Qualitative Findings – Qualitative Findings – EPIC IEPIC I

Madelyn Law & Janet YamadaMadelyn Law & Janet YamadaUniversity of TorontoUniversity of Toronto

On behalf of Dr. Bonnie StevensOn behalf of Dr. Bonnie StevensSick Kids, University of TorontoSick Kids, University of Toronto

EPIC/PHSI Training Workshop, Toronto, Ontario

November 9th-10th

A Qualitative Examination of A Qualitative Examination of Changing Practice in Canadian Changing Practice in Canadian Neonatal Intensive Care UnitsNeonatal Intensive Care Units

Bonnie Stevens, Shoo K. Lee, Madelyn P. Law, Janet Yamada Bonnie Stevens, Shoo K. Lee, Madelyn P. Law, Janet Yamada and the Canadian Neonatal Network EPIC Study Groupand the Canadian Neonatal Network EPIC Study Group

In press – Journal of Clinical Evaluation and PracticeIn press – Journal of Clinical Evaluation and Practice

OutlineOutline

Brief overview of theoretical background Brief overview of theoretical background and qualitative methodsand qualitative methods

ResultsResults

What to think of as you move forwardWhat to think of as you move forward

Purpose of the EPIC StudyPurpose of the EPIC Study

To implement and evaluate a national To implement and evaluate a national system for practice change in NICU’s system for practice change in NICU’s based on evidence and data. based on evidence and data.

Quantitative research componentQuantitative research component Qualitative research componentQualitative research component

Purpose of the qualitative studyPurpose of the qualitative study

The purpose of this study was to identify:The purpose of this study was to identify:

(a) existing successes and problems, (a) existing successes and problems,

(b) factors that affect successes and problems, (b) factors that affect successes and problems,

(c) potential challenges to change (c) potential challenges to change

associated with the implementation of changes to associated with the implementation of changes to infection control/chronic lung disease infection control/chronic lung disease practices in NICUs across Canada. practices in NICUs across Canada.

Driving Theoretical BasisDriving Theoretical Basis

Research on change in the Vermont Research on change in the Vermont Oxford NetworkOxford Network

• Pediatrics Issue111(4)Pediatrics Issue111(4)

Organizational structure and changeOrganizational structure and change• (Baker et al., 2003; Pettigrew, 1987)(Baker et al., 2003; Pettigrew, 1987)

The Improvement Cycles The Improvement Cycles • (Langley et al., 1998)(Langley et al., 1998)

MethodologyMethodology 13 sites13 sites

7 Chronic Lung Disease7 Chronic Lung Disease 6 Nosocomical Infection 6 Nosocomical Infection

154 participants154 participants 76 Individual interviews76 Individual interviews 14 Focus groups14 Focus groups

Health professionals representing the full Health professionals representing the full spectrum of NICU servicesspectrum of NICU services neonatologists, nurses, pharmacists, respiratory neonatologists, nurses, pharmacists, respiratory

therapists, managers, educators, parents therapists, managers, educators, parents

Data AnalysisData Analysis Thematic AnalysisThematic Analysis

“…“…involves the search for common threads that extend involves the search for common threads that extend throughout an entire interview or set of interviews.” throughout an entire interview or set of interviews.”

(Morse& Field, 1994)(Morse& Field, 1994)

First level of coding – Open coding:First level of coding – Open coding: Researchers read the interviews line-by-line and descriptive Researchers read the interviews line-by-line and descriptive

code names are written in the right hand margin of the transcript.code names are written in the right hand margin of the transcript.

Second Level of coding – Selective Coding:Second Level of coding – Selective Coding: Categorize, recategorize and condense all first level codes into Categorize, recategorize and condense all first level codes into

the main categories that will reflect the informationthe main categories that will reflect the information

ResultsResults

Three Overarching Themes found at Three Overarching Themes found at both CLD and Infection Sites:both CLD and Infection Sites:

1) Human resources1) Human resources

2) Organizational Structure2) Organizational Structure

3) Communications3) Communications

Human ResourcesHuman Resources

Staffing issuesStaffing issues SizeSize of staff of staff RatioRatio of educator to staff of educator to staff EducationEducation and experience levels and experience levels Staff Staff turnoverturnover

Consistency in practiceConsistency in practice InconsistenciesInconsistencies in practices even after a new practice in practices even after a new practice

was introducedwas introduced Need support from the Need support from the leadershipleadership to institute and to institute and

maintain new changesmaintain new changes

Organizational StructureOrganizational Structure

Approval ProcessApproval Process Long and tediousLong and tedious with many levels of approval with many levels of approval Loss of momentumLoss of momentum for the change for the change

Multidisciplinary Approach to careMultidisciplinary Approach to care Success attributed to the Success attributed to the engagementengagement of of

multidisciplinary teams multidisciplinary teams Peer Leaders/ChampionsPeer Leaders/Champions from the team to from the team to

lead the changelead the change

CommunicationsCommunications

Frequency and consistency Frequency and consistency of communicationsof communications

Variety of channelsVariety of channels for for communicationscommunications

InundatedInundated with information with information Disconnect Disconnect between the between the

generation of new information and generation of new information and practice to print form (i.e. updating practice to print form (i.e. updating manuals and website)manuals and website)

Rationale for changeRationale for change Need to know the Need to know the “WHY”“WHY” and and

“HOW”“HOW”

CommunicationsCommunications

Feedback ProcessFeedback Process UpdatesUpdates and results on how the change had and results on how the change had

impacted clinical problems in order to help impacted clinical problems in order to help reinforce the new practicereinforce the new practice

Include practitionersInclude practitioners in designing, in designing, implementing and evaluating changeimplementing and evaluating change

Unique to Chronic Lung DiseaseUnique to Chronic Lung Disease

Identification of Policies related to CLDIdentification of Policies related to CLD Participants had Participants had difficulty identifying the difficulty identifying the

existing policiesexisting policies and practices that were and practices that were currently in place to deal with CLD or to help currently in place to deal with CLD or to help prevent CLDprevent CLD

Creating a Creating a preventivepreventive and not reactive focus and not reactive focus to the care of CLDto the care of CLD

Unique to InfectionUnique to Infection

Unit specific policies for Unit specific policies for infectioninfection Differences in policiesDifferences in policies in the NICU in the NICU

compared to overall hospital policiescompared to overall hospital policies

Disconnect between policies Disconnect between policies and practiceand practice Staff are aware of policies and Staff are aware of policies and

procedures but also stated that procedures but also stated that these policies were these policies were not always not always followedfollowed

Unique to InfectionUnique to Infection

Environmental Environmental Design of the unitDesign of the unit in relation in relation

to number of sinks, to number of sinks, ventilation, traffic in the unit, ventilation, traffic in the unit, etc.etc.

VisitationVisitation in relation to in relation to number of people allowed at number of people allowed at the bedside and controlled the bedside and controlled entrances to roomsentrances to rooms

What to think of as you move What to think of as you move forward…..forward…..

Context (site) specific barriersContext (site) specific barriers What are the barriers related to the practice environment at your What are the barriers related to the practice environment at your

hospital?hospital?

The human side of changeThe human side of change Inform individuals why and how they should change their practiceInform individuals why and how they should change their practice Provide feedback on new knowledge and results of implementing Provide feedback on new knowledge and results of implementing

changechange Involve them in the change processInvolve them in the change process

What to think of as you move What to think of as you move forward…..forward…..

Structure for successesStructure for successes Focus on the team, champions, Focus on the team, champions, cultureculture, readiness for , readiness for

changechange Address human resources strategiesAddress human resources strategies

Communicate effectivelyCommunicate effectively Communications PlanCommunications Plan

Create a Culture of ChangeCreate a Culture of Change

Greater level of awareness

Level 1: Artifacts(meetings, reports, work environment)

Level 2 Values(moral codes, philosophies, values in use)

Level 3: Basic Assumptions(dominant values that have moved into the organizations members unconsciousness)

Visible but often not decipherable

Taken for grantedInvisible preconscious

Schien, 2004

Thank You!Thank You!