Nursing and Midwifery

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    Evaluation of a Practice Development Unit, Queen Elizabeth Central Hospital Malawi
    (Kamuzu University of Health Sciences, 2020-11-11) Watkins, Dianne
    2.1 The type of research study This is a mixed methods research study utilising the Medical Research Council process evaluation framework to assess the outcome of quality improvement initiatives implemented as part of a multidisciplinary practice development unit (model ward) on ward 3B Queen Elizabeth Central Hospital. 2.2 The problem (to be studied) Does establishment of a multi-disciplinary practice development unit on a male medical ward at a hospital in Malawi facilitate quality improvement, multi-disciplinary team working and improve staff morale? 2.3 The Aim/ objectives To evaluate the effect of establishment of a practice development unit on staff morale and the implementation of multi-professional quality improvement measures in relation to ward cleanliness; admission and discharge processes for patients with diabetes; and multidisciplinary teamworking. Specific objectives 1. To measure the impact of implementing an evidence-based protocol for ward cleaning; 2. To evaluate the impact of implementing a standardised approach to multi-disciplinary ward rounds; 3. To explore the effects of establishing multi-disciplinary team meetings utilising an evidence-based framework; 4. To investigate the impact of implementing an evidence-based protocol for the admission and discharge of patients with diabetes; 5. To assess the effects of the practice development unit on staff morale and their understanding of audit and quality improvement methods. 2.4 Expected findings and their dissemination It is envisaged that improvements will be made in the quality of care provided to patients with diabetes; to ward cleanliness and multi-disciplinary team working and that these improvements will positively influence staff morale and patient outcomes. The findings will be disseminated through presentations to major stakeholders (Ministry of Health, QECH Senior staff; staff at the University of Malawi and Cardiff University); through local, national and international conference presentations and through publication in prestigious peer reviewed journals. 3.0 Background information and introduction Malawi is a low-income country with a GDP that represents 0.01% of the world economy and provision of healthcare is limited. Life expectancy is poor compared to western countries and access to quality healthcare represents a significant problem. In 2018 Cardiff University (CU), School of Healthcare Sciences (HCARE) was awarded Erasmus plus funding to establish a ‘practice development unit (PDU)’ in a hospital in Malawi, with an aim of improving person centred, evidence based, multi-disciplinary care provided to patients. This project built on previously established relationships between HCARE and Kamuzu College of Nursing, 11-Nov-2020 Version 7 – re-submitted to COMREC 4 th November 2020 (DW & JC) University of Malawi (KCN). Discussions took place regarded where the PDU would be located and a decision made for this to be Ward 3B, a male medical ward located within Queen Elizabeth Central Hospital Blantyre. Blantyre is the second largest city in Malawi with a population of approx. 1.2 million. Queen Elizabeth Central Hospital (QECH) is the largest hospital in Malawi with approx. 1100 beds. Average life expectancy for males in Malawi is 61.4 years and the probability of dying between 15-60 years for a male is 312 per 1,000 population (WHO 2018). Communicable diseases including HIV, tuberculosis and malaria are the major causes of morbidity and mortality but non-communicable diseases such as cardiovascular, respiratory diseases and diabetes are also now major healthcare issues. A decision was made to establish a practice development unit (referred to as a model ward at QECH) utilising quality improvement methodologies to help improve practice on Ward 3B. There are various definitions for the process and practice associated with a practice development unit. Bradd, et al (2017) describes it as a facilitated process with the aim of improving person-centred and evidence-based healthcare using an emancipatory change approach. It can help with enhancing clinical services, such as quality and safety, improve communication between multi-disciplinary teams and aid the development of shared values and priorities (McCormack, 2013).Competent facilitators are required to enable evidence based knowledge to be translated into practice and improve quality of care through supporting practitioners and teams in identifying areas for change and implementing this change (Heyns, et al 2017). Progress with establishment of the PDU includes workshops (undertaken in November 2019 and in February 2020) introducing the concept to Ward 3B staff; identification of areas for potential improvement on Ward 3B; agreement on areas to take forward for quality improvement; audit of current practice in relation to the areas for improvement; and rapid reviews of the evidence base to support change in the identified areas of practice which include: i) Admission and discharge processes in relation to the patient with diabetes. ii) Ward cleanliness iii) Multi- Disciplinary Team Working (examples of the initial audits which provided a baseline to current practice can be found in appendix 6) An evaluation of the effectiveness of interventions put in place is essential, and thus the School of Healthcare Science (HCARE) Cardiff University applied and were successful in achieving Global Challenge Research Funding to undertake an evaluation of the PCU and its associated areas for quality improvement. The Medical Research Council Framework for process evaluation was chosen as the methodology which is commonly used for evaluating and reporting complex interventions, defined as those that consist of multiple interacting components (Moore, et al 2015). Moore, et al (2015) argue that to understand how interventions work in practice, an understanding of the causal assumptions underpinning the process are essential. Process evaluations can test causal pathways based on a hypothesis using quantitative data and use qualitative methods to understand causal pathways or mechanisms that impact positively or negatively on the change. The process evaluation outlined in this proposal will enable us to evaluate the barriers and facilitators involved in setting up a practice development unit in a male medical ward in QECH and to determine which are the most effective measures to improve care. This project aligns to UN Sustainable Development Goals 3, 10 and 17, focusing on improving health and well-being for patients in an area with high mortality and morbidity who are cared for by a healthcare system which has significant staffing issues, along with shortage of equipment and supplies. 3.1 Rationale/justification for the research project The aim of this proposal is to evaluate the outcomes of the ‘practice development unit’, currently being established on a male medical/ HDU ward (Ward 3B) at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi. The PDU is in the process of being established and measuring its effectiveness is essential to guide further quality improvement initiatives in Queen Elizabeth Central Hospital. Funding has already been invested via Erasmus Plus and Global Challenge Research funding and it is anticipated that this study will form the basis for further research where the impact on patient health outcomes can be measured. A rapid review of the evidence base has taken place in relation to the chosen areas, in line with improvement science. An audit of ward cleaning identified that no protocol is currently followed and roles and responsibilities are not clear (please see appendix 6 for base line audit). Evidence suggests it is vital to ensure ward floors, equipment and surfaces are cleaned effectively and efficiently to reduce cross infection (Royal College of Nursing (RCN) 2005). Similarly audits of the ward round found that they were primarily Doctor led with room for improvement; and multi-disciplinary team meetings were non-existent (please see appendix 6 for base line audit). The evidence suggests a checklist should be provided to underpin the ward round and decision making (Shetty 2018 and Krishnamohan 2019) and a communication tool such as SBAR can help enhance understanding (O’Learly et al, 2010; Randmar et al 2014). Research by Raine et al (2014) identify the characteristics of chronic disease MDT meetings associated with decision making and derived a set of feasible modifications to MDTs to improve decision making. This 21 point framework for effective multidisciplinary meetings which relates to a common purpose and function; team meeting processes; content of discussion; and the role of the patient will be implemented as part of the practice development unit, to enhance higher quality decisions that may lead to improved health outcomes. Improving the admission, care management and discharge of patients with diabetes is justified. Africa currently has 19 million suffering the disease and prevalence is expected to escalate to 47 million in 2045, representing a record-breaking increase of 143% (IDF, 2019). Sub-Saharan Africa is also a region with the highest proportion of undiagnosed diabetes; three out of five people who have diabetes are not aware that they have it (Assah & Mbanya, 2017; IDF, 2019; Nuche-Berenguer & Kupfer, 2018). Diabetes was projected to cause over 366, 200 deaths in Africa in 2019, and three out of four of these deaths were people below the age of 60years, the highest proportion among the IDF regions (IDF, 2019). As pointed out by Pastakia et al. (2017) and Nuche-Berenguer and Kupfer (2018), this mortality rate is largely attributed to late diagnosis and poor care for people living with diabetes. (Msyamboza et al., (DW & JC) 2014). Scaling up of health services in response to this increasing prevalence of diabetes is critical yet remains a challenge as the additional burden of managing complex co-morbidity is impacting significantly on hospital resources and ward routines (Atsalos et al., 2019). Public hospitals are under pressure due to increasing demands on services, economic constraints and imbalances in workforce supply, therefore, frontline health professionals such as nurses are facing challenges as they strive to maintain effective and safe health services (Dignam et al., 2012; Grosso et al., 2019). The complex and challenging nature of diabetes requires healthcare workers to have the capacity to provide optimal levels of care for patients (Atsalos et al., 2019; Molayaghobi et al., 2019; Navarro et al., 2019). Appropriate care and management interventions have proven to halt diabetes progression and minimise complications (Alotaibi et al., 2016). Evidence also demonstrates that nurses have an important role to play in diabetes care and have a major effect when supporting patients with self-management of their condition particularly using the proactive care management model and decision making support approaches (Olson & Rosenberg, 2019; Watts & Sood, 2016; Zupa et al., 2019). It is imperative that the practice development unit focuses on improving the care and management of patients with diabetes. A base line audit indicated that the admission and discharge of patients with diabetes was not in line with the evidence base for good practice (see appendix 6 for base line audit outcomes).