Nursing and Midwifery - Doctoral Theses

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Implementation of health and social care standards in health and social care services: development and feasibility testing of an implementation support tool
(University College Cork, 2023) Kelly Daly, Yvonne; Hegarty, Josephine; O'Rourke, Niamh; Keyes, Laura M.; Health Information and Quality Authority (HIQA); Health Research Board
Introduction Health and social care standards are complex quality improvement interventions. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve multiple stakeholders from multiple levels in the health system and apply to diverse services. There is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. There is a need to apply evidence-based, rigorous and transparent methods when selecting strategies to support the implementation of standards. Researchers have consistently highlighted a research-to-practice gap in this area. This PhD research aimed to develop and test an evidence- and theory-informed intervention to guide the identification of appropriate implementation strategies and the selection of tailored support tools and actions for use when implementing a set of standards. Methods The Medical Research Council (MRC) framework for developing and evaluating complex interventions guided a multi-methods sequential approach. A) Standards were conceptualised by narratively synthesising 12 definitions of standards used by standard-setting bodies internationally. B) The evidence-base was gathered by conducting: a systematic review (n=35 included studies) to identify and describe enablers and barriers to implementing (inter)nationally endorsed standards; and C) a qualitative exploration (focus groups (n=6), individual interviews (n=8)) of individuals’ (n=38) experiences, enablers and barriers to implementing nationally endorsed standards in Ireland. D) These enablers and barriers were used alongside implementation science theory, tools and methodologies to develop a digital intervention. Programme theory guided the development process. The Consolidated Framework for Implementation Research (CFIR), CFIR-ERIC (Expert Recommendations for Implementing Change) matching tool and the Behaviour Change Wheel (BCW) were used to develop a prototype of the content and interactive logic within a digital intervention. E) Co-design workshops (n=3) were held to refine the digital intervention with intended users (n=7). F) A feasibility study was undertaken with end-users (n=14) using a survey that measured acceptability, appropriateness and feasibility. Results A) There was variation in how standard-setting bodies define standards. The commonalities among definitions included the terms ‘quality’, ‘statements’ and ‘performance.’ B) Thematic statements describing enablers (n=22) and barriers (n=24) were created. The most frequently reported enablers related to available support tools, education and shared learning. The most frequently reported barriers related to a lack of knowledge of standards, staffing issues and insufficient funds. C) Six themes were generated from qualitative interviews. Key enablers identified related to teamwork, support tools, leadership and inspections. Key barriers related to workforce issues, a lack of awareness of standards and fear of inspection outcomes. D) Twenty-three enablers and barriers were prioritised using set criteria. E) Iterative feedback led to refinements of the intervention, creating the prototype for the feasibility study. The intervention was entitled SITAS (Selecting Implementation Tools and Actions for Standards). F) SITAS was perceived as acceptable and feasible in preliminary feasibility testing. Conclusion A feasible intervention was developed, enhanced by user involvement. SITAS is a practical digitally enabled intervention that can facilitate bridging the research-to-practice gap. SITAS aims to guide the process of selecting and tailoring implementation strategies to specific contexts, using core concepts of implementation science. Further research is required to undertake formal piloting on SITAS using a larger sample size before spread and scale up.
To what extent are Child and Adolescent Mental Health Services engaged in Trauma Informed Practice: an Irish study
(University College Cork, 2023) Heffernan, Sinead; Leahy-Warren, Patricia; Drennan, Jonathan; Dalton O'Connor, Caroline
Background: Children and adolescents attending the mental health services are likely to have experienced childhood or intergenerational trauma. International and national mental health policy recommends that services integrate TIP into mental healthcare provision. A lack of research studies exploring the integration of TIP, with this cohort were identified. Method: A descriptive correlational study design utilised a convenience approach to gain a sample from the target population: all CAMHS staff nationally. Data were collected using a psychometrically validated organisational assessment tool. Mostly descriptive, inferential, and some thematic analyses were deployed. Results: Respondents reported low levels of TIP, overall. The majority of respondents were female, community based, clinical staff. Levels of trauma informed therapeutic engagement with service users, and organisational supports for TIP were ascertained from a staff perspective. Results indicated a varied results with therapeutic engagement revealing higher scores than the organisational related areas in CAMHS. Areas that pertained to person centred approaches to consistent care delivery, safety and care planning, and de-escalation were to some extent developed. Gaps in care provision related to language, culturally sensitive care provision, and coproduction including eliciting feedback routinely, communication, flexibility, and staff supports to mitigate vicarious trauma were identified. Further gaps pertained to educating both service users and staff about trauma and its impact on mental health, as well as TIP delivery and evaluation. Overall organisational rather than individual staff factors represented require significant development to achieve TIP. The results of inferential analysis identified relationships between staffs’ levels of satisfaction in current role; which was found to be the strongest predictor of TIP (R2=14.7%, p<0.001), followed by location of role (R2=8.2%, p<0.001) and length of service (R2=3.3%, p<0.040). No relationships were found re: role in CAMH service (p=0.495) and attending TIP training (p=0.840). Thematic analysis found that training was not systematically provided or attended. Gaps in relation to TIP training content, frequency and duration were identified. Discussion: TIP has been described as a humanistic approach to care delivery that recommends approaches that can optimise therapeutic relationships and person-centred care characterised by flexibility, peer supports and collaboration and require further development. Organisational supports for training provision for all CAMHS staff, that is sustainable, evaluated, and accessible, is required. Staff supports that mitigate vicarious trauma for staff also requires further development. An organisational commitment underpinned by resources, strategies to deliver change, guided trauma-informed policy to support TIP, is recommended. Conclusion: CAMHS acute and even more so, community-based services are not currently engaged in TIP, as recommended by mental health policy. The multifaceted nature of TIP requires an organisational approach to guide implementation. The results from this study have identified gaps in relation to organisational support for TIP which can add to the growing knowledge base to support the integration TIP into CAMH Services.
Primary care reform: international evidence and primary care doctors’ perspectives within the context of health system reform in Saudi Arabia
(University College Cork, 2023) Alyousef, Mohammed; Naughton , Corina; Bradley, Colin; Savage, Eileen
Background The Kingdom of Saudi Arabia (KSA) has launched and ambitious reform programme Vision 2030 including health system reform (Government of Saudi Arabia, 2016a). The health system challenges include the increasing burden of chronic diseases, inadequate access to healthcare, and health service fragmentation. The health strategy articulates a new model of care (MOC), targeting financial reform, provider reform, eHealth development, and public private partnerships. A strategic priority for the KSA health system is to strengthen primary healthcare (PHC) and to position primary care (PC) as the first point of access to healthcare. To date there is limited evaluation of the health reforms with a particular evidence gap on reform implementation in PC. The research aims: 1) to examine the international evidence on the implementation of PHC reform for chronic conditions in countries with high or very high human development index (Review 1); 2) to examine the qualitative evidence on PC doctors’ perspectives on PC reform within the context of health system reforms (Review 2); 3) to explore PC doctors’ perspectives on PC reform within the context of the health system reform in the KSA using a qualitative study design. Methods Review 1 was guided by the PRISMA statement including academic articles and grey literature from 1 March 2008 to 1 September 2020. Descriptive analysis and narrative synthesis were applied. Review 2 used a thematic synthesis of qualitative studies guided by Thomas and Harden (2008) three stage framework to identify descriptive and analytical themes. The qualitative study used interpretive description (ID) methodology. Semi-structured interviews were conducted with a purposive sample of 14 PC doctors (general practitioners (GPs) & family physicians (FPs)), recruited from primary health care centers (PHCC) in the Makkah region of KSA. Constant comparative analysis and Thorne (2016) six-steps was used to analyze the data. Results Review 1 included eight articles from four countries. It revealed a shift in chronic disease management from hospital to PC services involving new organizational and funding models (PC networks, commissioning of services, and shared governance structures). The need for leadership and engagement from PC doctors to support PC reform was identified. Review 2 included sixteen qualitative studies from eight countries. Three themes were identified: (1) Health system reform: lacking integrated and co-ordinated services; (2) Funding primary care: competition versus collaboration; and (3) GP/FP engagement in shaping primary care reform. The qualitative study on PC doctors’ perspectives on KSA PC reform identified five major themes: Changes in daily practice; Changes in the infrastructure of PC; Changes in Relationships, Gradation of awareness to understanding of the PC reform; and Barriers and enablers to engaging in PC reform. Participants observed changes in their daily practice with reference to chronic disease prevention and early intervention with a shift from hospital to PC management model. This corresponded to changes in infrastructure especially diagnostic services, access to medication, and information systems. Changes in relationships with patients were perceived as more patient/person-centred wile relationships between PHCCs were described as more collaborative which was attributed to the formation of health clusters as a collective of PHCC and acute hospitals serving a defined population. In contrast, participants’ viewed relationships with the hospital sector as largely hierarchical with no real collaboration. Participants’ understandings and engagement with the PC reforms as stakeholders varied. While there was some understanding of the MOC especially among FP participants, their understanding of financial reform and provider payments was limited. The GP/FP participants believed they had an important contribution to make to the reform agenda as frontline providers. Barriers and enablers to engagement related to trusted sources of information, education and leadership opportunities, and communication with policy decision making. Conclusion This thesis provides important insights from the literature reviews and the qualitative study into the crucial role that PC doctors as frontline health service providers can play in PC reform. PC doctors’ experiences need to be considered by policy makers to ensure successful implementation of PC reform that meets individual and population needs, and that are adequately resourced financially. There is a need for a deliberate process to engage with PC doctors to help them appreciate how observed changes link to policy and to support them as change agents rather than passive actors in the reorientation of the KSA PHC and wider health system.
Advanced practitioners’ experience of interprofessional collaboration when implementing evidence-based practice into routine care: an Interpretative phenomenological analysis
(University College Cork, 2021-09-30) Clarke, Vanessa; Lehane, Elaine A.; Mulcahy, Helen; Cotter, Patrick
Background: Implementation of Evidence-based Practice (EBP) is essential in ensuring high quality healthcare at minimum cost. Nurse practitioners as clinical leaders are responsible for leading and collaborating with interprofessional teams to implement EBP across patient groups and embed practice change into routine care. Interprofessional collaboration has been identified as an essential element for the successful implementation of EBP into routine care. Limited evidence from previous literature findings indicated that collaborative practice issues impeded nurse practitioners in implementing EBP into routine care. However, findings were not adequate to inform specific practice and policy recommendations nationally and internationally. Further research was therefore required into this aspect of the nurse practitioner role. Aim: To understand Registered Advanced Nurse and Midwife practitioners’ experience of interprofessional collaboration in implementing EBP into routine care in the Republic of Ireland. Methods: Qualitative Interpretative Phenomenological Analysis (IPA) was used for this study. A purposeful sample of ten Registered Advanced Nurse and Advanced Midwife Practitioners from a range of practice settings participated in semi-structured interviews which were audio recorded and then transcribed verbatim. NVivo version 12 was used for data management purposes. Data were analysed using IPA. Findings: Six superordinate themes emerged from the interpretative analysis. Advanced practitioners perceived that at times “Understanding of Advanced Practice” was limited. Advanced practitioners described being “Treated as an equal and as a nurse”. Being treated as a “nurse” was associated with being treated as subordinate to other professionals. The extent to which advanced practitioners enjoyed “Nursing Management Support” varied. Some advanced practitioners described having opportunities to participate in their organisation’s executive and decision-making forums which afforded them the opportunity to have “A Voice to Implement Anything New.”. However, others were unable to avail of these opportunities. Levels of participant “Confidence” and “Emotional Intelligence” impacted relationships with members of the interprofessional team. The issues identified in the six superordinate themes influenced the extent to which advanced practitioners could collaborate effectively to implement EBP into routine care. Conclusion and Implications: There is scope to improve advanced practitioners’ ability to collaborate with the interprofessional team in implementing EBP into routine care. Ameliorative measures should focus on increasing understanding of the advanced practitioner role; facilitating advanced practitioner access to organisational decision-making forums; and developing skills and attributes necessary for interprofessional collaboration and the implementation of EBP into routine care.
The development and piloting of a discrete choice experiment to measure the support preferences of people with chronic respiratory diseases in Ireland
(University College Cork, 2020-10) O'Connell, Selena; Savage, Eileen; Mc Carthy, Vera; Murphy, Des; Health Service Executive (HSE)
Introduction: Healthcare systems are increasingly developing self-management support (SMS) frameworks to reduce the burden of chronic disease. This involves a whole-system approach which enables the person with chronic disease to actively participate in managing their wellbeing. A framework to support the implementation of SMS was launched in Ireland, with asthma and COPD among the chronic diseases targeted. As this framework is being implemented in Ireland, there is a need to ensure that patient preferences are considered. Aim: to examine the SMS preferences of people with asthma and/or COPD in Ireland through the development and piloting of a discrete choice experiment (DCE). Methods: Early work in the thesis identified and explored eight frameworks for SMS of chronic disease developed by national/state level health systems in different countries. Subsequently, a qualitative study was conducted with the implementation leads of three frameworks. This research indicated that greater input of people with chronic disease was important to advance SMS. Steps were taken to develop a DCE to measure the relative importance of support features from the perspectives of people with asthma/COPD in accordance with good practice. Firstly, a systematic review and thematic synthesis of qualitative studies was conducted in order to inform the attributes of the DCE. Secondly, a qualitative descriptive study using interviews and focus groups was conducted with people with asthma/COPD in Ireland (n = 20), 10 of whom had asthma. The qualitative literature along with clinical and methodological considerations informed the design of the DCE. The DCE was refined through cognitive interviews (n = 16). A pilot study was conducted (n = 38) and a multinomial logit model was used to examine the strength and direction of preferences. Findings: Fifteen articles were included in the thematic synthesis and three themes were identified: types of support, the support relationship and accessibility. Similar themes were identified in the qualitative descriptive study. In terms of accessibility, participants highlighted the need for both scheduled and flexible unscheduled access to support from providers with specialist knowledge. They valued comprehensive and person-centred consultations and a person-provider relationship which facilitated patient input and was characterised by continuity over time. A DCE which focused on support in managing symptoms of an asthma flare-up was developed where participants made choices between services that differed on six attributes. Pilot study data indicated that having a provider that listens to the patient’s concerns was most important when experiencing symptoms that may lead to an asthma flare-up. Specialist providers who can be accessed face-to-face on the same day as contacted and have previous knowledge of the patient’s history were also valued. Having a written plan to manage changes was less valued. Conclusions: The implementation of frameworks on SMS for chronic disease requires long-term buy-in from stakeholders and increased consultation with patients and providers. Qualitative research with people with asthma/COPD illuminated valued features of support such as communication and continuity in the patient-provider relationship that warrant greater attention in SMS interventions. The findings of the DCE pilot study need to be verified through conducting a study with adequate power to compare preferences across groups and to use more advanced models to account for preference heterogeneity. The findings suggest a model of support which includes timely, face-to-face access to a healthcare professional that knows the patient and fully listens to their concerns for managing symptoms of an asthma flare-up.

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