle, Critical Care Service Manager; Dr Sharon Fleming, Head of Research in Nursing and Melanie Foody, Patient Experience & PPI Manager, all at Royal Brompton & Harefield NHS Foundation Trust, for their support. Funding Acknowledgement: This project is funded by the NIHR Health Services and Delivery Research Programme (project number 10/1009/14). The views and opinions expressed are those of the author and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health Asselin M (2001) How a work group facilitator can help units reach goals. Dimens Crit Care Nurs 20(4): 34-8 Bate P, Robert G (2006) Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Qual Saf Health Care 15(5): 307-10 Bate P, Robert G (2007) Bringing User Experience to Healthcare Improvement: the Concepts, Methods and Practices of Experience-Based Design. Radcliffe Publishing, Oxford Darzi A (2008) High Quality Care for All: NHS Next Stage Review Final Report. DH, London. Department of Health (1999) Patient and Public Involvement in the New NHS. DH, London Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. DH, London Department of Health (2009) Putting People at the Heart of Care: The Vision for Public and Patient Experience and Engagement. http://tinyurl.com/ppvsfoo (accessed 22 January 2014) Department of Health (2010) Equity and Excellence: Liberating the NHS. http:// tinyurl.com/mk4m6hd (accessed 22 January 2014) Department of Health (2013) The NHS Constitution:The NHS Belongs to us All. http://tinyurl.com/c9qmsac (accessed 22 January 2014) Doyle C, Lennox L, Bell D (2013) A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 3(1): doi: 10.1136/bmjopen-2012-001570. Dr Foster Intelligence (2010) The Intelligent Board 2010: Patient Experience. Dr Foster Intelligence. London Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://www.midstaffspublicinquiry.com/report (accessed 22 January 2014) Farr M for The Kings Fund (2011) The Patient-Centred Care Project Evaluation
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Table 3. Verbal and non verbal facilitation skills
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ADULT CRITICAL CARE Report. http://tinyurl.com/obrj2be (accessed 22 January 2014) Gasper A (2010) Does patient experience correlate to the experiences of NHS staff? Br J Nurs 19(6): 386-7 Goodrich J, Cornwell C for The King’s Fund (2008) Seeing the Person in the Patient: the Point of Care Review Paper. http://tinyurl.com/qgy4t5r (accessed 22 January 2014) Kitzinger J (2013) Using focus groups to understand experiences of health and illness. In: Ziebland S, Coulter A, Calabrese J, Locock L (eds) Understanding and Using Health Experiences. Improving Patient Care. Oxford University Press. Oxford: Chapter 6 Locock L, Robert G, Boaz A, Vougioukalou S, Shuldham C, Fielden J, Gager M, Tollyfield R, Piercey J (in press) Testing accelerated experience-based co-design: a qualitative study of using a national archive of patient experience narrative interviews to promote rapid patient-centered service improvement. Health Services and Delivery Research. National Institute for Health and Care Excellence (2012) Patient Experience in Adult NHS Services. NICE clinical guideline 138. www.nice.org.uk/ guidance/CG138 (accessed 22 January 2014) NHS Confederation (2010) Feeling better? Improving Patient Experience in Hospital. http://tinyurl.com/otpweoo (accessed 22 January 2014) Maben J, Peccei R, Adams M et al (2012) Exploring the Relationship Between Patients’ Experiences of Care and the Influence of Staff Motivation, Affect and Wellbeing. Final Report. National Institute for Health Research Service Delivery and Organisation Programme, Southampton Piper D, Iedema R, Gray J, Verma R, Holmes L, Manning N (2012) Utilizing experience-based co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: an evaluation study. Health Serv Manage Res 25: 162–72 Raleigh VS, Hussey D, Seccombe I, Qi R (2009) Do associations between staff and inpatient feedback have the potential for improving patient experience?
KEY POINTS n Understanding
patients, carers and staff experiences of a service is essential in order to make quality service improvements
n Accelerated
experience-based co-design is a process that enables service users and providers to come together, develop new ways of working together and redesign the service to ensure it better meets the needs of all
n Effective
facilitation of the process is necessary in order to obtain the best outcomes
An analysis of surveys in NHS acute trusts in England. Qual Saf Health Care 18(5): 347-54 Rees F (2005) The Facilitator Excellence Handbook. 2nd edn. Pfeiffer, San Francisco Robert G, Cornwall J, Brearley S et al (2011) What Matters to Patients: Developing the Evidence Base for Measuring and Improving the Patient Experience. http:// tinyurl.com/c8f4hsl (accessed 22 January 2014) Robertson K (2009) Becoming a facilitator: tips for the uninitiated. Can Nurse 105(8): 6-7 Routhieaux RL, Higgins SE (1999) Best-practice guidelines for utilizing facilitators. Health Care Superv 17(3) 1-10 Tsianakas V, Robert G, Maben J et al (2012) Implementing patient-centred cancer care: using experience-based co-design to improve patient experience in breast and lung cancer services. Support Care Cancer 20(11): 2639-47
Critiquing Nursing Research 2nd edition About the book
The fundamentals of the book, however, remain the same. It focuses specifically on critiquing nursing research and the increasing requirement for nurses to become conversant with research and understand its link with the use of evidence to underpin practice.
This second edition retains all the successful Having read this book, nurses should be more familiar with the approaches and techniques involved in critiquing nursing research and be able to utilise some of these skills and techniques in their own efforts to critique. Accordingly, they will be better placed to make informed judgements regarding the quality of the research paper and the value of the evidence reported.
features of the first, plus additional material on psychiatric research and critiquing nursing research when writing a dissertation. As nurse education around the world increasingly moves towards an all-graduate discipline, it is vital for nurses to have the ability to critique research in order to benefit practice. This book is the perfect tool for those seeking to gain or develop precisely that skill and is a must-have for all student nurses, teachers and academics.
About the authors
Dr John R. Cutcliffe holds the as ‘David G.students Braithwaite’ Professor ofhave Very suitable toChairundertake Nursing Endowed at the University of Texas (Tyler); he is also an Adjunct Professor of Psychiatric Nursing at Stenberg College International School of Nursing, Vancouver, Canada and a Visiting Professor at the University of Ulster, United Kingdom. He is an Associate Editor for the Journal of Psychiatric and Mental Health Nursing and an Assistant Editor for the International Journal of Nursing Studies. John’s clinical background is in psychiatric and general nursing, having worked as a clinician and then as an educator in the United Kingdom. He is an international scholar having worked in universities in four different countries: England, Northern Ireland, Canada and the United States. Martin Ward is an Independent Mental Health Nursing Consultant; he is also Co-ordinator of Mental Health Nursing Studies at the University of Malta and Chair of the Expert Panel of Horatio - European Psychiatric Nurses, based in the Netherlands. From 1995 to 2000 he held the post of Director of Mental Health for the Royal College of Nursing. Martin has been a Trustee of the English Health Advisory Service (HAS) and a member of the HAS Inspectorate and has also been involved with work with the World Health Organisation. In 1997, both authors were instrumental in designing and launching the NPNR National Journal Club.
Critiquing Nursing Research
John Cutcliffe and Martin Ward
This second edition of Critiquing Nursing Research retains the features which made the original book a best-seller while incorporating new material in order to expand its applicability. In addition to reviewing and updating the material of the original text, the authors have added two further chapters: the first focuses on how to critique research as part of the work of preparing a dissertation; and the second on mental health research agendas throughout Europe.
Critiquing Nursing Research 2nd edition
a dissertation where they critique three pieces of nursing research.
ISBN-13: 978-1-85642-316-8; 234 x 156 mm; paperback; 244 pages; publication November 2006; £25.99
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www.quaybooks.co.uk or call our Hotline www.quaybooks.co.uk
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Foreword by Professor Kevin Gournay
John Cutcliffe and Martin Ward
ISBN 978-1-85642-316-8
John Cutcliffe and Martin Ward
The new and updated edition of the best-selling book
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