Using participatory, practice development, Delphi and realist research approaches to understand how frontline teams can use the workplace to make sustainable improvements in the quality of their practice

The symposium will share the approaches and findings from three funded national and international research studies which all contribute to the body of knowledge about how to support person centred, safe and effective care in the workplace. The final presentation will integrate the theoretical insights emerging from the three studies to present a model for sustainable transformation in frontline teams.

Paper 1
Safety culture, quality improvement, realist evaluation Authors and affiliations Professor Kim Manley CBE, (Presenter), Carolyn Jackson, Christine McKenzie, Anne Martin, Dr Toni Wright.

Abstract
Safety in health care is an international concern with impact on quality of care (Hollnagel, et al, 2015). A Regional Patient Safety Collaborative (PSC), one of 15 nationally set up to place patients, carers and staff at the heart of quality improvements in patient safety, supported four large acute NHS hospital trusts with a PSC model to help facilitators use safety and quality improvement tools with frontline teams and to be mutually supported through action learning. The evaluation used realistic evaluation (Pawson & Tilley, 2004) (and the study and its findings are reported using the RAMESES 11 international standards (Wong et al, 2017). The study took place between June 2016-October 2017. Its aim was to understand what works for whom 3S.40-5.10pm1 Symposia- – Tuesday 17 April 2018 and why, when: working with frontline teams in large acute hospitals to embed a safety culture, and grow leadership and quality improvement capability. Specifically, to identify which strategies are effective in supporting front line teams to sustain bottom up change and quality improvement driven by the needs of patients and practitioners.

The study drew on ethnographic principlesacross study sites usingdescriptive case study design. Mixed methods of critical observation of frontline practice, stakeholder evaluation,emotional touch points, self-assessment;qualitative 360 degree feedback; and the Texas safety culture survey tool were used to facilitate the development of a rich picture for each teamand each context so as to answer the evaluation questions. In tandem, interrogation of the literature to distilled relationships between context, mechanisms and outcomes generating hypotheses at individual, team and organisational level factors for safety culture.

Key findings identified an interdependence between clinical leadership within frontline teams, safety culture, safety behaviours and teamwork echoed in microcosm through safety huddles; the skills and attributes of facilitators;and the impact of organisations on microsystems. Theories of culture change at the microsystems level are further embellished.

References
Hollnagel E., Wears R.L. and Braithwaite J. From Safety-I to Safety II: A White Paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia. http://citeseerx.ist.psu.edu/viewdoc/download doi=10.1.1.911.6550&rep=rep1&type=pdf (accessed 1st November 2017) Pawson, R. & Tilley, N. (2004) Realist Evaluation. [Online]. Available at: < http://www. communitymatters.com.au/RE_chapter.pdf>. Accessed: 14th November 2014. Wong, G.; Westhorp, G.; Greenhalgh, J.; Manzano, A.; Jagosh, J.; Greenhalgh, T, (2017) Quality and reporting standards, resources, training materials and information for realist evaluation: the RAMESES II project. Health Services and Delivery Research, 5(28) National Institute for Health Research October ISSN 2050-4349 DOI 10.3310/

Paper 2
Developing integrated facilitation standards to embrace the facilitation of learning in the workplace using e-Delphi Authors and affiliations Professor Kim Manley CBE, (Presenter), Carolyn Jackson, Anne Martin, Dr Toni Wright.

Abstract
This paper shares insights into the impact of system wide leadership initiatives that develop the facilitation capacity of the workforce to be effective clinical leaders in a time of increasingly complex system wide change (Manley et al, 2016, Crisp & Wilson 2011). The aim of this Delphi study (2015-16), was to develop a set of standards that could be used to guide an integrated approach to facilitation in and about the workplace. This includes the key qualities and skills required of facilitators who aim to integrate learning, development, improvement, inquiry, knowledge translation and innovation in and about the workplace. The study influenced by the knowledge base underpinning practice development methodology engaged international facilitation expertise. Three e-Delphi rounds involved participants from ten countries with expertise in facilitating either one or more of the purposes in work and/or about the workplace. The result, a set of standards builds on the current knowledge base about facilitation. The standards clarify the key components that facilitators need to attend to when supporting individuals, teams, organisations and services to achieve higher order learning in and about the workplace and positively impact on person centred cultures and health outcomes. The contribution of practice development as a discipline that integrates all the agendas was highlighted and needs to be promoted more explicitly at the policy level.

The key messages from this work are that: Facilitators work within different contexts and help staff appreciate the broader contexts in which they work. These contexts impact on both facilitator and staff purposes within and across each context. An integrated approach to facilitation aims to support a number of purposes. Enablers, skills and strategies for achieving these purposes are identified in the set of standards developed Facilitators need to attend to the evaluation of outcome and impact in the given context whilst keeping focus on constantly refining the processes that are effective.

References
Crisp, J., & Wilson, V. (2011). How do facilitators of practice development gain the expertise required to support vital transformation of practice and workplace cultures? Nurse Education in Practice, 11(3), 173-178. Manley, K., Martin, A., Jackson, C., & Wright, T. (2016). Using systems thinking to identify workforce enablers for a whole systems approach to urgent and emergency care delivery: a multiple case study. BMC Health Services Research, 16(1), 1

Paper 3
Developing theoretical insights into sustainable transformation in front line teams – the Venus model Authors and affiliation Carolyn Jackson, Director, England Centre for Practice Development, Canterbury Christchurch University, UK (Presenter), Professor Kim Manley CBE, Anne Martin, DrToni Wright.

Abstract
Definitions for continuous Professional Development (CPD) tend to focus on individual objectives, yet the goals of CPD activity are mutually interdependent on individual and system aspects (Billet, 2002) This paper presents the theoretical and practical insights gathered from a realist synthesis and evaluation (2014-2015) that led to a tool designed to measure the impact of learning on individual, team and organisational effectiveness in relation to improvements in quality of care and patient outcomes in the workplace. The aim of the project was to develop and test a CPD Impact Tool that identifies mechanisms for measuring the impact of learning on individual, team and organisational effectiveness and the indicators useful for providing information on individual and team effectiveness in relation to outcomes in the workplace? The study used mixed methods across two phases with different stakeholder groups to first develop theories about the relationship between contexts, mechanisms and outcomes for CPD to help understand which strategies work best for whom in what circumstance and why?

Phase 1 methods included: a literature review, underpinned by 12 critical questions, to identify what is known about CPD across three broad themes 1) What is CPD is and why it is important? 2) Purpose and impact of CPD, and 3) Facilitating and Judging the Effectiveness of CPD. This together with a stakeholder surveyanalysis and documentary analysis of CPDlearning outputs informed the development of the CPD framework and indicators which was then further tested in phase 2 with CPD providers, learner and an expert international reference group.

Key findings centre on four transformation theories that underpin an overarching framework for understanding effective CPD and a set of Impact indicators for guiding evaluation In order for CPD to be effective it has to address all of the interdependent outcomes for individual, team, service and organisational transformation.

Reference
Billett S. Critiquing Workplace Learning Discourses: Participation and Continuity at Work. Stud Educ Adults. 2002; 34(1):56-67.

Paper 4
Developing theoretical insights into sustainable transformation in front line teams – the Venus model Authors and affiliation Carolyn Jackson, Director, England Centre for Practice Development, CanterburyChristchurch University, UK (Presenter), Professor Kim Manley CBE.

Abstract
This paper presents a synthesis of the theoretical insights emerging from the three research studies together with outputs from a workshop for an international network of fellows. This synthesis is presented as a theoretical framework – the Venus Model for sustainable person centered transformation. This framework describes the key elements and linked concepts (and relationships) required to support front line teams (micro-systems) transform practice through interprofessional learning, development, improvement and innovation, and the essential organisational and systems factors required to enable this.

The five key elements of the model are 1) supporting development of facilitation skills across a continuum of complex purposes, 2) leadership development at clinical to systems levels, 3) practice development - a complex methodology that focuses on collaborative, inclusive and participative approaches with stakeholders,to develop person-centred, safe and effective cultures, 4) using quality improvement skills and tools, and 5) the culture change skills at the front line of practice. Bottom up, as opposed to top down models for supporting complex change in organisations are crucial to understand how to transform systems, services and cultures of care within and across organisations to deliver new models for 21st century health and well-being.

The symposium will conclude by sharing implications for practice based research and inquiry, workforce development and new emergent roles by considering how best to support and evidence the contribution of nurses to the future workforce on a global platform. This will include consideration of how nurses can take a leadership roles in both the delivery and evaluation of sustainable transformation across the health economy to impact on future new models of care.