Staff
perceptions
of
a
Productive
Community
Services
implementation:
A
qualitative
interview
study
Dominique
Kim
Frances
Bradley
*,
Dr.
Murray
Griffin
UniversityofEssex,WivenhoePark,Colchester,Essex,UnitedKingdom
ARTICLE INFO Articlehistory:
Received3September2014
Receivedinrevisedform4February2015 Accepted6February2015
Keywords:
ProductiveCommunityServices ReleasingTimetoCare Thematicanalysis Innovation
ABSTRACT
Background:TheProductiveSeriesisacollectionofchangeprogrammesdesignedbythe
EnglishNationalHealthService(NHS)InstituteforInnovationandImprovementtohelp frontlinehealthcarestaffimprovequalityandreducewastedtime,sothatthistimecanbe reinvestedintotimespentwithpatients.Theprogrammeshavebeenimplementedinat least14 countriesaroundthe world.This studyexamines animplementationof the ProductiveCommunityServicesprogrammethattookplaceinaCommunityhealthcare organisationinEnglandfromJuly2010toMarch2012.
Objectives:Toexplorestaffmembers’perceptionsofaProductiveCommunityServices
implementation.
Design:Cross-sectionalinterview.
Settings:CommunityHealthcareOrganisationinEastAnglia,England.
Participants: 45participantswererecruitedusingpurposive,snowballingand
opportu-nisticsamplingmethodstorepresentfivemaintypesofstaffgroupintheorganisation; clinicalteammembers,administrativeteammembers,servicemanagers/teamleaders, seniormanagersandsoftwaresupportstaff.Teammemberswererecruitedonthebasis thattheyhadsubmitteddataforatleastoneProductiveCommunityServicesmodule.
Methods:Semi-structuredindividual andgroup interviewswerecarriedoutafter the
programmeconcludedandanalysedusingthematicanalysis.
Results:This report focuses onsixof thethemes identified. The analysis found that
communicationwasnotalwayseffective,andtherewasalackofawareness,knowledge andunderstandingoftheprogramme.ManystaffdidnotfindtheProductiveCommunity Servicesworkrelevant,andalthoughcertainimprovementsweresustained,suboptimal practicescreptback.Althoughnegativeoutcomeswerereported,suchastheprogramme taking time away from patients initially, many benefits were described including improvedstockcontrolandworkenvironments,andbetteruseoftheElectronicPatient Recordsystem.
Conclusions: Oneof thethemesidentifiedhighlighted thepositiveperceptionsofthe
programme,howeverafocusonfiveotherthemesindicatethatimportantaspectsofthe implementationcouldhavebeenimproved.Theinnovationandimplementationliterature alreadyaddressestheissuesidentified,whichsuggestsagapbetweentheoryandpractice forimplementation teams. A lack of perceived relevance also suggests that similar
* Correspondingauthor.
E-mailaddresses:[email protected](D.K.F.Bradley),mgriffi[email protected](M.Griffin).
ContentslistsavailableatScienceDirect
International
Journal
of
Nursing
Studies
journalhomepage:www.elsevier.com/ijns
http://dx.doi.org/10.1016/j.ijnurstu.2015.02.005 0020-7489/ß2015PublishedbyElsevierLtd.
Whatisalreadyknownaboutthetopic?
There is little published research on the Productive CommunityServicesprogramme,howevertheProductive Wardprogramme hasbeen reported tohave generated many benefitsincludingincreasedpatient contacttime, increasedqualityandreducedinefficiencies.
Muchoftheliteratureispositivelybiased,oftenusing participantsheavilyinvolvedintheprogramme. Relevantknowledgehasnotalwaysbeentransferredto
implementationsofProductiveWard. Whatthispaperadds
Thispaperexaminesanimplementationofthe Produc-tiveCommunityServicesprogramme.
The findings indicate that issues in communication, awarenessandknowledgeoftheprogramme,relevancy andsustainabilitydemonstratesthatknowledgetransfer for Productive Community Services implementation teamsneedstobeimproved.
The findingssuggest that programmeslikeProductive CommunityServicesneedtobemoreeasilyadaptablefor thevariousspecialismsthatexistinCommunityServices healthcareorganisations.
1. Introduction
The Productive Series is a collection of change pro-grammesdesignedbytheEnglishNationalHealthService Institute for Innovation and Improvement. Until March 2013thisorganisationwasestablished,‘‘...tosupportthe transformation of the NHS (National Health Service), through innovation, improvement, and the adoption of bestpractice,’’(NHSInstituteforInnovationand Improve-ment,2014). SinceApril2014,a neworganisation,NHS Improving Quality, has continued much of their work, includingtheadministrationoftheProductiveSeries(NHS InstituteforInnovationandImprovement,2014).In2007, the Productive Ward, the first of the Productive Series
programmes was launched in England (Wright and McSherry,2013), and theseries now caters for various healthcare settings, including the Operating Theatre, General Practice and Community Services (see NHS Institute for Innovation and Improvement, 2011). They havebeendesignedtoimprovequalityandreducewasted resources,inorderforstafftobeabletospendmoretime withpatients(NHSInstituteforInnovationand
Improve-ment, 2012b); hence the programmes’ secondary title,
‘ReleasingTimetoCareTM’.Thistimespentwithpatientsis often referred to as ‘Patient-facing time’ (York Health
EconomicsConsortiumandNHS InstituteforInnovation
andImprovement,2010)or‘Directcaretime’(Wrightand McSherry,2013).Theprogrammesalsoaimtoincreasethe capability of healthcare organisations so that staff are equipped to improve to their day-to-day processes themselves(Bevan,2010).
AlthoughWhiteetal.(2013)identifiedalargeamountof greyliteratureandreportsregardingtheProductiveWard programme, Wright and McSherry (2013) found only 18articlesthatpassedtheirqualityandrelevancy assess-mentpublishedbetween2005to2011,classingonlyfiveof theseasempiricalresearch.Theyidentifiedabiastowards the publication of positive results, and indications of sustainabilityissues,whereProductiveWard-related pub-licationsincreasedtowards2009andthendeclined.They propose a‘Productiveeuphoria’wasassociated withthis increase, which occurredbecause the programmes were seentooffersolutionstotheproblemsregardinginsufficient care that healthcare organisations were perceived to provide at thattime. A similar riseand declineof grey literatureandevaluationswasidentifiedbyabibliometric profile of ProductiveWardliterature publishedbetween 2006 and 2013, although the number of peer-reviewed articlesremainedsteadybutlow(Whiteetal.,2014).
Anecdotal and experiential articles (Wright and McSherry,2013)mostlyhighlightthebenefitsgenerated by theprogramme. Harrison(2008)demonstrates how ProductiveWardtoolshelpedstafftoidentifyissuesthat needed tobeaddressed(forexample,scoring0%onan observationaudit)andgivesexamplesofthestepsthey tooktoimprove.Similarly,aSeniorAssociateattheNHS Institute for Innovation and Improvement, (Manning, 2011) promotes the Productive Community Services, referring toimprovements such as a 48% reduction in stockheldforaschoolnursingteam.ProductiveWardhas also been associated with increased quality of patient observations and patient satisfaction (Lipley, 2009), increased staff satisfaction (Dean, 2014; Wright et al., 2012),increasedDirectCareTimewithpatients( Blake-more,2009),thereductionofhospital-acquiredinfections (Fosteretal.,2009;SmithandRudd,2010)staffsickness (Smith andRudd, 2010),and falls (Wilson, 2009),and moreefficientadmissionanddischargeprocesses( Len-nard, 2014). Fewof these articlesprovidemuch detail regarding the negative aspects of the programme’s implementation, although foran exception see Wright etal.(2012),whonotesthatimplementingjustthefirst module cost £236 per meeting in staff time before accountingforthetimetakentopreparedataandcarry outthemodulework.
The ProductiveSeries hasbeendistributed toatleast 14countries(NHSScotland,2013)includingNewZealand (see Moore et al., 2013) and Canada (see Avis, 2012), programmesneedtobemademoreeasilyadaptableforthevariedspecialismsfoundin CommunityServices.FurtherresearchonProductiveCommunityServices implementa-tionsandknowledgetransferisrequired,andpublicationofstudiesfocusingontheless positiveaspectsofimplementationsmayacceleratethisprocess.
althoughtheavailableliteratureontheseimplementations aremostlyinternalexperientialreportsratherthan peer-reviewedempiricalresearch.Forexample,NHSScotland (2008)evaluatedProductiveWardineightScottishNHS boards and reported benefits includingincreased direct care (rangingfrom 13 to43%),reducedunplanned staff absence(from6.27%to2.97%),andincreasedefficiency,for examplebyreducingthenumberofstepsrequiredtocarry outprocesses.HoweverNHSEastofEngland(2010)found that thegreat impactachievedbyProductive Wardwas difficult to quantify because measurable outcomes had notbeendefined.Communication‘fromwardtotheboard,’ (,p.19)andorganisationalengagementwereseenamong othersascrucialinmaximisingtheprogramme’simpact andsustainability.TheNationalNursingResearchUnitand
NHS Institute for Innovation and Improvement (2010b)
alsoproposethat,‘‘...thesinglemostimportantfactorfor thesuccessofProductiveWardisthatcliniciansneedtobe supportedandencouragedbytheseniorleadersintheir organisations,’’(NationalNursingResearchUnitandNHS Institutefor Innovation and Improvement,2010b,p. 6).
National Nursing Research Unit and NHS Institute for
InnovationandImprovement(2010a)notethattheclear communicationofmanagementsupportwaslikelytobe more difficult in organisations withmultiple sites than thoseonsinglesites.
QualitativeresearchbyDavis andAdams(2012)was carriedoutusingsemi-structuredinterviewswithsixstaff membersinordertoinvestigatetheirperceptionsabout ProductiveWard.Usingthematicanalysis,theyidentified fivemainthemes;‘‘Startingtoimplementtheprogramme, Anxietyanddefensiveness,TheImportanceofleadership and communication, Challenges,and Learning and per-sonal development,’’ (, p. 354). Although their study capturedsomeofthenegativeissues thatwere encoun-teredduringimplementation,theresponseswerewholly positive, although only a small sample of staff were interviewed,andtheparticipantswereleadingorheavily involvedwiththeprogramme.
White and Waldron (2014)reviewed literature
pub-lished between 2006–2013 toinvestigatethe impactof Productive Ward. By using qualitative contentanalysis, focusing on nurses’ perspectiveoftheprogramme, they foundthat‘Empowerment’,‘Leadership’and‘Engagement’ were the top three most common impacts reported. HoweveraliteraturereviewbyWhiteetal.(2013)focused more on the implementation process, which identified sevenkeycharacteristicsthatwereseentohaveadirect impactonProductiveWardimplementations.Robustand engagingcommunicationwasrequired,andsecond,itwas importantthatthewardleadersandfacilitatorsneededto empower and enable frontline staff to make changes. Third, all staff levels required appropriate training. Management and project planning of rolling the pro-gramme out, including the sequence in which teams implementedtheprogramme,wasimportant.Leadership, the fifth characteristic, highlighted a need for clear leadership,butalsoshowedhowtheprogrammeprovided opportunity for staff toenhance their leadership skills. Management support and engagementwas salient, and thisincludedgiving‘permission’tochallengeandchange
existingprocesses.Theseventhmainthemewas‘Financial and humanresource commitment’,and inorder forthe initiativetobesustained,thiscommitmentneededtobe long term(White et al.,2013). Theyalso notethat the implementationandchangeliteraturealreadyemphasises theserequirementsforeffectiveimplementations,which indicatesthatinmanycases,therelevantknowledgehas notbeentransferredtotheProductiveWard implementa-tions.
Thisstudyformspartofalargerpieceofresearchonan implementation of the Productive Community Services programme that was implemented from July 2010 to March2012inaCommunityServiceshealthcare organi-sationinEastAnglia,England.Themajorstudyemployeda mixed methods case study design using participant observationbythefirstauthorwhileworkingasaResearch Analyst as part of the Productive Community Services Implementation Team. It also involved the analysis of qualitative and quantitative data generated during the implementation.Theauthorsexaminedvariousaspectsof the implementation such as the tensions between the programmetheoryand practice,theoutcomesfromthe programme and the meaningfulness and reliability of theseoutcomes.Thisstudyfocusesoninterviewscarried out by the firstauthor afterthe programme concluded during the period April–July 2012, with the aim of exploring staff members’ perceptions of the Productive CommunityServicesimplementation.Given thepositive publicationbiasinpreviousliteraturedetailedabove(op cit.WrightandMcSherry,2013),theauthorsfocusmainly onthemeswhichhighlightaspectsoftheimplementation perceived as most likely to limit the programme’s effectiveness.Althoughsomecontextualdataispresented from the participant observation, examination of the resultsfrom thethematic analysis in isolation helpsto clearlyidentifytheissuethemesfromtheperspectiveof thestaffmembersinvolved.
AnImplementationTeamwascreatedtoimplementthe programmeinover50clinicalteamsrangingfromHealth Visiting and Physiotherapy to Smoking Cessation and Sexual Health services covering Modules 1–6, and six teams(includingDistrict Nursing,Speech and Language Therapyand theRapid AssessmentUnit) implementing Modules 1–9 (see NHS Institute for Innovation and
Improvement, 2012a and Fig. 1). The Implementation
Team consistedofthree staffsecondedfromwithinthe organisation,twoagencystaffandthefirstauthor,noneof
whom had experienced implementing change
pro-grammespreviously.TheProductiveCommunityServices ProjectManagerwassecondedfromtheirITmanagement rolefromwithintheorganisationandwasnotaclinician. ThreemembersoftheImplementationTeam(‘Productive CommunityServicesCo-ordinators’,twoclinicalone non-clinical)wereallocatedanumberofteamstoworkwith andworkedwithrelativeautonomy.Theyhadnodefined mandatory requirements apartfrom collectingthe data requiredfortargetsdesignedbytheCommissionersand the Productive Community Services Project Manager, whichmeantthatcoverageoftheProductiveCommunity Services material that was not directly related to the targetswasoptional.Thetargetsweredevelopedaspartof
theCommissioningforQualityandInnovationframework (CQUIN, see NHS England, 2014), and funding for the implementation was dependent on the targets being achieved. Mostof these targetswere linked to specific Productive Community Services modules, including, for example,a10%reductioninthetimetakentofindpatient information (associated with the ‘Patient Status at a Glance’module),and a 10% reduction in travelmileage claimed (associated with the ‘Planning Our Workload’ module).Theothertargetsrequiredthat patientcontact timeshouldincrease by10% (associatedwiththewhole implementation),andspecifiedthemodulesthatdifferent servicesshouldhave implemented.Interview data indi-cated that part of the motivation for implementing ProductiveCommunityServiceswasduetothe manage-mentteam’sneedtodemonstratetotheStrategicHealth AuthorityandPrimaryCareTrustthattheycouldbecome an independent organisation, and they felt that imple-mentingthisprogrammewouldstrengthentheircase.
2. Methods
2.1. Participants
61participantswereidentifiedusingsnowballingand purposivesampling(Ritchieet al.,2003,see Fig.2)and were invited by email to take part in the study. Eight participantsdeclined, n=11 didnot respond withinthe deadline,leavingn=32whowererecruitedusing purpo-sive methods, and n=10 using snowballing methods. Whencommencinginterviewswithtwooftherecruited participants, they requested that colleagues from their teamjointhem,formingtheopportunisticsample,n=3.In total,40interviewstookplacewithindividualstaff,and twogroupinterviewstookplace; oneconsisting oftwo
clinicalteammembersandtheirmanager(n=3);andthe other consisting of two administrative team members (n=2). The Author had knowingly met 58% of the participants(n=26)beforeinterview.
Inregardstothepurposivesamplingmethod, partici-pants were chosen to represent various types of staff groups(seeFig.3).OnememberoftheSystmOnesoftware supportteamwasalsointerviewed,asalthoughtheyhad nottakenpartintheimplementation,theyhadspentalot oftimeworkingwithstaffwhohad.Teammemberswere recruited on the basis that as a minimum, they had submitted data for at least one of the Productive CommunityServices modules(e.g.theyhadbeentimed findingpatientinformationforModule3).However,the teammembersalsoincludedstaffwhowouldhavebeen nominatedas‘ModuleLeads’oractedasthemainpointof contact with the Productive Community Services Co-ordinatorsduringtheimplementation(n=15,54%).Team members were also split fairly evenly over the main operationaldirectorateswherepossible(seeFig.4).
Fig.1.TheProductiveCommunityServicesHouse(NHSInstituteforInnovationandImprovement,2009,p.5)(modulenumbersandabbreviationshave beenadded).
2.2. Ethicalconsiderations
EthicalapprovalwasgrantedbytheUniversityofEssex and the Governance Committee responsible for clinical governance and researchwithin theorganisation under study.Allparticipantsweresentanemailwhichincluded information which adheredtoguidancefromtheEthics
CommitteeoftheBritishPsychologicalSociety(2009).This includedtheopportunisticsamplewhowereshownthe emailedinformationattheinterview,andsenttheemail retrospectively.Consentwasreceivedbyallparticipantsin writing(n=39)oraudibly recordedatinterview(n=6). Data was stored adhering to the organisation’s secure Information Technologypolicy,and SafeHouse software. Participantdatawasanonymisedusing3-digitcodes.
2.3. Datacollection
Thefirstauthorcarriedouttheinterviews,anda semi-structuredopen-responseinterviewmethodwasused.For theinterviewswithnon-SeniorManagement, theinitial interview questions regarding Productive Community Servicesweredesignedtodrawoutparticipants’ experi-ence of theimplementation, and as advocated by King
(1994), the interview schedule was slightly modified
during the process according to the responses of the participants. Interviews with Senior Management used schedules adapted from the National Nursing Research
UnitandNHSInstituteforInnovationand Improvement
(2010b)duringtheirworkintoProductiveWard,asthese weremoreappropriateforusewithseniormanagers(see
Fig.5forexamplesofthequestionsused).
Interviews were recorded by dictaphone, and were transcribedbythefirstauthorusingasimplifiedversionof Jeffersonian method (Potter and Wetherell, 1987) and guidanceinParker(1992)(seeFig.6).Interviewslastedon average19min,rangingfrom5to45min.
2.4. Dataanalysis
Thefirst author carried out thecoding and analysis, usingBraun andClarke’s(2006)guidancetoinformthe analyticaldecision-makingprocess.Arealistapproachwas adoptedastheexperienceoftheintervieweeswassought, andthereforethemeswereidentifiedatthesemantic,or surfacelevelofmeaningratherthanatalatent,underlying level(Boyatzis,1998). Thisanalysisaimedtoproducea, ‘‘Richdescriptionofthedataset,’’(BraunandClarke,2006, p.83)toemphasisekeythemes.Thesoftwareprogramme NVivo (version 9.2.81) was used. Following Braun and Clarke’s(2006)sixphases,thefirstauthorfirstfamiliarised herselfwiththedata,bytranscribingthedataand then reading and re-reading the dataset. The generation of initialcodes(Phase2)wascarriedoutusingthefollowing ideasthatarosefollowingthefamiliarisationprocess:
Fig.3.Distributionofparticipantsbystaffroleanddirectorate(n=45).
3 22% 24 1 17% % 17%
Distribuon
Team Me
% 17%n of
Service
M
embers
by
D
Com Ser Lon Reh Int Op Chi Se Pub NuManager
s an
d
irectorate
munity Hospita vices
g Term Condio abilitaon egrated Care Te
eraonal Manag
ldren & Young P rvices
lic Health Inter rse Leadership l Clinical ns & am ement eople's venon &
Fig.4.Distributionofservicemanagersandteammembersbystaffrole anddirectorate(n=41;theremainingn=4werenotassociatedwith specificdirectorates).
Example interview quesons for non-Senior Managers
• Can you think of any examples of the changes that have been made as a result of the Producve Community Services programme in your service?
• As a team you would have been allocated a dedicated Producve Community Services Co-ordinator. Was this useful? Would it have been possible to do the Producve Community Services work without one?
• Do you feel that management (e.g. your line manager or the management above them) supported Producve Community Services?
• If there were any changes, do you think these will be sustained now that the Producve Community Services programme is over?
Example interview quesons for Senior Managers (adapted from Naonal Nursing Research Unit and NHS Instute for Innovaon and Improvement, 2010b, p. 95)
• Can you just talk about the process of deciding to implement Producve Community Services in [the organisaon]?
• What prompted its implementaon?
• Was there any objecon to its being run in [the organisaon]?
• What is it about The Producve Community Services that appeals to healthcare organisaons?
• Have you had any feedback from staff who have implemented it?
Experience of Productive Community Services imple-mentation—whatProductiveCommunityServiceshador hadnotdone.
What might have affectedtheProductive Community Servicesimplementation.
Suggestionsastohowtheimplementationmighthave beenimproved.
Informationhelpingtowardsanarrativeofthe Produc-tiveCommunityServicesimplementation.
Oncethedatahadbeencoded,thefirstauthorgrouped thecodesintothemesandsub-themes(Phase3),andthen reviewed these (Phase4), checking for any duplication acrossthethematicmap,andtestingthethemesagainst thecodeddatawithinthem.Phase5involvedrefiningthe defining the theme names and also identifying the overarching narrative themes, before compiling the writtenreport(Phase6).
3. Results
Fig.7displaysthesixoverarchingnarrativethemesand 27associatedthemesidentifiedfromthedataset.There wereseveralthemesthathadaspectsthatwerelikelyto limit the potential of the programme, however in this reporttheauthorsfocusonfivethattheyperceivedwere likelytohavethemostimpact,inadditiontothethemeof participants’positiveperceptionsoftheimplementation. Thesethemesare:
1.Communicating Productive Community Services to Staff.
2.Awareness,knowledgeorunderstandingofProductive CommunityServices.
3.Sustainability. 4.Relevance.
(.) Pause
. Short pause
, Very short pause
Underlined Words uered with added emphasis
(inaudible) Round brackets indicate that material in the brackets is either inaudible or there is doubt about its accuracy [Area X] Material in square brackets is clarificatory informaon, anonymised informaon, or non-verbal acon (e.g. laughter) - Word sound interrupted (e.g. speaker stops mid-way through word)
? Pitch rises, similar to a queson
... Text or words of assent have been removed for brevity
Fig.6.TranscriptionconventionsusedadaptedfromsimplifiedJeffersonianmethodinPotterandWetherell(1987)andguidanceinParker(1992).
5.NegativeperceptionsofProductiveCommunityServices. 6.PositiveperceptionsofProductiveCommunityServices.
3.1. CommunicatingProductiveCommunityServicestostaff
FacetofacecommunicationfromtheImplementation Teamwasperceivedtobemoreeffectivethanviaemailor byreadingtheProductiveCommunityServicesmaterial. Staff felt that it was important for the Productive CommunityServicesworkloadtobedisseminated down tostaffmembers,howeverthestaffalsohada responsi-bilitytoretaintheinformationthatwascommunicated:
Ithinkallofthemwouldhaveheardaboutitbystaff meetings,butI suspectthatsomewillhaveretained thatandsomepeople,itwouldhavejustdroppedoff theradar.(037,Manager)
Staffreported thatthewaythattheprogrammewas communicated,for examplevia teammeeting oremail, wasnotalwayseffective.Therewasaperceptionofalack ofcommunicationandlittleexposuretotheprogramme. Staff had little contact with or knowledge of their ProductiveCommunityServicesCo-ordinator(theirmain contactwithintheImplementationTeam),andsomestaff responsessuggestedProductiveCommunityServiceshad beenmiscommunicated.Staffdidnotalwaysrealisethe need to disseminate Productive Community Services to other staff, and also perceived that the significance of ProductiveCommunityServicesbecamediluted.Onestaff membercommented,
...itwasjustsomethingwedidawhilebackandthen... it’sgone...whichisabitofashame...becausethere’sa lotofworkinvolved...it...sortofgetswatereddownI thinkasitcomesacrosstousperhapswewaterdown theimportanceofitandwhatwecould,whatwecould gainfromitandmaybethat’sapointthatneedstocome acrossifyoulaunchitagain...isactually,whatdoesit meantotheservice?...whataretheygoingtogetoutof it?(033,TeamMember(Clinical))
More communication about Productive Community Serviceswasdesired(e.g.throughorganisational commu-nication orworkshops),and moreneededtobedoneto introduceProductiveCommunityServicesatthebeginning oftheprocess,withclearercommunicationoftheoutcomes intended.
3.2. Awareness,knowledgeorunderstandingofProductive CommunityServices
Where staff were aware of Productive Community Services,theydidnotalwayshaveanunderstandingofthe wholeconcept:
045: Ithinkagainalotofus,knewweweredoingit but didn’t, really understand the whole, concept of Productive Community Services...I think the people that, in the office that co-ordinating it the adminis-trators and,management, understoodmore, thanwe didwewerekindof,moretoldtodo,todothisandthat ratherthan,maybewhyweweredoingit
Intvwr: sodoyouthinkallthemembersofyourteam knewaboutit?
045: (.) We all knew we were doing something... whenI,kindofbandiedroundtheofficelastweek‘Does anyoneknowanythingaboutproductivecommunities ‘cause I’ve got an interview’, I drew blanks from everybody apart from the administrators [laughs] (045,TeamMember(Clinical))
Participantsoftenstruggledtorecallchangesmadeby theprogramme.Althoughthiscouldberelatedtomemory
(and Kitchell, 1995 warns that memory affects the
measurement of innovation), this might also be due to changes not always being attributed to Productive CommunityServices,theprogramme’slackof sustainabil-ity,orthatitsimpactwassolittlethatitwashardtorecall thechangesmade.
Thedepthofawareness,knowledgeandunderstanding of Productive Community Services depended on staff members’involvement.Thiswasassertedexplicitly,but wasalsoimplicitinthatparticipantscouldtalkaboutwhat theyhadbeeninvolvedwith,butlittleornothingaboutthe ProductiveCommunityServicesworktheyhadnotbeen partof:
Ithinktheywerealltoldaboutwhethertheyalltook, theyalltookitonboard,I’mnot,certainIthink... espe-especially for the team,team members that weren’t directlyinvolved,itmayhavejustwentstraight,over theirheador,[ProductiveCommunityServices]wentin oneear and out, out theother.(020, Team Member (Clinical))
3.3. Relevance
Staff noted the individual nature of Community Services,whereteamsareoftenquitespecialist:
...I just think that we’re such a (.) massive, diverse organisation...Icanseethethoughtprocessesbehinda lotofthestuffwedoandIthinkthey’regood,but...it’s likeaone-sizefitsall...Whereas,howIworktohow, thenursesworktohowthe[OccupationalTherapists] workis allcompletelydifferent.(028, TeamMember (Clinical))
Althoughsomestaff felt that Productive Community Services did have some principles that were relevant acrossservicecontexts.
Youhaveto(.)thinkabout,dotheyactuallyapplyto you...BecauseasIsaidbefore itdoesn’tfocusonour serviceparticularly...Andtherearethingsbutyoucan workI–you can workround it. (009, Team Member (Clinical))
Howevera‘Lackofrelevancy’wasasubthemeclearly identified.Participantsnotedthatmoreshouldhavebeen donetoexaminewhatwasrelevanttoeachteam,andthe implementation needed to bemore bespoke. A pattern emerged where staff felt that Productive Community Serviceswasnotrelevanttothem,butfeltitmighthave beenforanotherservice(seeTable1).
This evidence suggests that in this implementation, Productive Community Services was not always made relevanttousers.ThismayhavebeenduetotheProductive Series’originsintheacutesectorwards,whichisarguably lessdiversethanCommunityServices,howeveraccording to the NHS Institute for Innovation and Improvement, Productive Community Services was not simply, ‘‘...a tweakedversionofTheProductiveWard’’(,p.15).Thislack ofrelevancyisnotjustareflectionoftheprogramme,but alsoofhowitwasimplemented.
3.4. Sustainability
Staffacknowledgedthatoldbehaviourscanoftencreep back,andthatsustainingthechangeswashardwhenfaced withotherworkpressures.Sustainingtheimprovements made by Productive Community Services was often affectedbyotherchangesmadeintheorganisation (for example,siteorpersonnelchanges).Some stafffeltthat changesmadeduringProductiveCommunityServiceshad been sustained, and that some of the concepts learnt duringProductiveCommunityServiceshadbeen integrat-edintothesystem.Forexample,thesoftwaresupportteam member witnessed staff continuing to use one of the ProductiveCommunityServicesinitiativeswhichwasto displaythecostofstockproductssothatstaffweremore awareofresources:
...aserviceturnedroundandsaid...‘Putthecostonthere, then’...AndIwasquiteimpressed...Ithought,ooh...It’s filteredthroughthey’vegotthat...soIthink, itwas a good,goodexercisegoodmessage(006,ChangeAgent) However, others felt that the changes implemented during Productive Community Services were not sus-tained,andthatinefficientpracticescontinued:
Personally I believe old habits die hard and I think people just gobacktotheway theywere...and so, althoughit wassupported wellbytheboardand,by especiallymy linemanageratthetime (.)Ithinkit’s kindofslipped...Idon’tthinkwe’re,usingeverything we learnt from it now, we’ve started hoarding stuff againand...perhaps,reportsaremadeandchartsgoup, fromthe reportsbut they’re, outof date they’renot kept,uptodate.(033,TeamMember(Clinical)) Staffalsoperceivedthatthepaceoftheimplementation was not sustained. One participant noted of her team leader,
...shewould feedbacktousatteammeetingsasto what was happening and when it was happening and...Whichmodules we would probably be,taking partin...But,asIsaidthatwasquitealongtimeagoand itallwentveryquietsoIwasn’treallysurewhetherwe werecontinuingwithit...Orifithadstopped...Ididn’t knowwhythatwouldbe...Idon’tknowwhetherit’s fizzledout...that’sjusttheimpressionIgot.(027,Team Member(Clinical))
3.5. NegativeperceptionsofProductiveCommunityServices
SomeparticipantswerefrustratedthattheProductive Community Services work had not been efficiently or effectively implemented, and the implementation was seentobeawasteofresources,withlittleornobenefit.The programmewasalsoseentotaketimeawayfrompatients andhadanegativeeffectonserviceandstaff:
... for instance timing...however many, number of patients on SystmOne we had to time looking at... gettingtheirinformation up...Andthen,re-timing it,
Table1
Evidencedemonstratingaperceivedlackofrelevancy.
Typeofstaffmember Relevant? Evidence
Relevanttoadministrators? No Interviewee015,AdministrativeStaff
‘‘Imeanwith,thefacetofaceandnon-facetofaceIdon’tknowhowrelevant thatwastome?...becauseI’mnot,clinical.’’
Relevanttoaclinician? No Interviewee002,ClinicianinAssessmentRehabilitationUnit
Sointhatrespectthatmoduledidseem,tobeabit,sortofpointlessforus...it didprovethatwelookafterourpatientsandtheyallhavethesamecare...for theirparticularcondition...buti-itmaybeitwouldhavebeenbetter,i-it workedbetterperhapssomewherelikethewardorsomewherelike outpatients.’’
Relevanttooutpatients, e.g.podiatry?
No Interviewee003,PodiatryManager
‘‘ForPodiatry,totalwasteoftime...Ican’tthensayfortheotherAHPs[Allied HealthProfessionals]...SoforSpeechandLanguageitmighthavebeen helpfulforthem.’’
Relevanttoanotherallied healthprofessional(AHPs), e.g.Speechandlanguagetherapy
No Interviewee047B,SpeechandLanguageTherapyTeamMember ‘‘Ithinkt-thewholepackage,seemedtobeverymuchdirectedtowards nursing...teamsratherthan,AHPteams...andintermsofAHPteamsSpeech andLanguageTherapy(.)arequitedifferentfromphysioand,andOTIthinkin thewaythatwe,wework,sotherewasquiteabitofitthatwasn’t(.)necessarily terriblyrelevant...toourservice.’’
Relevanttonursing? No Interviewee026,DistrictNurse
‘‘...itneverfelttherewasa...youknow,howitwasgoingto,revolutioniseour daytodayworking...Justanotherpieceofworktofitin...Possiblyhowitwas communicatedpartly...yeahI’mnotsuretheprogrammeitselfwas, relevant...Youknow?’’
once...all the information was on the front page... actually ittookuslonger...whenit wason thefront pagethanwhenw-,wewerelooking,allovertheplace ‘causeweknewwhereeverythingwasanyway...Soit made no difference...So, you know, I had to pull someoneoutofclinictodothetimingonthem...Twice. (003,Manager)
ParticipantssawProductiveCommunityServicesasyet ‘‘another’’thingtoaddtotheworkload,andyet‘‘another’’ one ofthesetypes ofprogrammes.‘Experience ofother programmesorinitiatives’wasanotherthemeidentified (seeFig.7)andtheregularimplementationofinnovations riskscreating‘InnovationFatigue’(WrightandMcSherry, 2014),whichwasindicatedinthedata.Thisalsohighlights theissueofnotlearningfrommistakesmadeinprevious programmes,asthisreducesstaffmembers’expectationof futureinitiatives.
Ithinkitwasthatitwasanother,anotherthingontopof the...workloadthat’s...happeningatthemoment,and also there’s so much change going on in, [this organisation]andgenerally...Ithinkitwas,ohitwas another,anotherthing,youknowburden...soIthink, unfortunately,that’s...(the)latestprojectthatcomesin everybody does see those as,as thelatest burden... (030,TeamMember(Clinical))
ProductiveCommunityServiceswasalsonotseentobe embeddedoracorepartofpractice:
...it felt, at the time as though we were being herded...and...rather than being, an integral part ofourserviceand,lookingatwhatweweredoingit was definitely a, a bolt-on...maybe if it...had,
seemed more relevant and we’d had more time
and,andweregoing toapply it,morein awaythat would have been relevant to our service, it would have been very useful to have somebody that we could contact, andsay this is what we wanttodo, how doesthat fit in with what youneed, but,you knowso,wedidn’tmaketheverybestuseof[the Co-ordinator]Isuspect...but...thatwaspartlyIthinkthe way the,thethingwas,setup.(047,TeamMember (Clinical))
3.6. PositivePerceptionsofProductiveCommunityServices
Participants generally felt that the concept behind ProductiveCommunityServiceswasgood,andit empow-ered staff.Staff reported theprogramme had increased awareness of their services, for example, in relationto performance,topoororinefficientworkingpractices,of stock andtime resources.Theparticipantquoted inthe extractbelowdescribedhowherteamengagedwiththe Module2workonservicestatistics:
...it’sbeenquiteinterestingbecause,forinstanceallthe statsandstuff,peoplearelookingatthemandgoing ‘oohooh’lotsof‘ums’and‘aars’and...sortof‘ohthat looksright’or‘ohthat’sgood’or‘that-youknowmaybe wecandosomethingaboutthat.’(001,TeamMember (Clinical))
Staffexperiencedmanybenefits,suchasthe improve-ment of stock control, working environment and time management,thesavingoftimeduringprocesses,better use of their Electronic Patient Records system, and a reduction in paperused. Processeswere improved,and improvementsmadeduringtheimplementationsparked furtherimprovement.
It’sprobablychangedhowIfeel,becauseIwasquite involvedinit...Justinerm(.)findingamoreefficient way,ofdoingthings...Itendtohavealotofmywork around me [laughs] and it has sort of made me (.)streamline ...what I do...so it has worked for me...andinsomeregardsithasworkedfortheothers but they’re just not aware that it’s [Productive CommunityServices]that’s,made thatchange. (033, TeamMember(Clinical))
4. Discussion
Theobjective of this study wasto explore organisa-tionalstaffmembers’perceptionsofaProductive Commu-nityServicesimplementation.Inadditiontothethemeof the positive perceptions of the programme, this report focuseson fiveofthethemesidentifiedwhich highlight partsoftheimplementation thatwerelikely tolimit its potential. In comparing these results with previous findings, other implementations of Productive Series programmes have been reported to generate various improvements (e.g. Dean, 2014; Lennard, 2014; Lipley, 2009),andsimilarlyinthisimplementation,staffreported benefits suchas improved stock control, time manage-ment,anduseofElectronicPatientRecords.Althoughthe existingliteraturefocuseslessonthechallengingaspects oftheprogramme,ina nationalweb-surveyoffrontline staff(n=150),NationalNursing Research Unitand NHS InstituteforInnovationandImprovement(2010b) identi-fiedsomeof thebarriersto implementationwhich had similaritieswiththeissuesidentifiedinthisstudy.These includedthefacilitators’lackofunderstandingofspecific wardcontexts(similartoissuesfoundwithinthethemeof Relevance, where the implementation appeared not to havebeenmaderelevanttodifferentservicecontexts)and thedifficulty ofsustaining improvements(found in the themeofSustainability).Inaddition,althoughopcit.Davis
and Adams’ (2012) smaller sampled study on staff
perspectivesalsoidentifiedsomenegativeaspectsofthe implementation (e.g. ‘Anxiety and defensiveness’ and ‘Challenges’),the analysis in this study offers a more detailednarrativeoftheimplementationwhichhighlights specificareasofdifficultythatfuturepractitionersofthe programmeshouldbeawareof.
Forexample,Whiteetal.(2013)proposesthatengaging
communicationiscrucialtoimplementation,andthedata indicatedthatthisrequirementwasnotalwaysmet.This maybeexplainedbytheinexperienceofthe implementa-tionteam,asalthough theyhad goodknowledgeofthe organisation,theyhad littleexperienceofimplementing change.Thechangeandinnovationliteratureemphasises the salience of communication (for example see Lewis etal.,2006), howeverthisknowledgedidnotreach the
team, or they were not able to effectively put it into practice.AsthisreplicatesfindingsbyWhiteetal.(2013)
fortheProductiveWardimplementations,thisreinforces theneedtofindwaystobetterbridgethegapbetween theoryandpracticeforimplementationteams.
There are clear links between the first two themes described,asawareness,knowledgeorunderstandingof aninnovationcanonlybeachievedbyeffective commu-nication.Facetofacecontactwasseenasmoreeffective thanemailcontact,andthisisimportanttoconsiderina CommunityServices organisationwherecommunication can be difficult across multiple sites (working across multiplesiteswasalsoidentifiedasabarriertoProductive WardimplementationbyNationalNursingResearchUnit
and NHS Institute for Innovation and Improvement,
2010b). For example, although communication by
tele-phoneoremailisrelativelyinexpensive,itmaybeabetter useofresourcestotraveltostaffinpersoniftheyaremore likelytoengagewiththeprogrammeasaresult.
Staffalsosuggestedthatcommunicationviaworkshops ororganisationalchannels(e.g.theintranet)mighthave improvedtheprocess.However,althoughawarenesscan beincreasedusing thesemethods(Leemanetal.,2007) implementationoradoptionoftheinnovationisstillnot guaranteed(Grimshawetal.,2004,citedinLeemanetal., 2007). Further researchisrequired toexplore themost effectivewayofcommunicatingtheinnovationorchange message, particularly in Community Service settings wheremanystaffareloneworkersorbasedovermultiple sites.
TheservicesinCommunityServicesorganisationsare also specialist and diverse, so innovations need to be alreadyrelevant,oradaptedeasilytobemaderelevantto potential adopters. However, the analysis found staff perceivedtheprogrammetohavelittlerelevancetotheir work.Theparticipantobservationoftheimplementation that was carried out identified other factors that were likely to contribute towards this lack of relevancy. For example, the Productive Community Services material appearsquiteprescriptive,emphasisingCommunity Nurs-ingmodelsofcareratherthanclinic-basedservices.The ImplementationTeam(mostlysecondedfrompostswithin the organisation) were inexperienced in programme implementationandhadtightdeadlinesimposedbythe Commissioners,andsostruggledtoadaptthematerialto be relevant to all services within the time available. Further research is required to explore this issue of relevancyinotherorganisationsimplementingProductive CommunityServices,andalsotolookathowknowledge transfer(Bertaetal.,2005)canbeimprovedforinternally resourced implementation teams, particularly as this optionislikelytobeutilisedmoreregularlyinfinancially challengedhealthcareorganisations.
Someothersignificantcontextualfactorsmayalsohave contributedtowardstheissuesidentifiedinthesethemes. Theseincludethemotivationoftheorganisation’s manage-mentteamtoimplementthe programme(tostrengthen their case to become a standalone organisation, which meantthatbeingseentoimplementtheprogrammemay have been more important than the outcome), that the majority of services only implemented six out of nine
modules, and also the way that the programme was commissioned.‘Localownership andrealempowerment’ wasoneoftheorganisationalfactorsidentifiedas influenc-ing the success of the Productive Ward programme (National Nursing Research Unit and NHS Institute for InnovationandImprovement,2010b),andimposinggeneric commissionedtargetstookthislocalownershipawayfrom frontlinestaff.Inaddition,duringtheparticipant observa-tion, the first author observed that there was a strong emphasisonimplementingtheworkthatwasrequiredfor theCommissioners’targets,whichmeantthatProductive CommunityServicesmaterialsurplustotheserequirements wasnotalwayscovered.Asorganisationsincreasinglyrely oncommissioningforinnovation,thishighlightsanareafor furtherresearch.
White etal. (2013)identified abias intheliterature towards the publication of positive results, but the publicationof morenegativeresultsarguably highlights moreclearlytheneedforfurtherresearchtobecarriedout. However, despitethenegative issues highlighted,other benefitswereidentifiedduringtheimplementationwhich includedthereductionofexcessstock,improvedreferral proceduresandreducedtimeinfindingpatient informa-tion. Itshould also beacknowledgedthat althoughthe programmeaimstoreleasetime,improvingqualitymay inconvenienceorhaveanegativeconsequencesforstaff members.Ideallythereshouldbeabalancebetweenthe impact on staff and other parties, however this is not alwayspossible.Thereforeitmaybeinevitablethatstaff will have negative perceptions of an improvement initiative,particularlyiftheycannotseehowthechanges benefitthepatient.Asnursesaremotivatedbybeingable tocare for and helppatients (Newton etal., 2009),the programmeshouldbecommunicatedsothatthe relation-shipbetweenthechangeimplementedandthebenefitto patientsisclear.
4.1. Limitations
Thefirstauthorwholedtheinterviews,hadbeenpart oftheimplementationteamandhadmetthemajorityof participantsin thatcapacity,sodemandcharacteristics mayhavebeendisplayed.Thefirstauthoralsoanalysed the data alone, so inter-rater reliability could not be measured.A‘criticalfriend’(McGrathandO’Toole,2012) was employed to read the final report, however the interviewer’s role in the construction of knowledge
(Rapley, 2001) should be recognised. Rather than
creatingapositivistic‘bias’,thefirstauthor’sexperience of the implementation wasan essential part of theory development.
Caution shouldalso be taken when generalisingthe resultsofthisanalysistootherorganisations,asthedata arebasedonthewaythatProductiveCommunityServices wasadaptedintheorganisationunderstudy.Focushere hasalsobeenonperceptionsoftheimplementationrather thanthestaffmembersthemselveswhoalsofactoredin theimplementation’seffectiveness.Inaddition,although the participants were not all heavily involved in the programme,therewasasamplingbiasasthecriteriafor TeamMembersensuredthattheyhadsubmitteddatafor
at leastone ProductiveCommunity Services module, so teammemberswhowerenotinvolvedinthiswaywere not represented.However, asthosethat tookpartoften knewlittleabouttheprogramme,thissuggeststhatthose withnoinvolvementwillhavehadevenlessknowledge. This bias then highlighted the salience of effective communication and staff involvement even more. This study alsoforms partof a largerpieceof research, and although some of the significant contextual factors identified in the major study have been discussed, the detail focused on here forms only part of the broader picture. Further findings from the major study will be submittedforpublicationinduecourse.
5. Conclusion
Much of the previous research on Productive Series programmeshasrecruitedparticipantsheavilyinvolvedin the implementation,and with a positive bias.Although positive benefits of the Productive Community Services implementationwerereportedinthisstudy,focusonfive ofthethemesidentifiedsuggeststhatmanyaspectsofthe implementationcouldhavebeenimproved.Therewasa lack of understanding or knowledgeof theprogramme, ineffective communication, and a perceived lack of relevance of the programme. This indicated that there wasaknowledgetransfergap,asimplementationtheory didnotappeartohavealwaysbeenusedinpractice.The ProductiveSeriesprogrammesaredesignedtobeledby frontlinestaff,howevertheissuesidentifiedsuggestthat this was not always achieved effectively. If healthcare organisations implement programmes using internal resources rather than employing experienced external consultants,theyneedtobewaryoffalseeconomy,and lookforwaystoensurethatimplementationknowledgeis transferred to the organisation. The designers of pro-grammes for CommunityServices inhealthcare suchas ProductiveCommunityServicesalsoneedtoensurethat theyaremaderelevantoreasilyadaptabletothevarious specialismsthatexistinCommunitycare.Theprocessof commissioning innovations like Productive Community Servicesandtheexperienceofimplementationteamsare alsolikelytohaveanimpactontheeffectivenessofthe implementation.Publicationofimplementationsfocusing on less favourable results may promote the need for furtherresearchtoimprovetheseareas.
Conflictofinterest
During the study the first author was carrying out
research on the programme as a member of the
implementation team, and is now working within the organisationunderstudy.
Funding
Thisstudywasfundedbytheorganisationunderstudy.
Ethicalapproval
EthicalapprovalwasgrantedbytheUniversityofEssex andtheorganisation’sGovernanceCommittee.
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