Complex Health Care Environment Research Articles

Designing health professional education curricula using systems thinking perspectives

BackgroundMedical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student’s preparedness for practice.MethodsBy framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media.ResultsWe describe how the 3P-6Cs toolkit captures a learner’s personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students’ developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions.ConclusionApplying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student’s preparation for lifelong practice.

Rethinking Strategies to Address Inequity in Immunization Services towards Achieving Universal Immunization Coverage (UIC) in Karachi, Pakistan

Karachi, the largest city in Pakistan, having high population growth and a complex health care environment, has highest density of unimmunized (zero dose) and under-immunized children. The main reasons of low immunization coverage in Karachi were lack of governance and accountability in a duplicative and fragmented health management structure, weak and inequitable immunization services, and lack of demand and trust among people for immunization services. The Expanded Programme on Immunization (EPI), Ministry of Health (MOH) in Sindh Province spearheaded a structured and collaborative process to develop strategies for addressing inequity in immunization services towards achieving Universal Immunization Coverage (UIC) in Karachi. The process included a situation analysis with gathering quantitative and qualitative information on the root causes of zero-dose and inequity of the immunization services. The strategies and interventions were developed with multi-layer input and feedback of the stakeholders and partners, and focusing primarily to address gaps in three program areas: governance, leadership and accountability; immunization service delivery; and building demand and trust among the people. The interventions were further prioritized for high-risk areas; identified based on maximum number zero-dose children, presence of large slum areas, measles outbreak and on-going circulation of wild poliovirus. Finally, costing for the Roadmap activities was done through consultation with partners and aligning domestic and external (donor) resources. In this paper, we have highlighted the unique process the Sindh Government undertook in collaboration with the stakeholders and partners to develop strategies and interventions for addressing inequity in urban immunization services in Karachi towards achieving Universal Immunization Coverage (UIC). Similar processes can be adapted, as a potential model, for developing strategies to achieve universal health coverage in the cities of Pakistan and in other countries.

SoS Explorer Application with Fuzzy-Genetic Algorithms to Assess an Enterprise Architecture – A Healthcare Case Study

Kevin Dooley (1997), defined Complex Adaptive System (CAS) as a group of semi-autonomous agents who interact in interdependent ways to produce system-wide patterns, such that those patterns then influence behavior of the agents. A healthcare system is considered as a Complex Adaptive System of system (SoS) with agents composed of strategies, people, process, and technology. Healthcare systems are fragmented with independent systems and information. The enterprise architecture (EA) aims to address these fragmentations by creating boundaries around the business strategy and key performance attributes that drive integration across multiple systems of processes, people, and technology. This paper uses a SoS Explorer to select an optimal architecture that provide the necessary capabilities to meet key performance attributes (KPAs) in a dynamic, complex healthcare business environment. The SoS Explorer produced an optimal meta-architecture where all but two systems (disease and facility processes) participated with many of the systems having at least four interfaces. The healthcare meta-architecture produced in this study is not a solution to address the challenges of the healthcare enterprise architecture but provides insight on the areas – systems, capabilities, characteristics, and interfaces – to pay attention to where agility is an important attribute and not to be severely compromised.

Authentic and ethical leadership during a crisis.

In today's climate and environment, the conventional relationship between caring, economic, and leadership practices may no longer meet the needs of patients, clinicians, providers, or systems. It is asserted that in the current complicated and complex healthcare environment challenged by a multitude of issues, a shift toward human caring values and an ethic of authentic healing relationships is required, especially in light of the current COVID-19 pandemic. The costs of unethical behaviour can be even greater for followers. When we assume the benefits of leadership, we also assume ethical burdens. It is the assertion and experience of the authors that the triangle of ethics and ethical behaviour, followers, and patient outcomes is closely interrelated and affects each other in a very intimate and direct way. Unethical leadership may lead to follower disappointment and distrust, leading to lack of interest and commitment, consequently negatively impacting patient outcomes and organizational effectiveness.

Human-centred leadership in health care: A contemporary nursing leadership theory generated via constructivist grounded theory.

To generate a unique and contemporary leadership theory reflecting the essence of nursing within a complex health care environment. As health care faces unprecedented change and increasing complexity, a nursing leadership theory embedded within complexity science is vital for teams to be innovative, nimble and focused on human-centred care. Constructivist grounded theory framed exploration of human issues embedded in nursing leadership. The constructivist approach sought thematic and theoretical sensitivity through the rich co-creative experience of participants, researchers, literature and data. Focus groups were convened over 18months with 39 nurse leaders from bedside to boardroom. Constant comparative methods resulted in 15 attributes. Advanced coding positioned the 15 attributes into constructs: Awakener, Connector and Upholder. Definitions emerged through the constructivist process organically connecting attributes and constructs to the potential outcomes identified in the theory as cultures of excellence, trust and caring. The final constructivist process revealed a nursing-specific theory: human-centred leadership in health care uniquely suited to assist leaders in addressing structure, process and outcomes. Efforts by nurse leaders to test the theory with metrics related to nursing excellence will result in validation of the theory and validation of the proposed sustained culture change.

Empowering Nurses with an Online Roadmap for Evidence-Based Practice

ABSTRACT Nurses are involved in an increasingly complex and changing health care environment. To be effective, nurses must have the skills to effectively engage in evidence-based practice (EBP) to improve patient care. In preparing for Magnet reaccreditation, an interdisciplinary team in one academic medical center recognized that there was variability in nurses’ understanding of the EBP process. This left nurses hesitant to engage in the process and resulted in the uneven quality of EBP project outputs. This article details a project lead by a health sciences librarian in collaboration with nurses to create and implement an online resource and reshape EBP instruction. This project aimed to increase the EBP knowledge of bedside nurses, increase overall nurse engagement with EBP, and bring uniformity to the EBP activities of nurses in the organization. The implementation plan, evaluation, and next steps for this project are shared to show the key role health sciences librarians can play in improving EBP in a health care organization.

SOARING: A Residency Program for Unlicensed Assistive Personnel: Meeting the Demands While Retaining Highly Skilled, Engaged Clinical Technicians.

A complex healthcare environment requires an optimal nursing skill mix at a reasonable cost to sustain safe, quality, and efficient patient care. An innovative, unlicensed assistive personnel residency program was developed to fill open positions with a skillful, confident, and engaged clinical technician workforce. The program resulted in highly skilled and confident clinical technicians, a 4% increase in engagement scores, and a 14% increase in retention rate.

Strategies to develop student support mechanisms in medical radiation sciences clinical education

Clinical placement experience is an important component of medical radiation science (MRS) education, equipping students to safely transition into complex healthcare environments. This commentary draws on evidence from the literature that reports challenges allied health students face in clinical environments. As several factors are implicated that could result in a higher prevalence of psychological distress and mental ill-health in MRS students, there is a need to re-emphasize the importance of developing strategies to support students in clinical education. A key recommendation is to identify associated risk factors early as they can impact on the quality of education and in severe cases be detrimental to students' psychological well-being. This requires an understanding of the full extent and nature of the challenges through partnered approaches between professional organisations, clinical departments, academics and students. Developing evidence-based strategies for improving students’ well-being in clinical environments is also essential.

Experience of nurses regarding the clinical mentoring of student nurses in resource-limited settings.

BackgroundOne of the major challenges associated with nursing education in this 21st century is the practice preparation of student nurses to serve in complex healthcare environments and to ensure their fitness to practise in these environments. Clinical mentoring has shown promise in providing clinical learning support for student nurses. Most approaches are, however, biased towards higher-income settings without giving due consideration to the resources, culture and structures of health systems in resource-limited settings. It is also unclear how qualified nurses who act as nurse teachers experience the clinical mentoring of student nurses in resource-limited settings.AimThis study aimed to explore and describe the experiences of qualified nurses regarding the clinical mentoring of nursing students in resource-limited settings.SettingThe study took place in Mauritius, a developing country.MethodsA qualitative, exploratory, descriptive approach was used with a purposive sample of eight nurses. Data were collected through face-to-face interviews and thematically analysed.ResultsThe findings indicated that mentoring per se was not practised, but rather general support, supervision or coaching. This resulted in the practice being less effective for its original purpose. Possible explanations included a lack of policy directives. Additionally, the mentoring practice was informal with unclear role expectations. Poor material and personal resources further compounded the challenges. An absence of buy-in and involvement of management along with a lack of monitoring clinical mentoring by the nursing school concludes the picture.ConclusionEffective clinical mentoring requires an understanding of the mentoring process from a broader perspective. Mentors should be equipped with core competencies. Successful mentoring outcomes are dependent on a conducive clinical learning environment and a clear mentoring approach.

Creating Microclimates of Change: Transparency in Disseminating Nursing Quality Performance Data.

Study objectives were to: 1) explore how nursing care quality data (NCQD) was understood and interpreted; and 2) identify, compare, and contrast individual and group responses. Little evidence exists on how to best disseminate NCQD information. This study explores the outcomes of implementing an NCQD and human-interest information slide show across an inpatient surgery nursing service line using electronic screens. Methods included semistructured interviews, qualitative analysis, and diagramming. The human-interest content most often attracted viewers' attention, but they were also exposed to NCQD. Interpretations and understandings differed among groups and between individuals. Among staff members, the human-interest content facilitated team-building, whereas NCQD provided meaningful recognition. Nursing care quality data evidenced the efforts that were being made to improve and provide excellent patient care. Using innovative dissemination methods can enhance understanding of NCQD among clinical providers. Creating microclimates of change and innovation within complex healthcare environments can benefit staff members and patients.

Developing a Plan for the Sustainable Implementation of an Electronic Health Intervention (Partner in Balance) to Support Caregivers of People With Dementia: Case Study

BackgroundGiven the increasing use of digital interventions in health care, understanding how best to implement them is crucial. However, evidence on how to implement new academically developed interventions in complex health care environments is lacking. This case study offers an example of how to develop a theory-based implementation plan for Partner in Balance, an electronic health (eHealth) intervention to support the caregivers of people with dementia.ObjectiveThe specific objectives of this study were to (1) formulate evidence-based implementation strategies, (2) develop a sustainable business model, and (3) integrate these elements into an implementation plan.MethodsThis case study concerns Partner in Balance, a blended care intervention to support the caregivers of people with dementia, which is effective in improving caregiver self-efficacy, quality of life, and experienced control. The large-scale implementation of Partner in Balance took place in local dementia case-management services, local care homes, dementia support groups, and municipalities. Experiences from real-life pilots (n=22) and qualitative interviews with national stakeholders (n=14) were used to establish an implementation plan consisting of implementation strategies and a business model.ResultsThe main finding was the need for a business model to facilitate decision-making from potential client organizations, who need reliable pricing information before they can commit to training coaches and implementing the intervention. Additionally, knowledge of the organizational context and a wider health care system are essential to ensure that the intervention meets the needs of its target users. Based on these findings, the research team formulated implementation strategies targeted at the engagement of organizations and staff, dissemination of the intervention, and facilitation of long-term project management in the future.ConclusionsThis study offers a theory-based example of implementing an evidence-based eHealth intervention in dementia health care. The findings help fill the knowledge gap on the eHealth implementation context for evidence-based eHealth interventions after the trial phase, and they can be used to inform individuals working to develop and sustainably implement eHealth.

Evaluating the implementation of an early supported discharge (ESD) program for stroke survivors: A mixed methods longitudinal case study.

Early supported discharge (ESD) models of care for stroke survivors coordinate inpatient and community services, with the aim of reducing length of stay. While there is an established evidence base around the clinical outcomes of ESD), less is known about the implementation of this approach into existing stroke care service. The aim of this case study was to describe staff perceptions of the implementation of an ESD model of care for stroke survivors at a large metropolitan public hospital in Australia. This case study utilised a mixed methods design, which was designed in explicit alignment with the Consolidated Framework for Implementation Research (CFIR). Participants included staff that referred patients for ESD, and staff involved in the planning, implementation or delivery of ESD. Survey data was collected at three time points (ESD commencement, 3 months and 6 months), and focus groups were undertaken at the conclusion of the study. All quantitative data was analysed descriptive, while qualitative data was evaluated using thematic analysis. Results from both sources of data identified changes in staff perceptions of ESD implementation over time. While very few changes were statistically significant, they were diverse patterns of change across the CFIR constructs over time. The characteristics of individuals and ESD characteristics attracted consistently positive perceptions, while patient needs and resources was the most prevalent theme within the data. While perceptions of factors related to the inner setting were mixed, there was a steady improvement in perceptions about the process across the later stages of implementation. The sophistication of knowledge translation and implementation in modern complex healthcare environments is highlighted by the multiple interactions between the CFIR domains and constructs. While the implementation process described was generally positive and effective, using the CFIR as a framework confirmed that it also entailed some challenges and unanticipated outcomes.

How Will Machine Learning Inform the Clinical Care of Atrial Fibrillation?

Machine learning applications in cardiology have rapidly evolved in the past decade. With the availability of machine learning tools coupled with vast data sources, the management of atrial fibrillation (AF), a common chronic disease with significant associated morbidity and socioeconomic impact, is undergoing a knowledge and practice transformation in the increasingly complex healthcare environment. Among other advances, deep-learning machine learning methods, including convolutional neural networks, have enabled the development of AF screening pathways using the ubiquitous 12-lead ECG to detect asymptomatic paroxysmal AF in at-risk populations (such as those with cryptogenic stroke), the refinement of AF and stroke prediction schemes through comprehensive digital phenotyping using structured and unstructured data abstraction from the electronic health record or wearable monitoring technologies, and the optimization of treatment strategies, ranging from stroke prophylaxis to monitoring of antiarrhythmic drug (AAD) therapy. Although the clinical and population-wide impact of these tools continues to be elucidated, such transformative progress does not come without challenges, such as the concerns about adopting black box technologies, assessing input data quality for training such models, and the risk of perpetuating rather than alleviating health disparities. This review critically appraises the advances of machine learning related to the care of AF thus far, their potential future directions, and its potential limitations and challenges.

On-Campus Clinical: Preparing Prelicensure Nursing Students for a Safe Clinical Practice.

Ensuring students are both confident and competent for clinical practice will lead to improved patient outcomes. Early exposure to delivering safe and effective care using knowledge, skills, and abilities that are consonant with professional practice is essential. Caring for an increasingly complex patient population is challenging. Entry-to-practice competencies must begin early in the student's education and be developed throughout. This educational initiative outlines an innovative and a collaborative evidence-based learning experience that prepares prelicensure nursing students to deliver safe and effective patient-centered care during their first clinical practice. Lecture and laboratory topics, clinical skills stations, and simulation scenarios were developed to promote critical thinking and clinical judgment in a complex health care environment. More than 2300 first-year clinical students, instructors, and staff participated in this rigorous course-wide experience. This 1-day immersion cultivates safe practice and may be incorporated throughout the curriculum as students encounter increasingly challenging clinical practice experiences.

Quantifying organization of care in a complex healthcare environment.

Quantifying organization of care in a complex healthcare environment.

What Keeps Neonatal Nurses Up at Night and What Gets Them Up in the Morning?

Occupational stress in neonatal nursing is a significant professional concern. Prolonged exposure to morally distressing patient care experiences and other healthcare issues may lead to worry among nurses. When worry becomes excessive, nurses and advanced practice registered nurses may lose joy that gives meaning to their work. Enhancing meaning in work may have a positive impact on nurse satisfaction, engagement, productivity, and burnout. To explore neonatal nurses' top professional satisfiers and top professional worries and concerns. A descriptive study was conducted in a convenience sample of neonatal nurses to identify the top professional satisfiers that get them up in the morning and the top professional worries and concerns that keep them awake at night. Complete data were available for 29 neonatal nurses. The top professional satisfiers were caring for infants and families, making a difference, witnessing resilience, intellectual challenge of specialty, positive working relationships with colleagues, and educating parents and families. The top professional worries and concerns were staffing, missed care, workload, making a mistake, and failure to rescue. Healthcare and professional organizations must develop strategies to address occupational stress in today's complex healthcare environment. Identifying professional worries and concerns may help nurses navigate challenging and distressing situations. Furthermore, understanding nurses' professional satisfiers may promote personal and professional resiliency and help organizations create healthier workplace environments. Future studies are needed to test effective interventions that may promote professional satisfaction and help neonatal nurses cope with occupational stressors.

Concept-based curriculum: design and implementation strategies.

Objectives Novice nurses are struggling to exercise the critical thinking skill set needed to make competent clinical decisions in today's complex health care environment. This poses immense threats to the health and safety of patients. To address this alarming concern, many prominent organizations have called for a widespread overhaul of nursing curricula. Methods A consistent theme among the recommendations for revising nursing curricula is the utilization of innovative curricula designs that focus on enhancing the critical thinking ability of nursing students, such as a concept-based curriculum. Results Planning and implementing a curriculum revision is an overwhelming undertaking. Conclusions Providing nurse educators with a guide on how to transition to a concept-based curriculum may help to facilitate a course revision.

The importance of power, context and agency in improving patient experience through a patient and family centred care approach

BackgroundResearch shows that the way that healthcare staff experience their job impacts on their individual performance, patient experience and outcomes as well as on the performance of organisations. This article builds on this literature by investigating, with multi-disciplinary clinical teams as well as patients and relatives, what factors help or hinder changes designed to improve patient experience.MethodsQualitative research looking at patient- and family-centred care (PFCC) on two care pathways (stroke and hip fracture) was conducted in England and Wales. A realist approach combined with participatory action research was used to account for the complexity of organisational context and power relations. Multiple methods were used, including documentary analysis, participatory steering groups with staff and patient representatives, observations of the care pathways (n = 7), staff and patient and relative focus groups (n = 8), and hospital staff, patient and PFCC staff interviews (n = 47).ResultsFindings highlight multiple factors that support and hinder good patient experiences. Within individual care, paternalistic values and a lack of shared decision-making and patient-centred care still exist. Supportive interdisciplinary teamwork is needed to address issues of hierarchy, power and authority amongst staff and managers. At the organisational level, key issues of waiting times, patient flow, organisational resources and timely discharge affect staff’s time and capacity to deliver care. In addition, macro contextual factors, such as finance, policy, targets and measures, set particular limits for improvement projects.ConclusionsGiven this context, improving patient experience needs to go well beyond small-scale projects at the micro and meso level to incorporate a more critical understanding of systems, the wider organisational context and how power operates at multiple levels to enable and constrain action. In order to more meaningfully understand and address the factors that can help or hinder activities to improve patient experiences, PFCC frameworks and methods need to account for how power inequities operate and require the adoption of more participatory co-produced and empowering approaches to involve patients, relatives, carers and staff in improving complex healthcare environments.

Strengths employed by resilient nurse managers in dealing with workplace stressors in public hospitals

BackgroundNurse managers work in complex health care environments that expose them to challenging workplace conditions. As nurse managers face significant workplace stressors, some will succumb to the pressure and stress contemplating to leave for other opportunities or even leave the profession. However, the resilient nurse managers seem to adapt, recover and have the strengths required to manage workplace stressors. ObjectiveTo explore and describe the strengths that resilient nurse managers employ when dealing with work related stress.Setting and sampling: A purposive sampling method was used with resilient nurse managers working in the general wards of the public hospitals in Botswana.Participants: A total of forty-two (42) resilient nurse managers who measured moderate to high resilience participated in the study. MethodsA qualitative exploratory design was used in the study. Data was collected through written narratives guided by a semi-structured data collection tool. Thematic analysis was used to identify strengths that resilient nurse managers utilized while dealing with workplace stressors. ResultsThe main themes that emerged from the study were: upholding personal values, employing life skills, applying appropriate leadership skills and access to social support. ConclusionsThe study revealed that the identified resilient nurse managers utilized their strengths and other resilient characteristics in dealing with workplace stressors. These strengths are used as buffers in dealing with workplace stressors, enabling them to overcome difficulties and provide quality nursing services.

Evolution of a Newly Licensed RN Transition-to-Practice Program: Theory and Development Supporting Accreditation.

Nursing leaders have embraced newly licensed registered nurse (NLRN) transition-to-practice programs, which contribute to nursing confidence, competence, work satisfaction, and retention in a complex healthcare environment. We report on the evolution of a Midwest urban pediatric medical center's transition-to-practice program, guided for 2 decades by foundational and emerging theory, research, and evidence that has supported accreditation with distinction as a Practice Transition Accreditation Program (PTAP) by the American Nurses Credentialing Center's Commission in Accreditation. Nursing leaders should use emerging evidence to inform curricular revisions that accelerate NLRN role transition and practice integration, increase organizational commitment, improve patient safety and satisfaction, and achieve PTAP accreditation.