PSIP 6 Test 1

Literature scan 1.5.15 - birth place, decision making, shared decision

making, maternity care midwifery led birth
Key background articles
Birth place study (NPEU)
My birthplace app
Health Foundation MAGIC shared decision making
NICE guidance for intrapartum care
The Kings fund- people in Control of their life and care-the state of
involvement
The first national maternity care shared decision making initiative -USA
Aims: Q1 What are you trying to accomplish.
1. Increase the number of women expressing a preference for birth at
an identified freestanding midwifery unit by 36 weeks of pregnancy
2. Improve the use of shared decision making during the antenatal
period for the place of birth decision??
Measures/evaluation: Q2 How will you know that a change is an
improvement
1. An increase in the number of women expressing a preference for
birth in the Freestanding Midwifery unit used in the SIP project
2. An increase in midwives/women?? reporting the use of shared
decision making for their conversations about place of birth??
Or the experience of women/midwives of using the SD process
during antenatal care
3. Changes: Q3 What changes can be made that will lead to or result
in improvement
3a What is wrong? Initial conversations with midwives show that
they give women access to the My Birthplace app (evidenced based
information about place of birth), but midwives do not follow the shared
decision making model that was used as part of the training programme
when My Birthplace was rolled out. They have limited conversations with
women about the evidence for place of birth and they have limited
understanding about why women express the preference that is recorded
in the notes. Consequently there is limited confidence in the womens
preference being influenced by their understanding of the evidence. This
leads to the default preference of birth in hospital.

3b What might work? Develop a shared decision making

tool/process with women and midwives (enquiry led) or adapt and test the
effectiveness of a tool already developed (intervention led).
PSIP 6 Test 2
Aims and Objectives:
Using the Model for Improvement (Langley et al 2009) I have been able to
clarify the issue as follows:
Q1: Aims - what am I trying to accomplish?
My aim is to improve the knowledge and understanding of personality
disorders of social workers working in children's services front line teams.
The purpose of this would be to improve the outcomes for children, young
people and their families by a more effective working relationship with
parents in particular. Whilst the literature search did not reveal anything
that specifically addresses this issue there is evidence that such training
would be of benefit to both families and their social workers due to the
higher prevalence of involvement with child protection services where
parents have personality disorders and high levels of 'burn-out' by social
workers which the literature suggests can contribute to poorer outcomes
for families.
Q2: Measures - How will I know that a change is an improvement?
Ultimately there would be a reduction in the number of children becoming
subject to the initial child protection proceedings and/or a reduction in the
time they remain under safeguarding processes, however, due to the
small scale of my SIP and time constraints it will not be possible to
measure this. Therefore I will focus my SIP on evaluating social workers
levels of confidence and skills in managing the behaviours presented by
parents with personality type disorders through either a 'before' and 'after'
questionnaire or focus group.

Q3: Changes - What changes can I make that will lead to or result
in an improvement?

Through the literature review, my experience of working in front line

children's teams and my conversations with the local authorities training
department I anticipate that through interviewing front line staff a
number of issues will be highlighted such as a lack of knowledge of
personality disorders and their prevalence and therefore there will be little
knowledge of 'tools' that can be used to help work with this condition.
These factors will inform the specific content of my intervention. I
envisage that this will most likely take the form of a short piece of basic
training for front line staff around ways to respond to personality disorders
but that will also seek to improve their confidence.
Process Strategy:
Considering the Plan, Do, Study, Act (PDSA) section of the Model for
Improvement indicates that it will be necessary to begin with an enquiryled strategy which will help me to better understand the presenting issues
and how these sit with the existing literature. The literature seems to
focus on either the impact of parental mental health, including personality
disorders, on outcomes for children or the contribution on outcomes, both
negative and positive, by social workers but does not focus on social
worker's skills and training in working with this group tending to
acknowledge the existing boundaries between mental health organisations
and children's services. I therefore need to find out from front line social
workers what they perceive are the difficulties and issues they face in
working with families and their understanding of their role around this.
The outcome of the initial focus group discussion will direct the design of
my intervention from which I will be able to reconvene the focus group for
a further conversation. From this I will be able to draw conclusions and
make recommendations to the training board who have asked me to
present my findings to them at a later date.
Research Question:
This leads me to consider the sub-questions of the Model for Improvement
(Langley et al 2009). "What is wrong?" and "What might work?" In light
of my research so far I have identified the issue to be, "Does the way
childcare social workers respond to parents behaviours have a negative

impact on the outcomes for children and their families?". In answer to the
second question I anticipate that a greater understanding, awareness and
knowledge of personality disorders by front line social workers will impact
positively on outcomes for children and families but I cannot be sure of
this therefore I will adopt an enquiry led strategy in order to clarify my
ideas for my intervention. I am aware from my research and experience
that there are well established methods of effective treatment for
personality disorders and these have been expanded upon and adapted
world-wide to become a significant body of useful tools and techniques.
Therefore I accept that my identification of what might work will need to
stick to basic concepts and simple but effective tools in order to ensure
that my SIP is feasible and doable remaining within the specific
parameters of the project.

PSIP 6 Test 3

Section one
Describe context: Role location, seasonal.
Key drivers for change/issue: White papers, increased demand acute
hospitals, transport infrastructure, population increase, patient choice,
local hospital infrastructure.
Personal approach to service improvement

Section Two lit review.

Minimal literature of MIUs email direct to sites with similar?
Enquiry led strategy

Section three Action plan strategy proposal.

Enquiry led Possible options to explore dependant on locality/staffing.

No clear intervention from literature in a community hospital setting.

Primary data input: Small virtual focus group with local team, debating
possible options, staff skills opinions/competence/concerns. Unable to
perform face to face focus group due to work patterns - to enable a focus
group the whole team will need to be involved (but only three
practitioners); use of technology? Small audit review of attendances of
agreed suitable patients to check for viability of a service post focus
group.
Expected impact strategy for treating fractures within the community
hospital- decreasing referrals, increasing easier local access for patients.
MFI:
1: Increase locally available services; decrease clinic referrals
2: Measure through focus group and audit is there a viable need?
3: What might work? Fracture clinic/multidisciplinary team
responsibility/same day discharge.

PSIP 6 Test 4

Will a process of mentorship of an Advanced Nurse Practitioner lead

to improved patient care that is innovative and cost effective?
There is a need in my service for more Advanced Nurse Practitioner
hours. It is seen as a unique role and there is a need to have tailored
training. It is thought that mentorship or coaching provides the best
opportunity to achieve this.
There are both local and national shortages of doctors.
There is a need to provide cost effective healthcare that meets
government and trust targets for efficiency savings.
The national lead is on reduction of hospital admission and
intermediate care services help to achieve this.

PSIP 6 Test 5
What am I trying to accomplish?
Improved clinical supervision and access to a community of practice

How will I know the change is an improvement?

Through qualitative research exploring personal views surrounding the
intervention

What change can I make that will result in an improvement?

Implementation of a community of practice. ANPs from various disciplines
undertaking group clinical supervision.

Implementation of a community of practice providing clinical supervision, meeting

continuing professional development and revalidation requirements, developing
knowledge and competence, providing opportunities for learning through peer
support and reflective practice enhancing patient care and safety.
Intervention led to fully evaluate the intervention and to inform future
recommendations
Still encompassing its key aims but taking clinical supervision away from the work
place

end.