Title: Using rich evidence and forum theatre to enhance practitioner mindlines: a pilot study of a new knowledge mobilisation method applied to post-injury psychological care
Funder: Department of Health and Social Care

Abstract: Background The impact of psychological sequelae, such as Post-Traumatic Stress Disorder, on the duration, extent and costs of recovery from unintended injury (in adults) is internationally recognised. This is not a minor problem; unintended injuries are a leading cause of disability worldwide accounting for 700,000 UK admissions per year. Of these >30% develop clinically significant psychological disorders within 12 months which can increase the non-fatal burden of injury by as much as 50%. Evidence regarding effective means to reduce and manage post-injury psychological morbidity is available in published systematic reviews. Yet the recent NIHR funded Impact of injuries study' among 668 injured adults (aged 16-70) confirmed the need to improve NHS post-injury psychological care.This is a good example where extensive evidence exists but is not practised. Many approaches have been tried to improve the uptake of research evidence. However Gabbay and Le-May (2010) asked instead what forms of evidence already underpin practice (and why)?' and how is this evidence modified and applied?' Their ethnographic study found practitioner decisions and actions are based on mindlines' (or tacit guidelines) combining multiple sources of evidence which equip practitioners with the contextual adroitness to manage complex NHS demands. Mindlines are formed and refined by largely social processes in clinical training and practice. Their work suggests the challenge for Knowledge Mobilisation (KM) is to augment practitioner mindlines using methods that replicate (or enhance) those in practice. Two existing service improvement methods could be extended for this pupose: Experience Based Co-Design (EBCD) and Forum Theatre (FT). Both incorporate facilitated social processes, patient/user stories, user-centric design and exposure to alternative evidence. Their use of film (or theatre) creates impact by evoking an emotional and rational response. EBCD maps key touch' points in the patient journey where improvement is needed. Aim To develop a new KM approach based on mindlines, EBCD and FT research to purposively influence the content, flexibility and application of trauma practitioners' mindlines to improve patient care: and evaluate it in the context of post-injury psychological care.Research Questions To what extent can: key touch points in the patient's journey map important differences in patient, practitioner and research perspectives on care? practitioner mindlines be influenced by interaction with a patient story using FT techniques? this method expand practitioners' knowledge base and skills and be translated into improvements in patient care? is this method applicable, transferrable and effective in improving KM in the NHS? The 6 phase study design involves patients, practitioners and experts in the field. Comprehensively capture patient narratives, practitioner mindlines and research evidence regarding post-injury psychological needs and care: using interviews, focus groups and literature review Systematically map and compare key touch points in these three perspectives using framework analysis Co-design a FT play to enact a blended patient story illustrating important differences between these perspectives at key touch points and their contribution to poorer outcomes Perform the play at two interactive filmed patient/trauma practitioner workshops using FT techniques to facilitate debate, create and rehearse new practices. Package fellowship generated resources (FT workshop, handbook, promotional films and FT expertise) to promote their wider use Evaluate the effectiveness of this KM method to achieve project aims and for wider application Summary of potential benefits to the patient/NHS Improve local post-injury psychological care Develop transferrable resources to improve NHS post-injury psychological care Reduce post-injury costs associated with psychological morbidity Improve the influence and impact of NIHR/other research Demonstrate strengths of greater service and user involvement in research Increase capacity for KM and research Develop an innovative KM method for wider use Develop resources and expertise to promote this methods' further use

Lay abstract: AimTo use participatory theatre to enrich trauma practitioners' knowledge of the psychological impact of injury and help them test new strategies to improve patient care.Background Accidental injuries are a leading cause of disability worldwide, with consequences for patients, families, the NHS and society. In the UK, 5.8 million people annually attend Emergency Departments following an accidental injury, 700,000 are admitted. Emotional distress is normal afterwards, but research shows that >30% of patients develop more serious psychological problems (e.g. Post-Traumatic Distress) which significantly delay and limit the extent of recovery and increase costs. Effective means to prevent, diagnose and treat post-injury psychological disorders are well known but poorly implemented in practice. Indeed the Impact of Injuries Study (IOIS), a large study of 668 injured adults in 4 UK cities found their immediate and longer-term psychological needs were often inadequately met. Poor evidence uptake is not uncommon, much of eight billion pounds annual expenditure on UK health research fails to have direct or significant impact on patient care. This has increased the emphasis on finding better means to ensure research evidence is implemented to improve practice. However in 2004 two researchers reframed this problem. They observed practice to see what sources of evidence were already in use (and why) and how practitioners developed and shared this knowledge. They concluded that practitioners make clinical decisions using mindlines' containing many different forms of evidence (including research). These mindlines' provide broad flexible knowledge and skills to manage the NHS's complex demands. Their research suggests that scientific facts alone are insufficient and evidence needs to be tried and tested in the real world to inform patient care. The question remains how can we intentionally influence practitioner mindlines so they can improve practice'? I think elements of two successful service improvement methods Experience based Co-Design' and Forum Theatre' could be adapted for this purpose. I propose to develop a new approach based on these methods and research, using post-injury psychological care as an example. I will collect patient stories and different takes (patients', practitioners' and research) on when and how injured patients need help with their psychological recovery. I will condense this information and present it at two patient/trauma practitioner workshops using Forum theatre (FT) techniques. FT uses drama to engage people and help them creatively apply their own and others' knowledge to solve difficult problems in real life. This study will test whether this approach can meld theoretical research evidence with emotional, practical and organisational realities to enhance practitioners mindlines and hence practice. Design and methodsPhase-1: Capture patient, practitioner and research perspectives on post-injury psychological needs and care using focus groups, interviews and literature review Phase-2: Systematically compare and map emotionally significant points in injured patients' recovery from these 3 perspectives. Phase-3: Use this data to develop a script for a short provocative play illustrating how differences in patient, practitioner and research perspectives can result in poor patient outcomes.Phase-4: Run 2 filmed patient/practitioner workshops including: the play followed by facilitated discussion, re-performance of the play with participants stopping it at any point to describe or act out alternative solutions. I will review workshop films to see how this process changes practitioners' mindlines, follow-up research will reveal resultant changes in practice. Phase-5: Develop promotional films and handbook to facilitate wider use of this approach Phase-6: Evaluate the process and make recommendations for its future use Patient and public involvement This research originated from an important gap revealed by IOIS patients, including 15 from Bristol who wrote afterwards to thank us for listening. Some offered more support and became active members of a Patient-Public-Involvement (PPI) group to ensure this study examined the right things. They stressed that injured patient's psychological needs are inseparable from the rest of care and gave examples where poor care increased their psychological distress. PPI will be extended in the next phase.Dissemination. This study will investigate how effectively this approach enhances practitioner mindlines and alters practice. In the future I'd like to: systematically test its impact on patient outcomes, roll it out to other trauma services and to address other NHS problems. I will ensure this approach is widely shared with practitioners and researchers locally and beyond through formal/informal means. This study will generate resources for future use including: A bespoke workshop to help improve post-injury psychological care in other NHS trusts A handbook containing essential information to help future workshop organisers 2 short films to promote this approach in practice and in research

Research activity codes: 8.4 RESEARCH DESIGN AND METHODOLOGIES (HEALTH SERVICES);7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH