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A realist evaluation of patient involvement in a safer surgery initiative

Roche, Dominic 2016. A realist evaluation of patient involvement in a safer surgery initiative. PhD Thesis, Cardiff University.
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Background Research has shown that healthcare organisations can cause harm to patients, much of which is avoidable, and there is reliable evidence to suggest that this harm is a widespread and recurring phenomena (Institute of Medicine 1999; Department of Health 2000; Leape et al 2002; de Vries et al 2008; Longtin et al 2009; Jha et al 2010). Encouraging patients to take an active role in their own healthcare was identified in the landmark patient safety publication ‘To Err is Human’ (Institute of Medicine 2000) as a vital factor in the quest to improve patient safety. It has since been contended that if patients were involved in their healthcare they could help to further reduce opportunities for accidents and errors during the course of their care (Vincent and Coulter 2002; Koutantji et al 2005; Weingart et al 2005; Unruh and Pratt 2006; Davis et al 2007). More recently, there has been growing interest in the development and use of interventions to promote and support patients’ roles in securing their own safety in healthcare contexts (Hall et al 2010; Longtin et al 2010; Peat et al 2010; Doherty and Stavropoulou 2012; Vaismoradi et al 2014). Aims The broad aim of this study is to explore the extent to which patients are involved in attempts to improve their own healthcare safety through enrolment in an enhanced recovery after surgery (ERAS) programme. Recognising that patient safety is just one aspect of the ERAS programme theory, this research evaluates those elements of the programme that see patients taking a role in their own healthcare safety. This is achieved by considering in realist terms the mechanisms of effect by which patients might contribute to their healthcare safety and investigating the conditions and circumstances (contexts) that are required to enable this involvement. The overall aim of this research is to seek out regularities in the patterns of these contexts and mechanisms which result in patient involvement in patient safety. The emerging theory will explain implementation variations, and the experiences of the programme participants in the different cases will provide an opportunity to make comparisons with initial programme theories, the objective being to better understand when and why patient involvement in patient safety works in an ERAS programme. Methods The underpinning methodological framework for this research is realist evaluation (Pawson and Tilley 1997), which is a technique concerned with exploring the interaction among context, mechanism and outcome, based on the realist principle of generative causation. This study uses an in-depth multiple case study approach, with each of the three surgical units under study purposively selected to represent involvement in the ERAS programme. To capture the complex and dynamic nature of the programme under investigation, the study draws on a wide range of empirical data sources, methods and materials, including ethnographic observations, semi-structured interviews and document analysis. Taking ‘early mobilisation’ as a tracer outcome, the study examines the mechanisms and contexts involved in programme outcomes in relation to patient involvement in patient safety. The first stage of the enquiry involves eliciting and formalising the programme theories relating to patient involvement in patient safety in an ERAS programme which are then articulated in conjectured context-mechanism-outcome configurations (CMO) terms. The next stage involves collecting data that will allow interrogation of these hypotheses, comparing the programme’s intentions with case study data of actual practice that occurred and the views and experiences of key stakeholders, including patients and nursing staff. This is followed by cross case comparisons which attempt to determine how the same mechanisms played out in different contexts. Key findings Overall, the findings show that there are many contextual factors relating to the successful outcomes of the programme theories postulated. The key findings of this study demonstrate that successful patient involvement in patient safety related elements of an ERAS programme requires that: ward staffs are aligned with the programme objectives; that patients’ expectations for their post-operative recovery are managed prior to surgery and the underlying rationale for their care is understood and; in the post-operative period patients’ enrolment in the programme is sustained and reinforced by ward based staff. The study also demonstrates how differences in the implementation of ERAS across the study sites, support for early mobilisation and individual patient differences (for example emotional status and operation type) were consequential for the outcomes of the programme theory. Conclusion This thesis sits at the interface of a number of health policy and quality improvement trends including patient involvement, patient safety, standardisation, patient centred care, co-production and the growing interest in healthcare with the implementation and embedding of interventions. The aspirations of policy and programme documentation to ‘empower’ patients to take a more active role in their care also proved more complex in reality. The study highlights the tensions between achieving a quality standard and patient centred care and how the approach to postoperative care in the three different case study sites shaped nurses’ willingness to adapt the programme and support patient involvement. The main areas for consideration from this study include the importance of the role of healthcare staff in attempts to involve patients in patient safety, along with the tensions between standardisation of care versus the aspirations of providing person-centred, individual care for patients. This is considered in relation to the ongoing standardisation of healthcare through an increasing reliance on protocols and pathways, such as the ERAS programme.

Item Type: Thesis (PhD)
Date Type: Completion
Status: Unpublished
Schools: Healthcare Sciences
Subjects: R Medicine > R Medicine (General)
Uncontrolled Keywords: patient safety, patient involvement, surgery, ERAS, enhanced recovery, realist evaluation, realism
Funders: NISCHR (Health and Social Care Research Wales)
Date of First Compliant Deposit: 3 January 2017
Last Modified: 08 Dec 2021 15:05

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