No abstract

ObjectiveAround one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care.DesignMixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods.Setting and participantsThree secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101).AnalysisQualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ2 and Wilcoxon signed-rank test for differences in current and future normalisation.ResultsParticipants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation).ConclusionsClinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.

Background Although most health care is high quality, many patients and members of staff can recall episodes of a lack of empathy, respect or effective communication from health-care staff. In extreme form, this contributes to high-profile organisational failures. Reflective learning is a universally promoted technique for stimulating insight, constructive self-appraisal and empathy; however, its efficacy tends to be assumed rather than proven. The Patient Experience And Reflective Learning (PEARL) project has used patient and staff experience to co-design a novel reflective learning framework that is based on theories of behaviour and learning. Objective To create a toolkit to help health-care staff obtain meaningful feedback to stimulate effective reflective learning that will promote optimal patient-, family- and colleague-focused behaviours. Design A 3-year developmental mixed-methods study with four interlinked workstreams and 12 facilitated co-design meetings. The Capability, Opportunity, Motivation – Behaviour framework was used to describe factors influencing the behaviour of reflection. Setting This took place at five acute medical units and three intensive care units in three urban acute hospital trusts in England. Participants Patients and relatives, medical and nursing staff, managers and researchers took part. Data sources Two anonymous surveys, one for patients and one for staff, were developed from existing UK-validated instruments, administered locally and analysed centrally. Ethnographers undertook interviews and observed clinical care and reflective learning activities in the workplace, as well as in the co-design meetings, and fed back their observations in plenary workshops. Main outcome measures Preliminary instruments were rated by participants for effectiveness and feasibility to derive a final set of tools. These are presented in an attractively designed toolbox with multiple sections, including the theoretical background of reflection, mini guides for obtaining meaningful feedback and for reflecting effectively, guides for reflecting ‘in-action’ during daily activities, and a set of resources. Results Local project teams (physicians, nurses, patients, relatives and managers) chaired by a non-executive director found the quarterly reports of feedback from the patient and staff surveys insightful and impactful. Patient satisfaction with care was higher for intensive care units than for acute medical units, which reflects contextual differences, but in both settings quality of communication was the main driver of satisfaction. Ethnographers identified many additional forms of experiential feedback. Those that generated an emotional response were particularly effective as a stimulus for reflection. These sources of data were used to supplement individual participant experiences in the nine local co-design meetings and four workshops to identify barriers to and facilitators of effective reflection, focusing on capability, opportunity and motivation. A logic model was developed combining the Capability, Opportunity, Motivation – Behaviour framework for reflection and theories of learning to link patient and staff experience to changes in downstream behaviours. Participants proposed practical tools and activities to enhance reflection ‘in-action’ and ‘on-action’. These tools were developed iteratively by the local and central project teams. Limitations Paper-based surveys were burdensome to administer and analyse. Conclusions Patients and health-care staff collaborated to produce a novel reflective learning toolkit. Future work The toolkit requires evaluating in a cluster randomised controlled trial. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 32. See the NIHR Journals Library website for further project information.

IntroductionPatient and staff experiences are strongly influenced by attitudes and behaviours, and provide important insights into care quality. Patient and staff feedback could be used more effectively to enhance behaviours and improve care through systematic integration with techniques for reflective learning. We aim to develop a reflective learning framework and toolkit for healthcare staff to improve patient, family and staff experience.Methods & analysisLocal project teams including staff and patients from the acute medical units (AMUs) and intensive care units (ICUs) of three National Health Service trusts will implement two experience surveys derived from existing instruments: a continuous patient and relative survey and an annual staff survey. Survey data will be supplemented by ethnographic interviews and observations in the workplace to evaluate barriers to and facilitators of reflective learning. Using facilitated iterative co-design, local project teams will supplement survey data with their experiences of healthcare to identify events, actions, activities and interventions which promote personal insight and empathy through reflective learning. Outputs will be collated by the central project team to develop a reflective learning framework and toolkit which will be fed back to the local groups for review, refinement and piloting. The development process will be mapped to a conceptual theory of reflective learning which combines psychological and pedagogical theories of learning, alongside theories of behaviour change based on capability, opportunity and motivation influencing behaviour. The output will be a locally-adaptable workplace-based toolkit providing guidance on using reflective learning to incorporate patient and staff experience in routine clinical activities.Ethics & disseminationThe PEARL project has received ethics approval from the London Brent Research Ethics Committee (REC Ref 16/LO/224). We propose a national cluster randomised step-wedge trial of the toolkit developed for large-scale evaluation of impact on patient outcomes.

From 1930 to 1990 annual age-adjusted breast cancer death rates for women in the United States remained remarkably constant, oscillating around 32 deaths per 100,000 over 60 years. During this long timeframe, the surgical treatment of breast cancer evolved from radical mastectomy with mandatory lymph node dissection to lumpectomy coupled with radiation therapy. With this new paradigm, lymph node dissection was reserved for women with tumor-invaded axillary lymph nodes. Beginning in the 1970s, chemotherapy after surgery (adjuvant) and before surgery (neoadjuvant) was added to surgical treatment. The radical diminution in the scope of breast surgery did not alter the national breast cancer death rate. Doing less surgery was neither harmful nor beneficial to long-term survival from breast cancer. In the 1980s two events changed this static picture: the addition of tamoxifen to adjuvant and neoadjuvant chemotherapy, and the introduction of mammography. Beginning in 1990 annual breast cancer death rates in the United States began to fall, and have continued to fall each year since then. In 2001, the last year of published statistics, the breast cancer death rate was 26 deaths per 100,000. Best estimates for where to credit this dramatic drop in death rate place approximately 50% of the credit with improved adjuvant chemotherapy and 50% with mammography. Abnormal mammograms demand a breast biopsy since only one in five abnormal mammograms is actually a breast cancer. Consequently, widespread adoption of mammography has produced an image-guided breast biopsy industry in the United States. Open, surgical breast biopsy has been replaced with image-guided breast biopsy because improved breast biopsy tools have made image-guided breast biopsy equivalent in accuracy to open, surgical breast biopsy. These tools, in turn, have changed the professional lives of surgeons, pathologists, and mammographers, leading to the development of dedicated breast surgeons, breast pathologists, and interventional breast radiologists.