Title: Patient Experience And Reflective Learning (PEARL)
Funder: Department of Health and Social Care

Abstract: This protocol responds to the HS&DR programme’s commissioned call for research into methods of using patient experience to improve health services and care, and to a recent call for patient experience data to be used systematically to improve care quality [Coulter 2014]. It will also make use of outputs from current work funded by the HS&DR programme, the Family Reported Experiences Evaluation (FREE) Study [http://www.nets.nihr.ac.uk/projects/hsdr/11200356] which is testing the psychometric properties of the FS-ICU and then evaluating reliability in a cohort study due to report in 2015. The Mid-Staffordshire Hospital enquiry appropriately stimulated national policy initiatives to use patient experience to improve care. However, our prior work shows that clinicians – and particularly doctors – are often disengaged by multiple policy initiatives [Dixon-Woods 2012, 2013]. Quality and performance metrics have greater impact on clinician behaviour when there is professional ownership, and when metrics are linked to particular patients or events with whom there is a direct fiduciary relationship. We therefore propose to examine techniques and contextual influences for acquiring and using patient experience in a vulnerable population (acutely and critically ill patients and their families) in two emergency settings in hospital: the acute medical unit (AMU) and the intensive care unit (ICU). Both these areas are important in terms of patient volumes, acuity, costs and outcomes, and both offer access to measures of case mix and performance. They also offer useful contrasts in terms of patient dependence, staffing, length of stay, and workload. We will develop a process to collect and present data on patient experience of different types ranging from questionnaire responses to complaints. We will then create a context-sensitive workplace-based forum where this information can be fed back to staff, and a protocol to encourage reflective learning so that staff continually improve their capacity for self-criticism and improvement. Adopting the MRC’s guidance on using a theory-driven approach for complex interventions [MRC 2014], we will base our approach on a theoretical framework: the COM-B model and the Behaviour Change Wheel [Michie 2011]. The Behaviour Change Wheel (BCW) [Michie 2011] (Fig 3) is a widely cited and tested synthesis of 19 behaviour change frameworks. The central tenet of COM-B is that Capability, Opportunity, and Motivation interact to generate Behaviour(examples in Appendix 1a-c). It has been used in a range of health contexts to make a ‘behavioural diagnosis’ of what needs to change in order for the desired behaviour to occur (Michie, Atkins & West, 2014). This model has been used successfully to effect improvements in teamworking in an emergency department [Frykman 2014], and is consistent with the Daniel Kahneman’s conceptualisation of ‘fast and slow thinking’ [Khaneman 2011] and that of Tacit/Implicit & Explicit knowledge. The hypothesis of the PEARL project is that patient experience can be used to change behaviour by facilitating transitions from implicit knowledge (System 1 thinking) to explicit knowledge (System 2), embedding that experience in a revised set of norms, and then returning the revised behaviours to System 1 for ‘habit-forming’ routine operation. The Programme Theory is presented in Fig 2 of the protocol.

Lay abstract: The Mid-Staffordshire Hospital report demonstrated that failure of compassion in care is a consequence of the dangerous combination of individual denial of responsibility within an inhibited system. Many of the failings of Mid Staffs may therefore be interpreted as a consequence of interactions between practitioner attitudes and behaviours on the one hand, and resources and structures on the other. These types of attitudes and behaviours are common enough in everyday social interactions, but become lethal within high-risk environments when there is a power imbalance between participants. The aviation industry recognised this many years ago and focused the entire workforce on safety; flattening working hierarchies, standardising practice and using the principles of ‘crew resource management’. However, in the healthcare setting, evidence that ‘non-technical skills’ training having a durable impact is not dependable. There are several challenges to training in non-technical skills: underlying attitudes are often obscure; the training environment is often artificial; the opportunity for reflection is greatly limited; the impact fading quickly; and the practitioner is not directly harmed by any error. Our research proposal focuses on the implementation of reflective learning; a central component of educational theory and practice. We define reflective learning in our proposal as “an experiential process of personal insight development” or more simply, it is the process of internally examining and exploring an issue of concern that is triggered by an experience, which in turn creates and clarifies meaning and results in a changed conceptual perspective. Our overall aim is to develop a theory-based framework to promote reflective learning which links patient experience as directly and immediately as possible, to both a group and an individual performance. Through the use of questionnaires, interviews and observations we will develop an understanding of how patients, relatives and staff understand the experience of travelling through the health system, how quality is perceived, and how attitudes and behaviours affect the overall patient experience. We will characterise individual and organisational barriers and facilitators of good practice. Building on existing quality control processes in hospitals, we will organise information on the patient experience in a form that can be easily understood. This information will be fed back to clinicians during organised quality improvement meetings where they will be mentored in the art of reflective practice so that, rather than being defensive, staff incorporate the ideas of self-criticism and continual improvement into their normal working lives. We will develop this into a framework of workplace-based reflective learning tools and processes with potential for incorporation in national training programmes. In short, and more importantly, we shall develop and pilot a tool for ‘culture change’; applying those so valuable lessons from the Francis Report outcome. We will locate this project in the acute medical and intensive care units of three hospitals for the very reason that these are high-risk environments in which vulnerable emergency patients benefit from multidisciplinary team (MDT) based care requiring a high level of integrated team working. The project builds on our previous successful patient experience work.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE