Despite the gap between the quality of healthcare that patients should receive and what actually happens, programmes to secure improvements in care quality have demonstrated inconsistent, variable and patchy results.110, 123,124 This in part reflects the fact that such interventions are more appropriately construed as events in multi-layered and interacting systems meaning that the organisational, political and social contexts in which the intervention is located are not simply background noise; they are part of the programme of change74,89, 90, 110,125-127 and interact with it. Other features of complexity include: the multiplicity of programme components and their dynamic and emergent nature such that different groups interact with programmes in different ways. PIE was fully adopted in only two of ten study wards; and had proceeded to innovation and sustainability in those. To explore why some wards adopted PIE and others only partially or not at all, we examined the relationship between what was intended to happen, what actually happened and the interface with the organisational context over time using a stages-of-implementation framework.69
Micro-level facilitators/barriers to change
Factors contributing to failure to proceed with PIE adoption were multiple and interactive. At a micro-level ward level they included leadership and stakeholder engagement, ‘fit’ with strategic priorities and the perceived salience of PIE to achieve valued goals
Drivers, facilitators, teams and networks
Engagement in PIE from initial implementation, through innovation to sustainability required active leadership out with the day to day demands of managing a ward; facilitative support and
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encouragement from senior ward staff; and collective team involvement to make change happen. These dimensions of PIE leadership and stakeholder engagement provided the necessary levers of change: key individuals beyond the ward whose professional authority and vertical networks legitimated the priority attached to the work of improvement in face of competing priorities; senior ward staff facilitating and encouraging direct involvement in the change process and in ensuring planned changes were communicated to the wider staff team; and implementation team members with respect of their peers to extend reach of the intervention to the ward. Only in Poplar and Crane were all of these elements in place; absence of one or more of them were contributory to failure to proceed to full adoption.
The conception of ‘facilitation’ in our study differs from that projected in some frameworks for implementing change, for example PARiHS128-130 and practice development131--133both of which place emphasis on skilled facilitation in effecting change. Here, the ward manager as facilitator did not drive’ implementation but played a critical role in extending its reach to the whole ward, necessary to effect practice change.
‘Fit’ with strategic priorities
PIE was not the only initiative aimed at improving the care of people with dementia underway in participating Trusts. In Seaford, there was heavy investment at strategic trust level with the establishment of a team of three specialist dementia matrons in early 2013, attached to each of three district general hospitals in the Trust, including the two wards in our study. They worked directly with ward staff to mirror good practice in dementia care, provided support and in-depth training around communication and in anticipating and responding to challenging behaviour; and engaged in high level organisational changes at Trust level (for example, developing dementia pathways). From the outset, the dementia specialists embraced PIE, as one vehicle through which to pursue practice change, the team lead acted as ‘driver’ of PIE in one ward and one of the dementia nurses actively supported PIE, in the other. The lead specialist matron had both seniority and a direct line to the senior management team, and provided a conduit between senior managers and the ward in both directions: securing high level commitment and resource for local PIE initiatives; these in turn were celebrated as exemplars of the wider strategy in action. In this respect PIE and the Trust dementia strategy were synergistic one on the other.
In other Trusts (City and Ironbridge), a high level priority and centrally driven was the creation of Dementia Champions and initiating awareness training for staff at all levels around dementia. The role appears to have been variously interpreted: from increasing awareness of dementia within a work arena; as a mirror of good practice vis a vis colleagues; and as a change mechanism within a
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workplace. How the recruitment of ‘champions’ would translate into a means of changing practice at ward level wasn't clear however; the conception underpinning the approach was that the creation of a wide network of ‘champions’ who would meet together at intervals would lead to change at workplace level. In City, the matron who had championed PIE envisioned that the initiative would feed into use of PIE at ward level; a vision that was not necessarily shared among those involved in developing the dementia strategy. For staff on Netherton, the Champions initiative appeared diffuse and lacking depth and impact. Further, as the initial focus of the initiative was in raising general awareness of dementia, this was not seen to address staff perception of the problem, namely how ward staff were to be provided with the skills necessary to work with challenging patients.
Salience of PIE to achieve valued goals
Focus of PIE in addressing practice change generated interest and enthusiasm among staff on wards that varied in the quality of care, and therefore scope for practice change. In both wards in Seaford, the process of PIE implementation engendered confidence, collaboration, sense of empowerment and agency among the staff group, including among HCAs in trying out new ways of working. Positive change was visible and in turn acted as a spur to keep going.
Among ‘partial’ implementers PIE was embraced enthusiastically at the outset. In Netherton, observation reinforced pride among the staff team of the general quality of care provided. Herein lay the difficulty. Translating observations into action plans that addressed valued goals proved more difficult. Although not articulated in the beginning, observations reinforced and solidified the primary goal of senior staff to improve patient care: reduction in the size of the ward and staff time to provide stimulating activities, neither seen as actions which could be pursued through PIE. This poses the question as to whether there exists a quality ‘ceiling’ effect in terms of a ‘person-focused’ approach within the constraints of acute care delivery. Additionally, within this ward, there existed a team culture and routine systems and mechanisms to engage in deliberative practice reflection to secure quality improvement; apart from observation, the additional work of PIE seemed superfluous.
Enthusiasm and interest in improving practice also required supportive environments to sustain belief in staff agency to affect change so that investment of time and resources was seen as worthwhile. Demand pressures and organisational uncertainty dampened both, evident not only in Rivermead but in all three Central Trust wards.