The benefit of focus groups: The experience of critical care nurses who participated in a needs assessment.

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1 The benefit of focus groups: The experience of critical care nurses who participated in a needs assessment.

2 Presenters Angele Landriault, RN, BScN, MEd student Royal College of Physicians and Surgeons of Canada; Practice, Performance and Innovation unit. Frances Fothergill Bourbonnais, RN PhD Professor Emeritus, School of Nursing University of Ottawa

3 Conflicts of Interest None reported Funding sources for this research project: CIHR LHIN 3

4 Research team Aimee J. Sarti MD Pierre Cardinal MD, MScEpi Angele Landriault, RN, BScN Stephanie Sutherland PhD Frances Fothergill Bourbonnais, RN, PhD Timothy Willett MD, MMed Redouane Bouali MD Stanley J. Hamstra PhD

5 Ministry of Health and Long-Term Care of Ontario Critical Care Strategy (2006) to improve: Access Quality System integration To ensure all citizens in Ontario have equal access to high quality care regardless of location MOH-LTC, 2013

Background Vision: Right care, right place, right time The care of critically ill patients in Canada Delivered by multiple interprofessional health teams - Within

6 Background Vision: Right care, right place, right time The care of critically ill patients in Canada Delivered by multiple interprofessional health teams - Within community hospitals - and referral hospitals Equal access and excellence in care requires: A collaborative approach Highly skilled teams Coordinated system of hospitals

7 Background Building relationships between centers has benefits: Increased patient and staff satisfaction More comprehensive training programs Improved financial performance Decreased delays in patient transfers Rusinova et al, 2009; Giacomini, Cook & DeJean, 2009; Patton, 2002 In order to facilitate change in clinical practice, it is important to understand: Organizational culture The complex health system Kern, Thomas & Hughes, 2009; Moore, Green & Gallis, 2009

8 In keeping with MOH-LTC mission Objectives of the main study Design and implement a needs assessment (NA) process Explore the different elements that impact care of critically ill patients in the community including the relationship between the community hospital (CH) and the referral hospital (RH) Identify any educational and system-level gaps. Data Approved collected by the between institutional June 2011 review and boards February at both 2012 sites.

9 MIXED METHOD RESEARCH The planned integration of qualitative and quantitative data within studies is described as mixed methods Loiselle, Profetto-McGrath, Polit, & Tatano-Beck,

10 Advantages of mixed methods The limitations inherent in one method may be compensated for by the other; The strengths of one method add to or even enhance the strengths of the other; Providing complementary information More complete and comprehensive explanation Loiselle et al, 2007; Risjord, Dunbar & Moloney, 2002 Researchers can be more confident about the validity of their findings. Loiselle et al, 2007; Patton, 1990

11 Methods - Conceptual Framework The System The critically Ill Patient COMMUNITY HOSPITAL REFERRAL HOSPITAL HUMAN, PHYSICAL & SOCIAL CAPITAL Patient and Family Beliefs/Expectations FAMILY Bourdieu (1986)

12 Methods - Conceptual Framework The System The critically Ill Patient COMMUNITY HOSPITAL REFERRAL HOSPITAL HUMAN, PHYSICAL & SOCIAL CAPITAL Human Capital: the collective human resources available their knowledge, skills and abilities gained through education and experience Patient and Family Beliefs/Expectations FAMILY Bourdieu, 1986; Becker, 2009; Schultz, 1961; Becker, 2009; Coleman, 1998

13 Methods - Conceptual Framework The System The critically Ill Patient COMMUNITY HOSPITAL REFERRAL HOSPITAL HUMAN, PHYSICAL & SOCIAL CAPITAL Human Physical Capital: the any collective assets, human which are resources applied to care available for critically ill their patients, knowledge, such skills as medications and abilities and equipment gained through education and experience Patient and Family Beliefs/Expectations FAMILY Bourdieu, 1986; Becker, 2009; Schultz, 1961; Becker, 2009; Coleman, 1998

14 Methods - Conceptual Framework The System The critically Ill Patient COMMUNITY HOSPITAL REFERRAL HOSPITAL HUMAN, PHYSICAL & SOCIAL CAPITAL Human Physical Social Capital: any the collective connections assets, human which between are resources applied professionals to care available for includes critically the ill their patients, connections: knowledge, such skills as medications within and the abilities and CH equipment gained through between the education CH and and RH experience Patient and Family Beliefs/Expectations FAMILY Bourdieu, 1986; Becker, 2009; Schultz, 1961; Becker, 2009; Coleman, 1998

15 Sample Different perspectives sampled: Regional leaders Health care professionals community hospital referral hospital Family members

16 Data collection Data sources included: Interviews (n=22) Walkthroughs (n=5) Focus groups (n=31) Database searches Context questionnaires (n=8) Family surveys (n=16) Simulations (n=13) n= number of participants in each data collection source

17 Data analysis Included the application of inductive coding techniques Codes were generated directly from the data sets Consistently applied to the data from Interviews Focus groups Walkthroughs Simulation debriefing sessions NVIVO software used for data management Giacomini & Cook (2000); Watkins, West Meiers & Visser (2011)

18 Methods - Analysis Selection of assessment instruments based on the conceptual framework Quantitative data collection and analysis Qualitative data collection and analysis Context, family input, performance during crises Themes Gap analysis and prioritization Vision Needs Solutions

19 Data analysis 4 researchers made up the Analysis team Coding training and meetings to develop the codebook Inter-rater reliability assessed Prior to independent coding And at mid-point Greater than 85% agreement Ongoing group discussion and agreement on emergence of new themes and addition of codes

Needs identified Community Hospital needs Need to improve

Bed flow and ICU bed use Gaps in Communication Lack of

Interprofessional team work Interhospital needs Inadequate

20 Needs identified Community Hospital needs Need to improve Access to Human Resources Gaps in Expertise Need to improve Bed flow and ICU bed use Gaps in Communication Lack of Educational opportunities Gaps in End of Life care Gaps in Interprofessional team work Interhospital needs Inadequate Hospital Network Gaps in Transfers and Repatriation (transfer back) 22

21 Discussion The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. 23

Discussion The ability to deliver high quality care to critically ill patients was impacted by both human and social capital Including gaps in Expertise Communication Interprofessional

22 Discussion The ability to deliver high quality care to critically ill patients was impacted by both human and social capital Including gaps in Expertise Communication Interprofessional teamwork Contributing to the gap in expertise for recognition and management of critically ill patients were: Lack of exposure to critically ill patients Lack of educational opportunities

23 Discussion Both the Referral Hospital and Community Hospital recognized the need for: An adequate hospital network requiring improved communication and collaboration between the two hospitals including: Education Consultation Feedback on patients transferred Gaps were identified with inter-hospital transfers Surrounding the decision to transfer Process of transfer and repatriation (transfers back to the Community Hospital).

24 Discussion Identification of potential solutions originating: Within the system by participants As opposed to solutions imposed from the outside Solutions Some were clinical/educational and centered on the processes of care - e.g. improved team skills during a crisis Others addressed the structure of care - e.g. implementation of a rapid response system Donabedian, 1988

25 Discussion Important consideration to improve patient outcomes: Combine educational solutions with organizational solutions to ensure that competent health care providers are available at the bedside when patients deteriorate.

26 Focus groups THE EXPERIENCE OF NURSES IN THE FOCUS GROUPS 28

27 Focus groups-what are they? Focus groups are staged events the purpose being to encourage informants to talk and express their views on a topic.

28 Focus groups A total of 6 focus groups conducted. Nurses involved in 5 of these. At the CH, 4 focus groups conducted. Nurses involved in 3. Discipline specific (2) Interprofessional (3) Interprofessional and intersite (1) We will zone in on the focus groups that involved CH nurses

29 Focus groups Participation in the study was entirely voluntary. Prior to each focus group, nurses read the consent form. The focus group with just nurses was approximately 120 minutes in duration. The focus group with both sites 150 minutes long Focus groups were taped and transcribed verbatim.

30 Focus groups To ensure consistency in the focus group interview process, the same co-investigator conducted all the interviews. Standard probes ensured consistency in the interviews. Morse, J. (1994) Critical issues in qualitative research methods. Sage publication: Thousand Oaks, CA.

31 Safe place to express concerns The Community Hospital focus group gave an opportunity to nurses from the different departments (ER, ICU, Ward) to engage in a dialogue about inter-departmental issues. [In the ER] when it's time to transfer to the ICU that s when they state they are not ready to take her. There's a staffing ratio, she needs to be one to one. Well if you re shipping five to one down in emergency... Sometimes I think that - why does she become one to one up in the unit when downstairs (CH Nursing focus group) 33

32 Safe Place to express concerns Nurses in ER in the CH felt that they were disliked by nurses in ICU and other areas of the hospital I think as a group we feel disliked strongly by the units- the fact that we are bringing a patient to an already tired busy unit (nursing focus group)

33 Safe place to express concerns Their advocacy role was expressed in both nurse specific groups and interdisciplinary groups Because you know what? You want to do what's best for that patient. (CH Nursing focus group) I know why I am here every single day- it is to take care of that person in the bed? (Interdisciplinary focus group) 35

34 The voices of nurses suggested what needed to be done Nurses, as front line workers, have insight into what is needed for improvement. The focus group was a venue to have their voices heard. Standing orders are awesome because it gives us we don t have to be calling for every little thing and gives us a wide spectrum of what we're allowed to do. (CH Nursing focus group)

35 The voices of nurses suggested what needed to be done I think you have to have a big team effort Perhaps we could have RN here speaking to RN in teaching hospital re nursing care We used to share (shift report) which was a way of teaching and now we don t share Could we have like more education? I know that up at the [Referral] Hospital they really have this well organized. Can we go too?

36 The voices of nurses suggested what needed to be done I had no hesitation participating in this focus group because for me. Communication is my main. If I do not have good communication, it s key I would like to have happen in this focus group here is to discuss a bit about pathways because it would make our lives in the ER much better if we knew where people were going.

37 Nurses challenges were validated In the interdisciplinary focus group, the challenges nurses faced were validated by other members of the health care team. And the nurses always do it (discuss DNR status) and I don t think that s fair to you guys. That s just my opinion on it. 39

38 A venue for establishing a shared understanding The interhospital interdisciplinary focus group brought forth greater understanding of the situation of nurses in the community hospital. I think some of us had that feeling but I thought she had an Intensivist on Like that s what I mean, you ve opened my eyes. But honestly, hearing what she said, that s enlightening, you know, we wake up when we hear this.

39 Their voice The medical directives are how we do our plans. But then there s also nursing directives that could influence care Here the nurse was referring to nurse- nurse consults between CH and referral hospital to help care for a patient

40 Their voice we are mired knee deep in paper work. We take wonderful care of our paper work. (Nurse only focus group) I am a little package of peanut butter and I was expected to cover 4 crackers. I am that same package of peanut butter and now expected to cover a loaf of bread. (Nurses only focus group)

41 Views as the moderator Given a voice Openness Vision that they all had for patient care Why this approach was so important in a needs assessment

42 Views as the moderator Nurses had a better understanding of the system and what can change Better understanding of each other with in their hospital. This helped them to see structure and process of what went on and then what could change over time.

43 Views as the moderator The opportunity to reflect on the vision of what should be and could be is empowering and brings hope. Their optimism of this process fuels what needs to happen Witnessing the behavior of the participants and how they interacted with each other. Their appreciation of the opportunity to have a voice in determining their future.

44 Views as the moderator How political decisions re services offered in a hospital impact on nurses ability to provide care our health teaching used to be huge We are still the circle of care but we are not really part of it any more because we have given it up (Nurse only focus group)

45 Conclusions Studies in the social sciences suggest that change in participants knowledge and/or behaviors at the individual and/or system level can occur simply by engaging in the process of evaluation. This concept can be extended to NAs for healthcare systems. The NA itself may be an important first step in the process of learning and practice change. Sutherland, 2004; Preskill, Zuckerman & Matthews, 2003; Fross, Rebien, 2002; Russ-Eft, Atwood & Egherman, 2002; Shulha, 2000; Norman, Shannon & Marrin, 2004.

46 Conclusions More broadly, the NA may also be a key step in organizational change necessary to optimize learning and improve patient outcomes. In this study, participants acknowledged that they gained new insight into the context of current practice and their needs. In addition, a deeper reflection and realization of self may have occurred, setting the stage for practice change or inspiring action to improve systems.

47 Conclusions In addition to providing rich data on the different elements that impact the care of critically ill patients in a community hospital, the focus groups provided a venue for nurses to share their experiences, gain a better understanding of the system and build a collective vision for patient care. 49

48 References Becker, G. (2009). Human capital: A theoretical and empirical analysis with special reference to education. University of Chicago Press: Chicago, Il. Bourdieu, P. (1986). The forms of capital. In: Richardson JG, ed. Handbook of theory and research for the sociology of education. Greenwood Press: New York: Coleman, J.S. (1988). Social capital in the creation of human capital. American Journal of Sociology, 94(Suppl): Donabedian, A. (1988). The Quality of Care. Journal of the American Medical Association, 260(12): Forss, K., Rebien, C.C. & Carlsson, J. (2002). Process Use of Evaluations. Evaluation, 8(1): Giacomini, M.K. & Cook, D.J. (2000). For the Evidence-Based Medicine Working Group. Users Guides to the Medical Literature. XXIII. Qualitative Research in Health Care: A. Are the Results of the Study Valid? Journal of the American Medical Association, 284(3):

49 References (continued) Giacomini, M., Cook, D. & DeJean, D. (2009). Life support decision making in critical care: Identifying and appraising the qualitative research evidence. Critical Care Medicine, 37: Kern, D.E., Thomas, P.A. & Hughes, M.T. (2009). Curriculum Development for Medical Education: A Six-Step Approach. JHU Press: Baltimore, MD. Loiselle, C.G., Profetto-McGrath, J., Polit, D.F., & Beck, C.T. (2007). Canadian essentials of nursing research. (2nd ed.). New York: Lippincott, Williams & Wilkins. Moore, D.E., Green, J.S. & Gallis, H.A. (2009). Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. Journal of Continuing Educcation for Health Professionals, 29(1):1-15. MOH-LTC Critical Care Strategy website. Accessed on January 3, 2013 from: etariat.aspx Morse, J. (1994) Critical issues in qualitative research methods. Sage publication: Thousand Oaks, CA. 51

50 References (continued) Norman, G.R., Shannon, S.I. & Marrin, M.L. (2004). The need for needs assessments in continuing medical education. British Medical Journal, 328: Patton, M. (1990). Qualitative evaluation and research methods. Beverly Hills, CA: Sage Patton, M.Q. (2002). Qualitative evaluation and research methods (3rd ed). Thousand Oaks: CA. Preskill, H., Zuckerman, B. & Matthews, B. (2003). An Exploratory Study of Process Use: Findings and Implications for Future Research. American Journal of Evaluation, 24(4): Risjord, M., Dunbar, S., & Moloney, M. (2002). A new foundation for methodological triangulation. Journal of Nursing Scholarship, 34, Rusinová, K., Pochard, F., Kentish-Barnes, N., Chaize, M. & Azoulay, E. (2009). Qualitative research: Adding drive and dimension to clinical research. Critical Care Medicine, 37(1):S140-S

51 References (continued) Russ-Eft, D., Atwood, R. & Egherman, T. (2002). Use and Non- Use of Evaluation Results: Case Studies of Environmental Influences in the Private Sector. American Journal of Evaluation, 23(1): Schultz, T.W. (1961). Investment in human capital. American Economic Review, 51:1-17. Shulha, L. (2000). Evaluative Inquiry in University-School Professional Learning Partnerships. New Directions for Evaluation, 88: Sutherland, S. (2004). Creating a Culture of Data Use for Continuous Improvement: A Case Study of an Edison School Project. American Journal of Evaluation, 25(3): Watkins, R., West Meiers, M. & Visser, Y.L. (2011). A Guide to Assessing Needs Essential Tools for Collecting Information, Making Decisions, and Achieving Development Results. Washington DC; The World Bank. 53

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