Workforce Engagement

Can we adapt the way we do research when involving healthcare staff as research participants?

Dr Raabia Sattar, Dr Jane Heyhoe & Professor Rebecca Lawton

NHS staff live the health system every day and have much to offer research about healthcare (Marjanovic et al., 2019). Their first-hand experience and insight means that staff have a unique role in applied health research that seeks to improve the delivery of care and support staff wellbeing. Applied health research is beneficial for patients, healthcare staff, and organisations. A review by Harding et al (2107) found that staff participation in research was associated with increased organisation level patient satisfaction, improved efficiency of care, and lower staff turnover. Increased levels of research engagement by healthcare staff may improve the processes of care (Boaz et al., 2015).

While NHS healthcare staff can make important contributions to research, there are a number of barriers to staff taking part. These include a lack of time to participate in research (Marjanaovic et al., 2019), a lack of funding to support engagement (Bryant., 2014; Brereton, L., et al., 2017), and a lack of support by leadership (Evanst et al., 2013; French et al., 2016; Mitchell et al., 2015). While research has been at the centre of an effective response to Covid-19, pressures on staff have only increased during the last two years, meaning that staff ability to be involved in research as participants is also under pressure. At the same time, the Covid-19 crisis and the associated changes in practice, work pressures and emotional toll mean that now more than ever the voices of NHS staff need to be heard. This is vital if we are to learn from and respond to their first-hand experiences of delivering care during these unprecedented times and to ensure the development of the most appropriate interventions, policies and frameworks to continue to improve healthcare.

The traditional ways of including staff in research have involved methods such as face-face interviews, focus groups and questionnaires, as well as observations of the work as done via ethnographic studies. Undoubtedly, these types of research techniques are needed to address certain research questions. However, as researchers, it is important that we take into account that when we ask healthcare staff take part in such research activities, they are away from their clinical duties and responsibilities. We must also consider, what are we offering staff in return for their time? Can we adapt the way we involve participants in our research so that there is greater participant gain? Below, we provide an example of an alternative participation approach we have used for one of our research projects.

An example of an innovative approach: CASE (Conversations About Safety and Emotions)
How we express emotion and interpret emotion in others is integral to important aspects of healthcare such as decision making, team functioning and effective leadership. Healthcare professionals are required to make clinical decisions in contexts that are emotionally charged and require healthcare staff to actively manage their own and others emotions (Kozlowski et al, 2017). Although there is now increasing recognition that emotions play an important role in staff wellbeing, patient experience and the delivery of safe care, research within this area is limited. Therefore, the aim of this study was to explore the role of emotion in maternity practice within hospital settings.

We were planning this study during the initial months of Covid-19, and we quickly realised that healthcare staff within the NHS were now being faced by immense service pressures. After discussions with a member of our team, a consultant obstetrician, we started to think more about reciprocity as part of the research contract. Most research groups provide feedback to participants about the findings of their research and make recommendations that can be used to improve practice, but benefits associated with the ‘process’ of being a participant in research are less frequently deliberated. This notion of benefits of participation was central to our research design. We worked with our clinical partners to develop a workshop series focusing on delivering evidence and supporting staff to think about the evidence on emotion and safety. The series – Conversations About Safety and Emotion was delivered during scheduled training time (Friday afternoons). Whilst delivering the workshop we planned to collect data by recording the break out room discussions which we ran as short focus groups. Using this innovative approach allowed us as researchers to capture the data we required for our study, whilst also offering healthcare staff training.

This study is now underway and takes the form of a programme of four online interactive training workshops, with a mixture of teaching and group discussions. These workshops are multi-disciplinary in nature, and include maternity clinicians including midwives and obstetricians as well as senior leaders. The workshops are delivered by psychologists and a consultant obstetrician. We have delivered the first workshop which focused on feeling psychologically safe in teams, to a mixture of 37 midwives and obstetricians. All participants signed up and consented to the recording and analysis of discussions during the workshops, at least 24 hours in advance of the training workshop. Feedback on the experience from staff was that they were supported and encouraged to engage in discussions about challenging issues in a safe space and that both the formal presentation and the discussions contributed to their learning. We believe this is a mutually beneficial method of delivering research, as we are able to collect research data, whilst also providing healthcare staff with evidence-based training and knowledge which they are able to apply to real life settings within their NHS workplace.

Conclusion
Involving NHS healthcare staff within research is fundamental to improving patient care, staff wellbeing and patient safety. However, due to the immense work pressures healthcare staff are facing, as researchers, we must adapt the way we involve staff in our research to ensure that they benefit from taking part. We are keen to hear from others about how they have adapted research so that healthcare staff benefit from the process of being engaged in that research. We also welcome the views of healthcare staff on how they would like to be involved in research and what we, as researchers, can do to reduce the burden and increase the benefits.

Please comment below.

Workforce Engagement and Wellbeing Research Theme In Patient safety, view all PSTRC blogs, Workforce Engagement

Beyond the outcomes: The benefits of the ‘process’ of doing applied health research

By Rebecca Lawton, Luke Budworth, Beth Fylan and Laura Sheard

Like other research endeavours, applied health research rewards us with new and effective interventions and technologies, a better understanding of phenomena, and evidence-based recommendations for how best to deliver a service. Uniquely, however, applied health research also helps to understand how best to translate interventions, knowledge and recommendations into everyday practice. For anyone who is interested in making a difference to patients, staff, healthcare systems and society, this is an exciting field to work in.

Nevertheless, as researchers, we often fail to consider or evaluate the impact that the process of conducting research has on these same patients, staff and healthcare systems. In this piece we focus on the huge potential that applied health research has to deliver benefits in the process of creating new knowledge. We want to open this debate up and would encourage other applied health researchers to contribute their own experiences of conducting research that made a difference ‘in the doing’.

To tell us about your views on this topic, as a researcher or NHS staff member, please follow link below.

https://www.surveymonkey.co.uk/r/SNW2WMW

Applied health research per se is undoubtedly beneficial for patients, healthcare staff and organisations. Within institutions with higher versus lower research participation, previous studies have identified improved patient health outcomes (including cancer mortality rates), reduced staff turnover, improved organisational efficiency and increased patient and staff satisfaction (e.g. Harding et al., 2017; Downing et al., 2015; Hanney et al., 2013). There are many potential explanations for these positive effects. For patients, this is often explained by the direct health benefits of exposure to novel interventions or procedures, and for staff, being able to develop their skills and experience. There may, however, be other, more indirect, reasons for these positive outcomes. In this blog, we are interested in those largely unrecognised benefits that funders may never find out about and that rarely, if ever, make their way into the published literature.

The benefits of research interviews

During her PhD, one of our research students reflected on how several of her participants emphasized how significant the interview process was for them, how rarely they had the opportunity to talk about their feelings with a non-judgmental listener and how they appreciated the opportunity to do this while potentially benefitting others. Many people who interview patients will be familiar with this apparent parallel between therapy and research interviews. Indeed, this benefit of the research process has received considerable attention. In 1994, Hutchinson’s review of the literature in this field concluded that catharsis, self-acknowledgement, a sense of purpose and self-awareness were all outcomes for patients associated with involvement in qualitative research.

In our own research on the experiences of staff who have been involved in patient safety events, the benefits for staff of being interviewees has revealed findings consistent with the above literature. Staff have reported that they felt a weight had been lifted, and that being given time to just talk to non-judging individuals who understood patient safety issues was highly cathartic. Indeed, for many, although it was painful, they felt they could now ‘move on’ from the event.

In the above cases, skilled interviewers have, during their work, developed much more than a better understanding of a phenomenon; they have developed a relationship of trust and mutual respect. For us, this is a mark of high quality research that we pay little attention to; often being the subject of a sentence or two in the reflective section of a thesis or manuscript.

And what about the broader benefits for staff of participating in applied health research?

For patients, this question has been investigated and there is now evidence from many studies that patients perceive a multitude of benefits to be associated with research participation, including greater knowledge and awareness of their health/condition, access to treatments or services, pride in taking part, a desire to help others, and the opportunity to talk to someone (c.f. Castillo et al., 2012; Gysels et al., 2008; Tolmie et al., 2004).

The benefits associated with the process of conducting an interview study represent only the tip of the iceberg, however. We recently asked for feedback from our team of 25 staff and PhD students, all engaged in applied health research. Below is a flavour of what they told us about the ways that the research process had benefitted staff and/or the health service involved in their work. Some of these were ideas were based on opinion, others were articulated by healthcare staff during the research process. Let’s be clear: we are absolutely not talking about the outcomes of research here, but what happened while they were collecting data, running co-design workshops, working with staff to consider how they might be involved in evaluating a new intervention, or understanding how teams work together (or don’t).

These are some of the benefits the research group identified:

Increased knowledge of a topic;
A safe space to talk about feelings, grievances, and frustrations;
The time to think about things differently, perhaps from a different perspective;
An opportunity to be more engaged at work, to do something different, to make a change;
An opportunity to contribute, to feel valued;
An opportunity to think critically/identify problems with current practice;
A chance to try something new, to be creative, to demonstrate expertise, to be valued and listened to;
A space to stop and think (particularly for staff);
A boost to morale through positive feedback.

Despite this list, a brief review of the literature reveals very little about the benefits of the process or activity of being involved in applied health research for staff. In 1996, Buxton and Hanney published an article examining the ‘payback’ for applied research. In this article they hint at the benefits of the process of research, referring in their model to the fact that ‘some outputs/paybacks may flow directly from the processes and the fact that the research is being carried out’ (Buxton and Hanney, 1996, p.39). However, in later frameworks of Research Impact (e.g., Kurivilla, Mays, Pleasant and Walt, 2006) the impacts of the research activity itself are not acknowledged and, given the challenges of measuring the impact of research, even when focus is on outputs alone, this is perhaps unsurprising.

As applied health researchers we often engage in participatory forms of research and work closely with those at the sharp end as well as those in managerial positions in healthcare organisations. It is this direct contact with people in the service that means the potential to do good (and bad, but this is not the focus here) is huge. Our aim in writing this piece is to start a dialogue with other researchers about the benefits of the activity or the ‘doing of’ research in health and social care settings. If we can better understand and capture these benefits then we might be in a stronger position to demonstrate the value or ‘cost-effectiveness’ of our research to funders, stakeholders and participants alike.

We are seeking feedback on:

1 Your own experiences of the benefits for healthcare staff (managers, clinicians or any other staff group) of being involved in doing research via a short survey:

https://www.surveymonkey.co.uk/r/SNW2WMW

2 Research papers that address this topic directly

3 There is one tool, Visible Impact of Research (VICTOR), developed by Jo Cooke and team within the Yorkshire and Humber CLAHRC, that has acknowledged, at least some of the benefits of the research process. Primarily, this tool aims to identify the health and economic impact of the research, the reputational benefits, the generation of knowledge and building of capacity for research. However, the VICTOR tool also includes an assessment of workforce impacts. Two of these questions ask specifically about benefits for workforce skills and practice of their involvement in the research process and another item asks about whether taking part in the research has influenced teams to do something different together. There may be other tools like this out there, that we are yet to come across – if so, please do let us know.

Workforce Engagement and Wellbeing Research Theme In Patient safety, view all PSTRC blogs, Workforce Engagement

Improving wellbeing and safety at work using collective wisdom: what more can we learn from other sectors?

In collaboration with Veterinary Surgeons Sarah Hunt and Caroline Dennis

Our aim as a Patient Safety Translational Research Centre (PSTRC) is to learn from and draw on ideas from other sectors. Healthcare has done this successfully in the past. For example, procedures used in aviation inspired the use of the surgical safety checklist and the racing car industry has provided insight into safer handovers during complex care. However, other topics that are relevant to many safety-critical organisations, including healthcare, are how staff make difficult decisions in uncertain and difficult situations and how we enable staff to do their job safely.

Safety-critical industries: what are the links?

Sectors such as healthcare, veterinary medicine, maritime, police and fire services share important aspects in their day to day work. They are high risk, complex environments. But links run deeper than this. Workforces in these sectors are increasingly under pressure to perform well despite limited resources. Staff are working in time-critical situations where high stakes decisions have to be made, often in the context of limited or incomplete information. In addition, they are also under constant scrutiny with the threat of litigation if something goes wrong. These disciplines are therefore all facing similar issues in terms of the impact on the staff delivering the service. Staff sickness, burnout, and turnover are all consequences and the evidence of the link between wellbeing and the effectiveness and safety of the service being delivered is growing. Our own work has shown links between staff wellbeing and patient safety in a healthcare setting (e.g. Hall et al, Johnson et al, Louch et al) and conversations with colleagues working in other safety-critical sectors have indicated that they too are facing similar work-related issues that affect safety and wellbeing.

What has already been done to address this?

Colleagues in other sectors such as veterinary medicine – the VetLed HALT Campaign and Vets Now, police and the fire service now recognise the important link between staff wellbeing and safety and are beginning to develop solutions. In 2005, the BMJ and Veterinary Record issued a joint special issue which sought to stimulate debate about possible links between approaches in human and veterinary medicine to improve practice. More recently, interest in attempting to improve healthcare safety by bringing together perspectives from human and animal healthcare has emerged. However, while such initiatives demonstrate potential value, they remain sparse.

How can we move forward?

We think there is now a need to foster synergy and promote learning from each other by sharing perspectives and insights. This will allow us to develop a collective wisdom and move beyond our own professional communities; forming a collaborative approach to the shared challenges posed by the link between wellbeing and safety. Through doing this, we hope sectors will be encouraged to consider strategies that are being implemented in each other’s industries, increase knowledge about how these strategies shape the work environment and impact wellbeing and safety, and whether they are transferable to other settings. This will enable us all to develop alternative and novel strategies which are of value to others as well as within the context from which they originate.

What next: a shared interactive workshop

We are bringing together individuals interested in enhancing staff wellbeing through learning from and sharing with colleagues in other sectors for an innovative interactive workshop at our national patient safety conference on 15^th October 2019.

The workshop will include colleagues from veterinary medicine, fire, police, maritime and healthcare services who will:

explore the concept of well-being and its impact on aspects of safe practice from each of their service sector perspectives
share experiences and insight across different service sectors
explore common factors affecting well-being at work and identify current strategies to address these
explore how to take forward shared learning and insight

How can I get involved?

You can follow our workshop on Twitter #wellbeing4safety

For more information about this work please contact: Jane Heyhoe or Gillian Janes

Workforce Engagement and Wellbeing Research Theme In view all PSTRC blogs, Workforce Engagement

Supporting the ‘second victims’ of patient safety incidents

Researchers at our PSTRC have developed a unique range of online support to help the ‘second victims’ of patient safety incidents: clinicians and healthcare workers.

Patient safety incidents are any unintended or unexpected incident, such as a medical error or system failure, which could have, or did, lead to harm for a patient receiving healthcare. When things go wrong in the NHS the first priority is always to support the patient affected and their family. But this sometimes means that the needs of healthcare workers at the centre of patient safety incident investigations are almost forgotten, even when the impact can have far-reaching consequences for the person and their organisation.

Now health researchers from the PSTRC, the Yorkshire Quality and Safety Research Group and the Improvement Academy, based at the Bradford Institute for Health Research, have launched a website www.secondvictim.co.uk with a wealth of resources to support clinicians and organisations.

The project is focused on how clinicians are supported through these events; not because their needs are greater than the patient or their family’s – far from it, but because the impact of the event on the clinician has a knock-on effect on the care they are able to give their next patient. One clinician described it in this way:

It hit me for the first time that I’ve had something actually go wrong, then that opened a door to me imagining, second guessing everything all the time, imagining things going wrong. And how you can have an effect on a person’s life if something does go wrong. I think that’s what really hit me, and knocked my confidence for that time.

This clinician, with others, has told their story by film on the website. Users of the website have found these films helpful, and several have offered to share their own experiences. It’s been so useful for the project team to hear the real experiences of people who will be able to benefit from using the website, and to recognise the impact that making a mistake has on the clinician and their colleagues. In particular this story stands out because when the incident was investigated the clinician was found to be not at fault, due to a communication error about what needed to be done.

These stories clearly resonate with other clinicians, but importantly when clinicians talk about mistakes it enables learning; in this instance the way that treatment plans are communicated around the hospital could be improved, reducing the risk of a recurrence for another patient.

To hear these stories go to www.secondvictim.co.uk