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ESSEnCE: Amalgamating marginal gains in ESSEntial Nursing CarE

Professor David Richards, Dr Claire Pentecost, Angelique Hilli MSc Complex Interventions Research Group

University of Exeter Medical School

http://medicine.exeter.ac.uk/research/healthserv/complexinterventions/projects/essence/

BACKGROUND

Nursing care matters a great deal to patients and the public. When nursing care is sub-optimal patients experience health care negatively. Failure to assure the quality of nursing care leads not only to distress and dissatisfaction, but also to wider patient safety failures as demonstrated in two recent high profile reports - Winterbourne View and Mid Staffordshire.

In this research we want develop a method of nursing that improves patients’ experiences of nursing care.

OBJECTIVES

Our overarching aim is to develop and test an innovative approach to integrating and improving nursing care based ‘amalgamation of marginal gains’ (AMG) as used by others - and evaluate how this innovative approach to nursing care impacts on patient outcomes.

Our main research questions are:

1. What is the impact of an AMG focused integrated essential care nursing intervention for adults in hospitals in terms of patient comfort, experience of care, quality of life and costs?

2. What are the factors that might mediate this AMG intervention?

With our National Institute for Health Research (NIHR) Programme Development Grant (Feb 2016-Aug 2017) we will first address critical uncertainties that need to be answered before we can progress to answering our main research questions.

These uncertainties will be addressed by three key activities, activity 1, activity 2 and activity 3.

ACTIVITY 1

Research question: What relevant procedures can we adapt from the methods used by elite sports teams and healthcare innovators to identify, address and amalgamate marginal gains in nursing?

Methods: Qualitative interviews

Sample: Up to thirty people who have adopted an amalgamation of marginal gains philosophy in non-health and healthcare arenas. We will approach members of current and past coaching, managerial, administrative staff and athletes from successful sports teams, plus healthcare innovators, including the NHS Enhanced Recovery Programme teams in surgery, anaesthesia, paediatrics and stroke care.

Analysis: We will use a conventional framework approach in which themes will be developed to identify key concepts. Interview transcripts will be examined thematically across the whole data set as well as in the context of each interview, using a constant comparative analysis approach.

Research question: What is the evidence for the effectiveness of component elements of a complex nursing intervention addressing the essential communication, nutrition/hydration, elimination, mobility and hygiene needs of patients?

Methods: Mixed studies systematic review

Sample: We will include published articles reporting studies that identify, describe and/or test the relationship between nursing behaviours and patient experience in meeting the communication, nutritional/hydration, elimination, mobility and hygiene needs of patients. We will also include studies that canvass the narrative views of patients and nurses on essential care behaviours.

Analysis: Our mixed studies review will follow a sequential explanatory design where synthesis of numerical (quantitative) data precedes a meta-synthesis of narrative (qualitative) data.

ACTIVITY 2 ACTIVITY 3

Aim: To develop and strengthen the research team and our stakeholder advisory group

Procedure: Although our applicant team includes clinical academic nurses, a clinical nurse specialist, nurse managers, Patient and Public Involvement (PPI) representatives, methodologists, an allied healthcare professional and a sports scientist we will build improved stakeholder collaborations across our three proposed NHS research sites, particularly Plymouth and Southampton.

Analysis: We will analyse the strengths and weaknesses of our current collaborations in Southampton and Plymouth and develop an action plan to address identified weaknesses. We will strengthen our stakeholder representation from carers and family members and from organisations representing older people including charities.

CURRENT PUBLICATIONS

Richards DA. (2015). The complex interventions framework. Complex Interventions in Health. An overview of research methods. Richards DA. & Rahm Hallberg I. pp. 1-16. Routledge: Oxon. Richards DA. Complex interventions and the amalgamation of marginal gains: A way forward for understanding and researching essential nursing care? Int J Nurs Stud. 2015;52(7):1143-5.

We plan to design and test a new method of nursing based on a process called the ‘amalgamation of marginal gains’ (AMG). This has been used very successfully in Olympic Gold medal winning GB cycling and Team Sky cycling team and in some health care settings, but not so far in nursing. The AMG system will be designed to help nurses achieve small improvements in many different areas leading to overall better quality care.

We will focus on the ‘essentials of nursing care’: communicating with patients; helping patients with eating and drinking; going to the toilet; moving around; and being clean and comfortable.

For more information: 01392 724653 or C.Pentecost@exeter.ac.uk Credit to: www.britishcycling.org.uk