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Presenter

Dr Justin Aunger, Research Fellow, Midlands Patient Safety Research Collaboration

Abstract

Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. It is pervasive in acute health care settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety, and organisational resources. While interventions have been implemented to mitigate UB, there remains limited understanding of how and why they may work and for whom. Similarly, while contributors to these behaviours have been investigated, understanding of how they interact and how they can be targeted by interventions can be improved. To address these knowledge gaps, we performed a realist review, drawing on 148 literature sources and 42 reports of interventions, to better understand how these contributors lead to UB and worsening of its impacts. We also investigated when and how these complex, context-dependent interventions to reduce UB work. This presentation will explore our findings and present implementation guidance to help others address UB in the healthcare workplace in the future.

Biography

Dr. Justin Aunger is a researcher with a background in behavioural science applied at individual, team, and organisational levels. He is interested in addressing complex challenges in healthcare organisations and has recently worked on multiple projects drawing on realist methodology. This includes understanding how inter-organisational collaborations work, and how unprofessional behaviours between staff can be addressed. He has experience developing and delivering multiple kinds of research, including behaviour change interventions in a healthcare context, realist reviews and evaluations, and qualitative studies.

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Abstract

Background

Patients who clinically deteriorate without recognition and/or response are at risk of unplanned admission to intensive care, cardiac arrest, and/or death (termed Serious Adverse Events (SAEs)). To mitigate SAEs, track-and-trigger tools are used internationally to prompt healthcare practitioners (typically nursing staff) to recognise physiological changes that signal deterioration, and to contact a practitioner with expertise in acute/critical illness. In the United Kingdom and parts of Europe, the National Early Warning Score (NEWS) (track-and-trigger tool) was developed and disseminated widely to standardise practice. Despite evidence track-and-trigger tools (like NEWS) improve patient outcomes, their translation into clinical practice is inconsistent. This is partly attributed to nursing staff failing to change their behaviour.

Aim

The aim of the project was to develop a theory-based behaviour change intervention to enhance enablers and overcome barriers, to Registered Nurses (RNs) and Healthcare Assistants (HCAs) enacting expected behaviours in recognising and responding to signs of patient deterioration.

Methods

A mixed methods design was used with three phases: 1. Focused ethnography on two clinical floors in an acute hospital to compare directly observed behaviours (of RNs and HCAs) with those specified in policy. From directed content analysis of field notes, target behaviours were identified, specified, and shortlisted; 2. Brief (not audio-recorded but recorded in field notes) interviews were conducted soon after direct observation of relevant behaviour. Some brief interview participants were recruited for an audio-recorded, semi-structured, interview informed by a Theoretical Domains Framework (TDF) topic guide. Interview data were analysed deductively (the 14 TDF domains were coding categories) and inductively to identify determinants (i.e. barriers and enablers) of target behaviours. TDF domains representing important determinants were identified using published criteria and linked to Behaviour Change Techniques (BCTs) from expert consensus literature; 3. BCTs were shortlisted by the research team and presented to clinical stakeholders alongside example applications (i.e. concrete strategies for operationalising BCTs). Using Nominal Group Technique, stakeholders ranked BCTs and their potential applications for acceptability and feasibility. Ranking data were used to inform the content of a preliminary intervention.

Results

During 300 hours of fieldwork, 499 items of data (i.e. an episode of observation or a set of vital signs from chart review) were recorded; 289 (58%) associated with expected (i.e. policy-specified) behaviour; 210 (42%) associated with unexpected behaviour (i.e. alternative behaviour or no behaviour). Ten behaviours were identified as potential behaviours for change; shortlisted to seven target behaviours. Brief interviews were conducted with 39 RNs and 50 HCAs, and semi-structured interviews with 16 RNs and 16 HCAs. Quotes from interviews were linked to nine (for brief interviews) and 14 (for semi-structured interviews) TDF domains. Nine TDF domains were identified as being of high importance: Knowledge, Social Professional Role and Identity, Beliefs about Consequences, Reinforcement, Intentions, Goals, Memory, Attention and Decision Processes, Environmental Context and Resources, Social Influences. These domains were linked to 50 BCTs; shortlisted to 14. Ranking data from two nominal groups held with 19 stakeholders were used to shortlist further, resulting in a preliminary intervention that includes an educational package and 12 BCTs that will be delivered through workshops and on acute wards, using 18 applications.

Conclusion

This research made a unique contribution to the international body of evidence, as it is the first study where a theoretical framework of behaviour change and a taxonomy of BCTs were used to model an intervention to improve responses to clinically deteriorating patients. The intervention is preliminary, as it is anticipated that it will be piloted in clinical practice and refined during a subsequent feasibility study.

Biography

Dr Smith  is a clinical-academic nurse with a background in acute and critical care spanning two decades. Duncan holds a Senior Lecturer post in the School of Health and Psychological Sciences at City, University of London where he is a module leader for the MSc in Advanced Clinical Practice and a contributor to the PGCert in Critical Care. Alongside his academic role, Dr Smith is an honorary Consultant Nurse with the Patient Emergency Response and Resuscitation Team (PERRT) at University College London Hospitals (UCLH) NHS Foundation Trust where he continues to work clinically. Duncan’s clinical experience as a critical care outreach nurse in several organisations across London shaped his research activities pre-doctorally and informed his PhD. In April 2018 Dr Smith was awarded a National Institute of Health Research (NIHR) Clinical Doctoral Research Fellowship to complete a programme of work titled: DEveloping a Complex Intervention for DEteriorating Patients using Theoretical Modelling (DECIDE study). The aim of his doctoral research was to develop a theory-based, complex, behaviour change intervention to optimise recognition of, and response to, patients with signs of clinical deterioration. Dr Smith has recently been awarded a NIHR Development and Skills (DSE) Enhancement grant to upskill ahead of applying for an advanced clinical academic fellowship. For his post-doctoral work, Dr Smith anticipates designing and delivering a feasibility study to pilot the intervention at multiple hospital sites and to test the feasibility of using a cluster RCT to evaluate its efficacy.

Abstract

Nurses play a key role in patient safety, but little is known about how they make sense of who they are and what they do when they work alongside trainee doctors with regards to patient safety and being competent as the latter progress in their medical careers. In this seminar, Dr Ray Samuriwo will present his work on how experienced nurses make sense of who they are and what they do, in terms of their identity as they work with trainee doctors to keep patients safe. This work has helped to describe the different identities and roles that nurses have and occupy as they strive to keep patients safe with trainee doctors. Ray will share his findings about how nurses make sense of who they are and what they do to ensure patients are safe when working with trainee doctors, and to support the latter to develop their competence as doctors.

Biography

Dr Ray Samuriwo is an Associate Professor in Adult Nursing at the University of Bradford, who carries out research on patient safety and decision-making in healthcare. His work is informed by principles and ideas from the humanities and social sciences.  The focus of Ray’s work is on creating, testing, and improving theories that can be that people receiving healthcare are kept safe and always receive the best possible care.

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Abstract

It is now well accepted that patients, their families and carers should be engaged in their care. What is only more recently becoming accepted is their wide ranging contribution to both their own safety, the safety of others, and the safety of healthcare systems. In this talk, Professor O’Hara presented a brief social history of the ‘patient involvement in patient safety’ movement, describing how it emerged alongside wider patient safety theory, policy and practice. She also described how patients and families have moved from being seen as passive recipients of care, to valuable partners in the provision of safe care. To illustrate, Professor O’Hara used examples from over a decade of research by the Yorkshire Quality & Safety Research Group, and discussed what it means for today’s policy and practice, and what it might mean for the future.

Biography

Jane O’Hara is Professor of Healthcare Quality and Safety, based within the School of Healthcare, University of Leeds. Since 2019, Jane has led a large, NIHR-funded programme of work aimed at co-designing and testing new processes for involving and engaging families in investigations and learning responses following healthcare safety events (https://learn-together.org.uk/). This work has had a significant impact, most recently informing the development of the new national level policy guidance: ‘Engaging and involving patients, families and staff following a patient safety incident’, with the NHSEI and Healthcare Safety Investigation Branch. Jane also leads the NIHR-funded Response Study, which seeks to evaluate the implementation of the new Patient Safety Incident Response Framework (PSIRF) across the English NHS (May 2022-July 2025). Jane is Deputy Director of the Yorkshire Quality and Safety Research Group, and as of April 2023, jointly leads a theme entitled ‘Safer Systems, Cultures and Practices’ with Professor Carl Macrae, within the NIHR Yorkshire & Humber Patient Safety Research Collaboration. Jane has over thirteen years’ experience of leading patient safety research, and a further eight years of applied psychological research prior to that. Her interests include: involving patients and families in investigations, safety initiatives and quality improvement; the measurement and monitoring of patient safety; safety theory and resilient healthcare approaches; and, co-production.

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Abstract

People with symptoms that may indicate cancer fall into two groups: (1) patients with (relatively few) alarm symptoms, for whom guidelines recommend urgent referral for specialist assessment, and (2) patients who present initially with non-specific symptoms with a low predictive value for cancer for whom there is a scarcity of evidence-based guidelines and who may be managed for long periods in primary care. Cancer patients in the latter group typically require multiple consultations before being diagnosed either through GP urgent or “routine” referral, or through emergency diagnosis. While some diagnoses can be made during a single healthcare encounter, the diagnostic process is more often than not dynamic and distributed in space and time, involving many different healthcare professionals, often at different locations and times.  In this talk Dr Georgia Black considered how we can manage the risk that a patient’s cancer diagnosis will be delayed by considering different approaches and interventions, drawing from their recent research.

Biography

Dr Georgia Black has recently joined Queen Mary’s University London as Reader in Applied Health Research within the Wolfson Institute of Population Health. Georgia is a social psychologist whose research has two main foci: patient safety in primary care and across cancer pathways and the effect of socioeconomic inequalities and specifically exclusion from healthcare. In 2019, Georgia was awarded a Postdoctoral Fellowship by The Health Improvement Studies (THIS) Institute. Georgia’s fellowship examines diagnostic safety culture in non-specific symptom pathways for cancer (previously Rapid Diagnostic Centres), using a case study design. Georgia’s work supports healthcare improvement locally and nationally, including strong relationships with cancer charities, cancer alliances, and executive membership of the Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis. Georgia co-founded the UCL Qualitative Health Research Network to create a community of health services researchers dedicated to pushing the boundaries of qualitative methods and reflexivity in healthcare improvement. Dr Black has experience in a wide range of applied qualitative methodologies including interview studies, ethnography, case studies, policy analysis and literature reviews.

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Abstract

Surgery, by its very nature, is challenging work. When the experience of adverse surgical events is factored in, surgeons can experience significant negative effects on their psychological wellbeing. In this presentation Helen Bolderston and Kevin Turner will summarise the findings of a UK national survey of surgeons which provided evidence of the impact of adverse events on surgeons, especially when those events are perceived as errors by the surgeons involved. This research led to the Bournemouth University Surgeon Wellbeing Research Team convening a national, multidisciplinary working group tasked with developing good practice guidelines addressing the support of surgeons in the immediate aftermath of adverse events. The guidelines will be outlined, with specific focus on the recommendation for organisations that employ surgeons to develop ‘First Responder’ surgeon support schemes. Recent developments in relation to such First Responder schemes will be discussed.

Part 2. Preparing healthcare professionals for adverse events: Reboot coaching programme

Adverse events are a common occurrence in healthcare and most healthcare professionals will be involved in a patient safety incident at some point during their career. However, many professionals report feeling unprepared for how to manage and cope with the psychological distress they may experience in response to these events. The Reboot (Recovery-boosting) Coaching Programme was developed to fill this gap. It is the first prophylactic psychological intervention designed to prepare healthcare professionals for the occurrence of adverse events. Reboot has now been evaluated in two completed studies. The first reported on Reboot when delivered via an in-person modality to multidisplinary healthcare professionals prior to the Covid-19 pandemic. The second reported on an evaluation of Reboot delivered via a remote format to Critical Care Nurses during one of the peaks of the Covid-19 pandemic. Studies are currently underway evaluating Reboot in medical students and surgeons. This talk will provide information about Reboot, describing the components of Reboot and evidence regarding its potential value to healthcare providers.

Biographies

Dr Helen Bolderston
Helen Bolderston has over 30 years’ experience as a clinical psychologist and psychotherapist. She was a consultant psychologist in NHS mental health services for many years before moving to an academic post at Bournemouth University. She trains and supervises clinical psychologists and psychotherapists nationally and internationally, specialising in empirically-supported mindfulness and compassion-based psychotherapies such as Acceptance and Commitment Therapy. Her research focusses on three main areas: 1. Evaluating psychotherapeutic interventions, particularly mindfulness and compassion-based therapies. 2. Investigating psychological processes implicated in the development and maintenance of mental health problems. 3. Addressing psychological wellbeing, resilience, and burnout in health and educational settings. She is a member of the Bournemouth University Surgeon Wellbeing Research Team. As part of this work she took the lead for an RCT testing a resilience-enhancing training intervention for trainee surgeons and contributed to the RCS Good Practice Guide “Supporting surgeons after adverse events.”

Professor Kevin Turner
Kevin Turner was appointed as a Consultant Urological Surgeon in Bournemouth in 2007 and is a Visiting Professor at Bournemouth University. He trained in Urology in Oxford, Edinburgh and Melbourne. His clinical interests are in urological cancer, particularly resectional surgery for pelvic cancer and robotic / minimally invasive surgery. He was elected an Hunterian Professor of the Royal College of Surgeons of England whilst still a trainee, was awarded the European Association of Urology Thesis Award for his research in renal cancer, and is co-editor of the Oxford Handbook of Urological Surgery. In 2015 he co-founded the Bournemouth Surgeon Wellbeing Research Team with colleagues in the Department of Psychology at Bournemouth University. The aim of the team is to generate original research data concerning the psychological health of surgeons including in relation to the impact of adverse events on surgeons. The team develop and trial novel interventions designed to ameliorate the impact of adverse events and more generally, to increase surgeon resilience and wellbeing. Results of the team’s national survey have been published in the British Journal of Surgery, an RCT of the effectiveness of a resilience training intervention for surgical trainees has been completed, and in 2020 (in conjunction with RCS England) the team led the multidisciplinary panel that wrote the RCS Good Practice Guide “Supporting surgeons after adverse events.”

Dr Judith Johnson
Judith Johnson is an Associate Professor in Psychology at the University of Leeds and holds adjunct roles at the Bradford Institute for Health Research, UK and the University of New South Wales, Australia. She gained a PhD from the University of Manchester and a ClinPsyD (Practitioner Doctorate) from the University of Birmingham. She is an HCPC registered Clinical Psychologist. Her research interests focus on healthcare staff wellbeing and burnout, patient safety and communication in healthcare settings. She is particularly interested in developing interventions which can support healthcare providers better in order to improve the delivery of patient care. She has published over 60 peer-reviewed articles in high-quality journals including the BMJ, International Journey of Surgery and Academic Medicine. Her work has been covered by The Guardian newspaper and BBC News and has been referred to in policy documents published by the World Health Organization, the British Medical Ultrasound Society and the Society and College of Radiographers.

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