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Welcome to symposium 14 about protocol-based / standardised care. Chair: Dr Susan Read, RCN Fellow . Programme:. Welcome: Dr Susan Read, RCN Fellow Introduction: Dr Jo Rick Presentations:

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Welcome to symposium 14 about protocol based standardised care l.jpg

Welcometo symposium 14 about protocol-based / standardised care

Chair: Dr Susan Read, RCN Fellow


Programme l.jpg
Programme:

  • Welcome: Dr Susan Read, RCN Fellow

  • Introduction: Dr Jo Rick

  • Presentations:

    • Development and implementation of protocol-based care. A systematic literature review. Dr Irene Ilott

    • Impact of protocol-based care on nurses' experience of work. National survey. Malcolm Patterson

    • Competing ideologies in maternity care: a discourse analysis. Rose O'Neill

  • Discussion about the recommendations


Evaluating protocol based care a mixed method approach l.jpg

Evaluating protocol-based care: a mixed method approach

Dr Jo Rick, Malcolm Patterson, Dr Irene Ilott

& Rose O'Neill

RCN 2008 International Nursing Research Conference

9th April 2008, Liverpool


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Acknowledgement

This symposium presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Programme.

The views expressed in this presentation are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

The NIHR SDO programme is funded by the Department of Health.


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Protocol-based care: policy driven 'standardised care'

“By 2004 the majority of NHS will be working under agreed protocols identifying how common conditions should be handled and which staff can best handle them.

The new NHS Modernisation Agency will lead a major drive to ensure that protocol-based care takes hold throughout the NHS …

to develop clear protocols that make the best use of all the talents of NHS staff and which are flexible enough to take account of patients’ individual needs” (p83).

Department of Health (2000). The NHS Plan. A plan for investment.

A plan for reform. London: The Stationery Office.


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Standards: shaping or determining care?

“The introduction of standards and guidelines should help reduce the gap between what people who receive the best care and treatment and those who are missing out. However, it is clear that the NHS needs to implement these standards and guidelines more consistently” (p41)

“In an organisation as big as the NHS, some differences are to be expected. In fact, they should be encouraged so that services can be free to develop. But differences should not result in services for some falling below acceptable standards” (p68)

Healthcare Commission (2005) State of Healthcare. London.


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Evaluation framework

Opinion Leader Interviews

Systematic Literature Reviews

National Survey of Nurses, Mid-wives

and Health Visitors

Detailed Case Study Work at Five Sites


Interviews l.jpg
Interviews

OPINION

LEADER

INTERVIEWS

  • AIM:

  • Understand current thinking on standardised care from different perspectives:

  • Practice

  • Policy

  • Research

Literature

Reviews

National Survey

Case Studies


Search for evidence l.jpg
Search for Evidence

Interviews

  • AIM:

  • To establish what evidence exists on standardised care

  • Development & implementation

  • Impact

  • Costs

SYSTEMATIC

LITERATURE

REVIEWS

National Survey

Case Studies


Standardised care in practice l.jpg
Standardised Care in Practice

Interviews

  • What really goes on… developing,

  • implementing and sustaining?

  • How does it impact on those delivering care?

    • New national guideline

    • Health visitor x 2

    • End of Life care

    • MI care pathway

Literature Reviews

DETAILED

CASE STUDY

WORK

National Survey


User views l.jpg
User Views

  • Survey to explore

    • attitudes,

    • beliefs &

    • experience –

    • Job satisfaction

    • Mental health

    • Feelings of competence & autonomy

Interviews

Literature Reviews

Case Studies

National Survey

of Nurses, Midwives &

Health Visitors


Search for evidence12 l.jpg
Search for Evidence

Interviews

  • AIM:

  • To establish what evidence exists on standardised care

  • Development & implementation

  • Impact

  • Costs

SYSTEMATIC

LITERATURE

REVIEWS

National Survey

Case Studies


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Development, implementation and impact: a systematic literature review

Irene Ilott, Andrew Booth, Jo Rick, Rose O’Neill & Malcolm Patterson

RCN International Nursing Research Conference

April 8th 2008, Liverpool


Content l.jpg
Content

  • Method:

    • Systematic literature review and qualitative analysis

    • Appraising practitioner and research knowledge

  • Key findings:

    • Multiple purposes of standardised care

    • Different approaches to development

    • Complex, time-consuming process

    • Challenge of change

  • Some questions and implications


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Systematic literature reviews

"are a method of making sense of large bodies of information, and a means of contributing to the answers to questions about what works and what does not - and many other types of question too.

They are a method of mapping out areas of uncertainty, and identifying where little or no relevant research has been done, but where new studies are needed" (Pettigrew & Roberts 2006, p2)


Two systematic literature reviews l.jpg

Protocol-based care

Search of 20 databases yielded only 56 papers

heterogeneous

24 excluded as about software

Standardised care

Search terms: protocols, and guidelines, and pathways

6,901 studies from 5 ‘nursing’ databases and hand search of J. Integrated Care Pathways

3,872 - Ist sift using Ref. Manager

859 - 2nd sift data extraction

289 - papers about development & implementation

64 - papers appraised - data about impact on staff outcomes

Two systematic literature reviews:


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Impact: international studies

Included studies:

  • 64 studies published between1990-2005

  • Source: 27 USA, 24 UK, 4 Netherlands, 4 Australia, 2 Ireland, 1 New Zealand, 1 Saudi Arabia, 1 Hong Kong

  • About: nurses (n=59), midwives (n=4) and public health nurses(n=1)

    Findings:few studies, poor methodological quality but consistent positive (eg. empower, expanded roles, team working) and negative outcomes (restrict decision-making and deskilling)


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Review: representative set UK papers about development and implementation

  • 33/117 papers reviewed by two people, in different ways:

    • inductively using Qualitative Assessment and Review Instrument (QARI) from The Joanna Briggs Institute

    • deductively – comparing descriptions with 12-step MA/NICE (2002) framework for developing protocols

  • Trustworthiness: reflexivity, data saturation and audit by an independent researcher


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UK perspective derived from: implementation

  • 33 UK papers published between 1991-2006

  • 27 in England, 3 in Scotland, 2 in Wales, 1 England and Wales

  • 20 in hospitals/secondary care: 5 ICU/HDU, 2 A&E, 4 nurse-led day care/clinics

  • 3 District Nurses, 2 Community Nurses, 1 Health visitors

  • 1 Midwives (as part of a md, inter-agency team)


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‘Appraising’ practitioner knowledge implementation

  • Everyday experience - authenticity and credibility of the source (Pawson et al 2003)

  • Purpose: sharing learning and positive experience about a specific standardised care, at particular time and place

    • 10 contained extracts of ‘standardised care’

    • 7 ‘pilot studies’ about safety re changes in working practices on patient outcomes and costs

  • Most described development process – many different purposes, details and activities


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Approaches to development implementation

  • Problem orientated local innovation eg District Nurses registering expected out-of-hours death (28/33)

  • Macro level, national to local guidance or policy-led change eg reducing waiting times (5/33)

  • Formalising or making current practice evidence-based eg management of constipation in critical care unit

  • Adopting/adapting something used elsewhere eg Liverpool end of life care pathway introduced in two Primary Care Trusts


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Primary and secondary purposes implementation

26/33 gave multiple aims that included:

  • Policy: workforce modernisation and standardisation of procedures or service

  • Improving quality of patient care

  • Organisational reasons – increased demand

  • Team working – improve consistency

  • Staff reasons – expand scope of practice

  • Task related purposes – ‘unappreciated’ aspect of care eg oral care


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Tool-box for a spiral process rather than a 12-step linear process

Varied sequence with some steps or parts:

  • missed (patient involvement, process mapping)

  • repeated and ongoing (stakeholder support)

  • not mentioned (using information scientists, interpreting the evidence & drafting the documents)

    Guidance estimated 3-6 months from start to use:

  • Time reported in 10/33 studies

  • Range 6-36 months, took an average 15 months


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Example: step 3 of 12 processInvolve patients & users

1 - instigated by patient representative support group: protocol for improving consistency of diagnosis and treatment of symphysis pubis dysfunction

6 – produced patient information leaflets

1 – questioned patients about preventative information they had received


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Staff perspective process

  • Most made only ‘passing reference’ to staff and impact, eg. about empowerment and control

  • Nurses’ contribution was understated/difficult to identify; 10/33 re nurse-led care/role expansion

  • Doctor-nurse relationship: assessment of competence 4/33, challenging adherence 1/33


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Implementing and sustaining change process

“Despite the long run-in period involving staff consultation and preparation, it took nearly a year before the use of the protocol (for weaning ventilated patients) was successfully embedded into unit practice” (on an intensive care unit)

Bruton & McPherson 2004: 438


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Thank-you process

Any questions or comments?

  • Does the UK literature reflect your experience in the UK and elsewhere?

  • What’s the impact of the growing number of national guidelines on local developments?

  • What’s the implications of policies/procedures manuals as important sources of knowledge - evidence-based practice (Gerrish et al 2008)


References l.jpg
References process

Bruton A & McPherson K (2004) Impact of the introduction of a multidisciplinary weaning team on a general intensive care unit. Int J Therapy and Rehabilitation, 11, 9, 435-430.

Gerrish K et al (2008) Developing evidence-based practice: experiences of senior and junior nurses. Journal of Advanced Nursing, 62, 1, 62-73.

NHS Modernisation Agency and National Institute for Clinical Excellence (2002) A Step-by-Step Guide to Developing Protocols.

Pawson R et al (2003) Knowledge Review. Types and Quality of Knowledge in Social Care. SCIE/The Policy Press.

Petticrew M & Roberts H (2006) Systematic Reviews in the Social Sciences. A Practical Guide. Blackwell Publishing.


Standardised care in practice31 l.jpg
Standardised Care in Practice process

Interviews

  • What really goes on… developing,

  • implementing and sustaining?

  • How does it impact on those delivering care?

    • New national guideline

    • Health visitor x 2

    • End of Life care

    • MI care pathway

Literature Reviews

DETAILED

CASE STUDY

WORK

National Survey


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Competing ideologies processin maternity care: A discourse analysis

Rose O’Neill, Malcolm Patterson & Jo Rick

RCN 2008 International Research Conference

Liverpool, 9th April 2008


Background l.jpg
Background process

  • Very detailed research in five case study sites to examine standardised care in practice

  • Influence of clinical settings leads to considerable variation in acceptance and use of standardised care

  • Midwifery example to explore the impact of existing ideologies on perceptions of standardised care stringency


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Content process

  • Competing ideologies in midwifery

    • ‘With woman’ versus ‘with institution’

  • Basic principles of discourse analysis

  • Findings from interviews with midwives

  • Influence of ideological preference on midwives’ perceptions of clinical guideline stringency


Definition and types of ideologies l.jpg
Definition processand types of ideologies

  • “shared, relatively coherently interrelated sets of emotionally charged beliefs, values, and norms that bind some people together and help them to make sense of their worlds” (Trice & Beyer, 1993, p.33)

  • Differing professional specialties adopt different ideologies

  • Individuals acquire sense of professional legitimacy by adopting ideology

  • Ideologies are often in conflict e.g., tension between medical intervention and more natural models (Meyerson, 1994)

  • Tension particularly evident in midwifery care (Hyde & Roche-Reid, 2004)

    • Midwifery profession founded on autonomy and independent clinical practice


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Ideologies processin maternity care (1)

  • ‘With woman’ ideology (Hunter, 2004)

    • ‘Mid’ = ‘with’ and ‘wif’ = ‘woman’

    • Midwifery model of care

    • Natural, normal birth

    • Midwives are experts in normality

    • Autonomous, independent practitioners

    • Continuity of care

    • Woman-centred care


Ideologies in maternity care 2 l.jpg
Ideologies processin maternity care (2)

  • ‘With institution’ ideology (Hunter, 2004)

    • Medical model of care

    • Dominant model

    • Standardisation, medical intervention

    • Strict protocols – “fossilise into rules” (Kirkham, 2004, p.273)

    • Erosion of traditional midwifery, loss autonomy

    • Discrepancies between midwives’ core values and medical model of care (Curtis, Ball & Kirkham, 2006)


Discourse analysis l.jpg
Discourse analysis process

  • Ideologies manifest in language

    • Study of midwives’ language ideal methodology

  • Individuals use language to construct their reality

  • Discourse analysis enables in-depth exploration of specific language use

    • Aim to understand how specific language is used to construct reality

  • Looking for the use of particular words, for vivid images, metaphors, or figures of speech

  • Important to acknowledge my own role in interpretation of the discourse

    • Highly subjective process

    • No claims made as to objectivity or generalisability of findings


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Research aim and question process

  • To explore the competing ‘with woman’ and ‘with institution’ ideologies underpinning maternity care in a midwifery-led care unit and a consultant-led care unit, respectively

  • How do midwives use language to construct the realities of a midwifery-led care unit following a ‘with woman’ ideology and a consultant-led care unit following a ‘with institution’ ideology?


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Reality of woman-centred v task focused maternity care process

  • “The difference is, I can explain it very, very simply, that in the community you worked for the woman, when she needed it, how she needed it. When you go into the hospital you really start working for the institution, so you have to do things which you know are not necessarily the best thing for the woman or the baby, it’s because you’re in a building, an institution, with its own rules and requirements so you have to do things in a certain way. And those ways are often very time consuming and take the focus away from the woman herself.”

    Midwife 8


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Reality of midwifery v obstetric nursing process

  • “…you’re not giving sort of 100% midwifery care, you’re giving medicalised care, you’re giving obstetric nurse care, you know, you’re not doing…like when I’m down on midwifery led care, generally you’re on your hands and knees, you’re on the floor you know, you either get along with your woman or you don’t go in there, do you know what I mean? Up here they’ve not got that, that kind of connection with you, it’s not the same because they’re sat on a bed, they see the doctors coming in and out, telling you what to do, and it’s just like you’re a little handmaiden running in and out, not doing your job. I mean you do your best to make it as normal as possible for them but it’s not always easy and it does, it takes away your satisfaction as a midwife. And like I say, it’s not being a midwife up here, it’s just being an obstetric nurse because you’re just caring, you’re taking care of people’s needs from a medicalised point of view, and that’s not what I became a midwife for”

    Midwife 2


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Reality of guidelines v protocols (1) process

  • “that’s why it’s called a guideline – the midwives should, in theory, be given the confidence to use a guideline, know the guideline, acknowledge the guideline, but also be able to justify their actions or potential delays that they might do through their clinical skills”

    Midwife 4

  • “obviously guidelines are not gospel they are there as guidance.”

    Midwife 6


Reality of guidelines v protocols 2 l.jpg
Reality of guidelines v protocols (2) process

  • “guidelines are guidelines, I mean you either go with them or you go with your experience and you work as an autonomous midwife”

  • “I mean we know it’s all for safety and patient care and one thing and another…butI think sometimes there needs to be that leeway”

  • “I mean we all know that we’ve got to work within the protocols but I think sometimes we just need that, that little bit of space”

    Midwife 2


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Clinical guideline stringency (1) process

  • Midwives’ ideological preference influenced their perceptions of clinical guideline stringency

    • Power of ideology over attitudes and behaviours

  • Consensus regarding standardised care on midwifery-led care unit

    • Strongly evidence-based “guidelines”

    • Supportive towards best practice and flexibility to accommodate women’s individual needs

  • But discrepancy regarding standardised care on consultant-led care unit

    • Midwives favouring a ‘with woman’ ideology described standardised care as much more restrictive than midwives favouring a ‘with institution’ ideology


Clinical guideline stringency 2 l.jpg
Clinical processguideline stringency (2)

  • ‘With woman’ ideological preference

    • Talked about strict, inflexible “protocols” and “rules” on consultant-led care

    • Highly medicalised, proceduralised care

    • Limited abilities to practice autonomously and provide individualised care

    • Profound incongruence with core midwifery values

    • BUT, did acknowledge the importance of highly medicalised and proceduralised care for dealing with rare, life threatening emergencies


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Clinical guideline stringency (3) process

  • ‘With institution’ ideological preference

    • Talked about “consultant-led care guidelines”

    • More prescriptive than midwifery-led guidelines, but still flexible “guidelines”

    • Still able to use clinical judgement to deviate when necessary and provide individualised care

    • No perceived loss of autonomy

    • Compatible with core midwifery values


Key findings l.jpg
Key findings process

  • Conflict exists between competing models of maternity care and their underpinning ideologies

    • Midwifery v medical models

    • ‘With woman’ v ‘with institution’ ideologies

  • Important to acknowledge strong influence of ideological preference (and core midwifery values) over perceptions of standardised care

    • Flexible care guidelines v strict protocols

    • Potential incongruence with core midwifery values

    • What impact does this have?


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Conclusion process

  • The findings presented here are specific to midwifery, however pre-existing values and beliefs are present in any branch of nursing

  • Such values and beliefs need to be taken into account for the successful development and implementation of standardised care

  • They are equally important for understanding how standardised care can impact on the professional identity of nurses and the way they experience their work


Thanks for listening l.jpg
Thanks for listening… process

  • Any questions or comments?

    • How do these findings fit with your experience in your speciality and country?


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References process

  • Curtis, P., Ball, L. and Kirkham, M. (2006). Why do midwives leave? (Not) being the kind of midwife you want to be. British Journal of Midwifery, 14, 27-31.

  • Hunter, B. (2004). Conflicting ideologies as a source of emotion work in midwifery. Midwifery, 20, 261-272.

  • Hyde, A. and Roche-Reid, B. (2004). Midwifery practice and the crisis of modernity: Implications for the role of the midwife. Social Science and Medicine, 58, 2613-2623.

  • Kirkham, M. (2004). Choice and bureaucracy. In M. Kirkham (Ed.), Informed Choice in Maternity Care (pp.265-290). New York : Palgrave Macmillan.

  • Meyerson, D. E. (1994). Interpretations of stress in institutions: The cultural production of ambiguity and burnout. Administrative Science Quarterly, 39, 628-653.

  • Trice, H. and Beyer, J. (1993). The Cultures of Work Organizations. Englewood Cliffs, NJ : Prentice Hall.


User views51 l.jpg
User Views process

  • Survey to explore

    • attitudes,

    • beliefs &

    • experience –

    • Job satisfaction

    • Mental health

    • Feelings of competence & autonomy

Interviews

Literature Reviews

Case Studies

National Survey

of Nurses, Midwives &

Health Visitors


An investigation into the impact of standardised care on nurses experience of work l.jpg

An investigation into the impact of standardised care on nurses’ experience of work

Patterson, M., Lekka, C., Ilott, I. & Rick, J.

RCN International Nursing Research Conference

Symposium 14: April 9th 2008, Liverpool


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Why study the impact of standardised care on staff? nurses’ experience of work

  • Standardised care key part of clinical practice and used for the delivery of a variety of tasks (assessment, intervention etc)

  • Little is known about the impact of standardised care on practitioners’ experience

    • Effects may be positive (e.g. guidance, empowerment) and/or negative (e.g. restriction of clinical autonomy, deskilling) (Lawton & Parker, 1999; Greenhalgh et al., 2004; Dodd-McCue et al. 2005)

  • Theory and research on workflow formalisation suggests the implications could be profound


Formalisation l.jpg
Formalisation nurses’ experience of work

  • Extent of written rules, procedures, and instructions

  • Standardised care as formalisation because it specifies the precise rules and procedures to be followed in delivering patient care

  • Considerable research on the impact of formalisation on attitudes and well-being

  • Conflicting assessments on the effect of formalisation


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Formalisation nurses’ experience of work

  • Negative path - stifles innovation, reduces autonomy, promotes ‘tick-box’ mentality and demotivates employees. Negative assessments with well-being, absence, satisfaction, commitment, powerlessness, alienation

  • Positive path - provides needed guidance and role clarity, reduces role stress, and increases self-efficacy, helps staff be and feel more effective

  • Tension between compliance and technical efficiency


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Emergent Themes nurses’ experience of work

”I think some people see protocols as being restricting, inflexible and constraining on their individual care decisions. Whereas others see them as being supportive and informing and supporting and facilitating care of an equal standard rather than inconsistent decision making”

Practising nurse


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A Framework for Interpretation nurses’ experience of work

  • Coercive and enabling bureaucracy (Adler & Borys, 1995)

    • Enabling factors codify best practice, enhance user skills and fully use employee capabilities

    • Coercive factors force reluctant compliance and lead to deskilling

  • Enabling Bureaucracies deliver ‘efficiency without enslavement’


Features of enabling bureaucracies l.jpg
Features of Enabling Bureaucracies nurses’ experience of work

  • Goal congruence

  • Formulating procedures (involvement, training)

  • Transparency

  • Flexibility

  • Repair

  • Decentralisation of power, skills, and knowledge. Employee voice


Method l.jpg
Method nurses’ experience of work

1. Piloting (July – August 2007)

- Face validity (appropriateness of ‘language’ and terms used) and ease of completion / clarity of instructions

2. Survey distribution (October 2007– January 2008) to random sample of 4,000 registered nurses, 4,000 midwives and 5,000 health visitors

  • Survey completion paper or web-based

    3. Approximately 2-week follow-up postal reminders (November 2007)


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Findings: Descriptives nurses’ experience of work

  • Total of 1,287 web and paper-based responses received (32% response rate)

  • Nursing sample characteristics:

    • Gender split: 92% females

    • Mean age: 43.8 years

    • Average tenure: 5.9 years

    • Experience in nursing, midwifery or health visiting: 20.7 years

    • 19% holding managerial posts


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Findings: Beliefs about impact nurses’ experience of work


Measures predictors l.jpg
Measures: Predictors nurses’ experience of work


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Measures: Outcomes (1) nurses’ experience of work


Measures outcomes 2 l.jpg
Measures: Outcomes (2) nurses’ experience of work


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Impact of standardised care: Flexibility nurses’ experience of work

Autonomy

Flexibility in using standardised care

.27, p<.001

Individualised care

.33, p<.001

Role clarity

Anxiety-Contentment

Competence

Job satisfaction

Depression-Enthusiasm


Impact of standardised care transparency l.jpg
Impact of standardised care: Transparency nurses’ experience of work

Transparency of standardised care procedures

Autonomy

.22, p<.001

Individualised care

.18, p<.001

Role clarity

Anxiety-Contentment

.23, p<.001

Competence

Job satisfaction

Depression-Enthusiasm


Impact of standardised care involvement l.jpg
Impact of standardised care: Involvement nurses’ experience of work

Involvement in standardised care

Autonomy

.22, p<.001

Individualised care

.19, p<.001

.21, p<.001

Role clarity

Anxiety-Contentment

Competence

Job satisfaction

.25, p<.001

Depression-Enthusiasm


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Impact of standardised care: Ideological Fit nurses’ experience of work

Autonomy

Ideological Fit

Individualised care

.19, p<.001

.22, p<.001

Role clarity

Anxiety-Contentment

Competence

Job satisfaction

.23, p<.001

Depression-Enthusiasm


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Conclusions nurses’ experience of work

  • Standardised care can be either a threat or a benefit to health practitioners experience of work dependent upon local understanding and implementation

  • Coercive and enabling bureaucracies offer a framework for exploring the conditions under which protocols are a threat or a benefit

    • Encouraging flexibility and involvement in standardised care enhances nurses’ experience of work including their satisfaction and well-being

    • Investment in training to use standardised care is important in enhancing transparency of procedures and consequently role clarity and feelings of self-efficacy

    • Resource intensive

    • Right balance between standardising practice and allowing staff to use clinical judgement


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References nurses’ experience of work

Adler PS & Borys B (1996) Two types of bureaucracy: enabling and coercive. Administrative Science Quarterly, 41, 1, 61-89.

Dodd-McCue D et al(2005). The impact of protocol of nurses’ role stress: A longitudinal perspective. Journal of Nursing Administration, 35(4), 205–16.

Greenhalgh T et al (2004) How to Spread Good Ideas. A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. London: NCCSDO.

Lawton R & Parker D (1999) Procedures and the professional: the case of the British NHS. Social Science and Medicine, 48, 353-361.


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Thank you… nurses’ experience of work

Any questions?


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Headline recommendations nurses’ experience of work

  • Development:

    • direct or indirect involvement for ownership

    • complex, time consuming process with hidden costs

  • Implementation:

    • change management and organisational resources

    • strategic and operational support for sustainability

  • Impact:

    • 'tool not a rule' to use with discretion for individualised care, autonomy and accountability


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The presentations – with references - will be on our website this week

http://sdo-protocols.group.shef.ac.uk/index.shtml