Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

Considerations in the design of a mixed-method cluster evaluation of a community programme for 'at-risk' young people

This article discusses the design of a comprehensive evaluation of a community development programme for young people 'at-risk' of self-harming behaviour. It outlines considerations in the design of the evaluation and focuses on the complexities and difficulties associated with the evaluation of a community development programme. The challenge was to fulfil the needs of the funding body for a broad, outcome-focused evaluation while remaining close enough to the programme to accurately represent its activities and potential effects at a community level. Specifically, the strengths and limitations of a mixed-method evaluation plan are discussed with recommendations for future evaluation practice.

I have faith in my thing, you know what I mean? Mixed method elements on individual investments on religious markets.

In contemporary society, religious signification and secular systems mix and influence each other. Holistic conceptions of a world in which man is integrated harmoniously with nature meet representations of a world run by an immanent God. On the market of the various systems, the individual goes from one system to another, following his immediate needs and expectations without necessarily leaving any marks in a meaningful long term system. This article presents the first results of an ongoing research in Switzerland on contemporary religion focusing on (new) paths of socialization of modern that individuals and the various (non-) belief systems that they simultaneously develop

A Mixed-method Social Networks Study Design for Research on Transnational Families

This paper advocates the adoption of a mixed-methods research design to describe and analyze ego-centered social networks in transnational family research. Drawing on the experience of the Social Networks Influences on Family Formation project (2004-2005), I show how the combined use of network generators and semistructured interviews (N = 116) produces unique data on family configurations and their impact on life course choices. A mixed-methods network approach presents specific advantages for research on children in transnational families. On the one hand, quantitative analyses are crucial for reconstructing and measuring the potential and actual relational support available to children in a context where kin interactions may be hindered by temporary and prolonged periods of separation. On the other hand, qualitative analyses can address strategies and practices employed by families to maintain relationships across international borders and geographic distance, as well as the implications of those strategies for children's well-being.

Young Registered Nurses’ Intent to Leave the Profession in Finland - A Mixed-Method Study

The purpose of this study was to examine and expand understanding concerning young Finnish registered nurses (RN) with an intention to leave the profession and the related variables, specifically when that intention has emerged before the age of 30. The overall goal of the study was to develop a conceptual model in relation to young RNs’ intention to leave the profession. Suggestions for policymakers, nurse leaders and nurse managers are presented for how to retain more young RNs in the nursing workforce. Suggestions for future nursing research are also provided. Phase I consists of two sequential integrative literature reviews of 75 empirical articles concerning nurses’ intention to leave the profession. In phase II, data had been collected as part of the Nurses’ Early Exit (NEXT) study, using the BQ-12 structured postal questionnaire. A total of 147 young RNs participated in the study. The data were analysed with statistical methods. In phase III, firstly, an in-depth interpretive case study was conducted in order to understand how young RNs explain and make sense of their intention to leave the profession. The data in this study consisted of longitudinal career stories by three young RNs. The data was analysed by using narrative holistic-content and thematic methods. Secondly, a total of 15 young RNs were interviewed in order to explore in-depth their experiences concerning organizational turnover and their intent to leave the profession. The data was analysed using conventional content analysis. Based on earlier research, empirical research on the young RNs intention to leave the profession is scarce. Nurses’ intention to leave the profession has mainly been studied with quantitative descriptive studies, conducted with survey questionnaires. Furthermore, the quality of previous studies varies considerably. Moreover, nurses’ intention to leave the profession seems to be driven by a number of variables. According to the survey study, 26% of young RNs had often considered giving up nursing completely and starting a different kind of job during the course of the previous year. Many different variables were associated with an intention to leave the profession (e.g. personal burnout, job dissatisfaction). According to the in-depth inquiries, poor nursing practice environments and a nursing career as a ‘second-best’ or serendipitous career choice were themes associated with young RNs’ intention to leave the profession. In summary, young RNs intention to leave the profession is a complex phenomenon with multiple associated variables. These findings suggest that policymakers, nurse leaders and nurse managers should enable improvements in nursing practice environments in order to retain more young RNs. These improvements can include, for example, adequate staffing levels, balanced nursing workloads, measures to reduce work-related stress as well as possibilities for advancement and development. Young RNs’ requirements to provide high-quality and ethical nursing care must be recognized in society and health-care organizations. Moreover, sufficient mentoring and orientation programmes should be provided for all graduate RNs. Future research is needed into whether the motive for choosing a nursing career affects the length of the tenure in the profession. Both quantitative and in-depth research is needed for the comprehensive development of nursing-turnover research.

Becoming Peer Health Leaders: A Mixed-Methods Evaluation of a Youth Leadership Camp Preparing Peer Leaders for Participation in a Health Promotion Initiative.

Youth are critical partners in health promotion, but the process of training young people to become meaningfully involved is challenging. This mixed-methods evaluation considered the impact of a leadership camp in preparing 42 grade seven students to become peer health leaders in a ‘heart health’ initiative. The experiences of participants and their sense of agency were explored. Data were collected from pre and post camp surveys, focus groups, student journals and researcher observations. Findings indicate that relationships with peers and adults were key to agency development, and participants appeared to broaden their perspectives on the meanings of ‘health’ and ‘leadership.’ Significant changes on two sub-scales of the Harter Perceived Competence Scale for Children were also found. Suggestions for practice and further research are provided.

A Mixed-Method Study of Educator Knowledge and Practice Related to Student Socio-moral Development

The purpose of this study was to explore elementary educators’ knowledge of moral development, how this knowledge relates to their beliefs and sense of efficacy pertaining to character education practices and the socio-moral reasoning of their students. It was hypothesized that educators’ beliefs and practices related to character education would reflect their pedagogy rather than knowledge of moral development theory. It was further hypothesized that there would be differences in student socio-moral reasoning specifically the beliefs and desires that guide actions would differ based on grade and gender. This mixed-method study employing self-report questionnaires, open response vignettes, and semi-structured educator interviews yielded quantitative and qualitative data. Findings indicated socio-moral reasoning of students differed according to grade (age) and gender. Knowledge of moral development theory was found to vary among participants however some practices employed by educators did align with a social cognitive approach to moral development. Significant variables identified consistently among educator and student participants included, autonomy, social competence, sense of school community, and supportiveness. These variables, in conjunction with a sense of fairness, have been identified elsewhere as foundational to moral development (Nucci, 2009), and intrinsic motivation (Ryan & Deci, 2000) and are relevant to educators working to develop student socio-moral reasoning as an aspect of character.

The Mixed-Method Library: Qualitative Research and the Future of Assessment in Higher Education

This presentation was offered as part of the CUNY Library Assessment Conference, Reinventing Libraries: Reinventing Assessment, held at the City University of New York in June 2014.

Describing the Situational Contexts of Sweetened Product Consumption in a Middle Eastern Canadian Community: Application of a Mixed Method Design

Little is known about the situational contexts in which individuals consume processed sources of dietary sugars. This study aimed to describe the situational contexts associated with the consumption of sweetened food and drink products in a Catholic Middle Eastern Canadian community. A two-stage exploratory sequential mixed-method design was employed with a rationale of triangulation. In stage 1 (n = 62), items and themes describing the situational contexts of sweetened food and drink product consumption were identified from semi-structured interviews and were used to develop the content for the Situational Context Instrument for Sweetened Product Consumption (SCISPC). Face validity, readability and cultural relevance of the instrument were assessed. In stage 2 (n = 192), a cross-sectional study was conducted and exploratory factor analysis was used to examine the structure of themes that emerged from the qualitative analysis as a means of furthering construct validation. The SCISPC reliability and predictive validity on the daily consumption of sweetened products were also assessed. In stage 1, six themes and 40-items describing the situational contexts of sweetened product consumption emerged from the qualitative analysis and were used to construct the first draft of the SCISPC. In stage 2, factor analysis enabled the clarification and/or expansion of the instrument's initial thematic structure. The revised SCISPC has seven factors and 31 items describing the situational contexts of sweetened product consumption. Initial validation of the instrument indicated it has excellent internal consistency and adequate test-retest reliability. Two factors of the SCISPC had predictive validity for the daily consumption of total sugar from sweetened products (Snacking and Energy demands) while the other factors (Socialization, Indulgence, Constraints, Visual Stimuli and Emotional needs) were rather associated to occasional consumption of these products.

Computer-based summative assessment of clinical reasoning in clerkships: A mixed-method comparison of key feature problems with case-based multiple choice questions

Background: It is yet unclear if there are differences between using electronic key feature problems (KFPs) or electronic case-based multiple choice questions (cbMCQ) for the assessment of clinical decision making. Summary of Work: Fifth year medical students were exposed to clerkships which ended with a summative exam. Assessment of knowledge per exam was done by 6-9 KFPs, 9-20 cbMCQ and 9-28 MC questions. Each KFP consisted of a case vignette and three key features (KF) using “long menu” as question format. We sought students’ perceptions of the KFPs and cbMCQs in focus groups (n of students=39). Furthermore statistical data of 11 exams (n of students=377) concerning the KFPs and (cb)MCQs were compared. Summary of Results: The analysis of the focus groups resulted in four themes reflecting students’ perceptions of KFPs and their comparison with (cb)MCQ: KFPs were perceived as (i) more realistic, (ii) more difficult, (iii) more motivating for the intense study of clinical reasoning than (cb)MCQ and (iv) showed an overall good acceptance when some preconditions are taken into account. The statistical analysis revealed that there was no difference in difficulty; however KFP showed a higher discrimination and reliability (G-coefficient) even when corrected for testing times. Correlation of the different exam parts was intermediate. Conclusions: Students perceived the KFPs as more motivating for the study of clinical reasoning. Statistically KFPs showed a higher discrimination and higher reliability than cbMCQs. Take-home messages: Including KFPs with long menu questions into summative clerkship exams seems to offer positive educational effects.