The study investigated how creative practice and co-design methods could be used to support the dissemination of positively deviant strategies for improving quality and evidence about newly characterised best practice within elderly patient medical wards. The research was funded through the Evidence Based Transformation Theme of the NIHR (National Institute for Health Research) CLAHRC (Collaborations for Leadership in Applied Health research and Care) YH (Yorkshire and Humber) and is supported by the Translating Knowledge into Action (TK2A) theme
Funded by : CLAHRC NIHR YH
Partners: University of Leeds
Project team: Paul Chamberlain Claire Craig Anne Marie Moore
Positive deviance is an asset-based, bottom-up approach to behavioural and social change within communities. It draws on individual and community strengths and pre-existing resources considered positively deviant (Tuhus- Dubrow, 2009, Sternin and Choo, R., 2000; and Singhal et al., 2010).
The approach assumes that problems can be overcome using solutions that already exist within communities. Despite facing the same constraints as others, ‘positive deviants’ identify solutions and succeed by demonstrating uncommon or different behaviours (Baxter et al 2016 p.2).
This approach holds much promise and attention has turned to how it might be applied within health service contexts.
If the potential of the positive deviance approach within healthcare is to be realized it is necessary to find ways to identify positive deviant wards, cultures and individuals within complex and ever-changing systems and create mechanisms to communicate what these are to create the potential for their implementation.
Baxter et al. (2015) examined whether a positive deviance approach could be used to identify ward teams that were performing exceptionally well on patient safety and explored strategies for achieving success.
Hypotheses about strategies, behaviours, team cultures and dynamics that facilitated the delivery of safe patient care were generated and 14 key themes representative of positively deviant elderly patient medical wards were identified. These were; Knowing Each Other, Trust, A Multidisciplinary Approach, Integrated Ward Based AHPs, Working Together, Feeling Able to Ask Questions or for Help, Setting Expectations, It’s a Pleasure to Come to Work, Learning from Incidents, Acquiring Additional Staff, Stable and Static Teams, Focus on Discharge, Directorate Support, and Keeping Patients and Relatives Informed.
Baxter’s study raises interesting research questions, particularly in relation to dissemination and adoption of findings. If the strength of the positive deviance approach is its focus on community engagement and involvement, seeing solutions located within existing resources, how is it possible to translate these findings to other communities/settings/wards which have not been involved in the process? If solutions are internally generated rather than externally imposed how can they be regarded as feasible within the resources of other contexts? What are the implications of this in relation to dissemination and knowledge mobilization?
Co-design workshops were undertaken with participants recruited from a local ward team (site 1). The research team used findings from the co-design workshops to develop a set of interventions and artefact installations designed to embody some of the positively deviant strategies and characteristics.
The project involved the intervention and installation of the co-created artefacts into sites 1 and 2 (not involved in the co-design):
The study research questions were as follows:
1) Can creative co-design help ward teams to disseminate positively deviant strategies?
2) Does using creative practice and co-design methods to support the dissemination of positively deviant strategies have an impact on the ward?
3) What is the experience of being involved in this process for staff on the units?
4) Is there a difference in the experience and impact of the critical artefacts between wards engaged in creative practice and co-design of creative interventions and those that were not?
5) Which types of creative co-design methods work well in this context?
‘The books have gone down a treat with established members of the team as well as new starters’..
An evaluation is currently being undertaken with participants from both sites to explore whether there was a difference in the experience and impact between wards engaged in the creative practice and co- design of the critical artefacts in comparison to the ward that was not. It will reflect on how the artefacts had been utilised and any possible strategies that the wards have found useful in relation to identifying and implementing positive deviant behaviours
General anaesthesia for obstetric surgery, including caesarean section, is often delivered in emergency situations where some of the specific physiological features relating to an individual patient that might affect oxygenation and airway management can be overlooked.
Failure to intubate the trachea (insert a tube for ventilation) can have disastrous consequences for both the mother and unborn baby due the resulting lack of oxygen. It is therefore important that anaesthetists are given appropriate training for this patient group.
However since general anaesthesia in obstetrics is relatively uncommon, training opportunities for anaesthetists are limited. The use of simulation and trainers for anaesthetists and their assistants is important in developing and maintaining their obstetric airway skills.
Current airway management trainers exist mainly for adult males, paediatric and neonatal models, including models for rare conditions. There are no obstetric specific airway management trainers for sale on the current market.
Many of the physical changes which present themselves throughout pregnancy are not incorporated into the generic adult models and specific procedures in relation to obstetric patient positioning are not achievable.
By incorporating the specific functionality needed, we hope to produce a much more realistic obstetric patient training tool which will support learning in obstetric anaesthesia.
Andy Stanton, lead designer
Working with anaesthetists as representatives of Sheffield Teaching Hospitals, Lab4Living is developing a prototype obstetric airway management training tool which incorporates obstetric related functionality. This functionality includes:
Varying degrees of upper respiratory tract swelling depending on length of labour, conditions such as pre-eclampsia and use of oxytocin.
Enlarged breasts making insertion of the laryngoscope more difficult.
Longer hair and use of hair pieces leading to exaggerated neck flexion and suboptimal patient positioning.
The facilitation of a left lateral tilt of the operating table with potential incorrect application and direction of cricoid pressure with resulting vocal cord deformity.
Shorter neck with the growing prevalence of obesity in this population.
By incorporating interchangeable functionality to present differing emergence scenarios, the design team aims to produce a more realistic training tool to better inform clinical teams in the area of obstetric anaesthesia.
Partners: British Geriatrics Society Sheffield Teaching Hospitals NHS Foundation Trust Age UK Evaluation Partner : NW London CLARHC Royal College of Physicians
Project team: Paul Chamberlain Rebecca Partridge
This project explores opportunity for design beyond the creation products and focuses on how design might help change culture and behaviour within a health care environment to improve the safety of frail older people admitted to hospital. frailsafe was created to explore whether a check and challenge approach could be translated into the complexity of acute medical care and safety of older patients. The project was was supported through the Health Foundation as part of the Breakthrough Series designed to help organizations by creating a structure in which they can easily learn from each other and from recognized experts in topic areas where they want to make improvements.
International studies indicate that approximately 10% of all patients who are admitted to hospital suffer some form of adverse event (AE). An AE can be defined as an unintended harm to a patient resulting in injury, death or a prolonged admission. Older people are more likely to suffer AEs and the consequences of an AE are often more severe in frail, older patients.
12 hospitals were purposively sampled to replicate the proportion of patients in District General / Teaching and Urban / Rural settings around the UK. Design researchers were involved more than 100 hours across the 12 hospitals shadowing different health professionals, following ward rounds, board rounds, triage meetings, handover discussions and multidisciplinary (MDT) meetings. In addition three two-day residential learning sessions located away from the immediate local pressures of work were scheduled over the duration of the project. These offered a creative space to collaboratively engage through a series of Design activities that were developed and facilitated by the design researchers.
Staff found their participation in the improvement team as one of the most rewarding aspects of the project and showed spill-over effects in the wards. The project provided a platform and protocols for increased multidisciplinary working and enhanced communication on what constitutes good care for older patients in AMU.
In addition to co-designing with hospital staff a series a videos were co-created with older people to explore the notion of frailty from a personal perspective.
The research highlights the scope for designers to facilitate co-design that can be embedded as a lasting legacy in communities helping them to learn from each other through improved communication and empowering them to create and implement their own new ideas.