PSIP 6 Test 1Literature scan 1.5.15 - birth place, decision making, shared decision making, maternity care midwifery led birthKey background articlesBirth place study (NPEU)My birthplace app Health Foundation MAGIC shared decision making NICE guidance for intrapartum careThe Kings fund- people in Control of their life and care-the state of involvementThe first national maternity care shared decision making initiative -USAAims: 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 pregnancy2. 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 improvement1. An increase in the number of women expressing a preference for birth in the Freestanding Midwifery unit used in the SIP project2. 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 2Aims 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 enquiry-led 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 oneDescribe 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 too 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 focus group whole team will need to be involved (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 referrals2:Measure through focus group and audit is there a viable need3:what might work ? fracture clinic/multidisciplinary team responsibility/same day discharge.

PSIP 6 Test 4Will 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 Model For Improvement Questions 1-3 - thinking so far

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. Strategy proposal Enquiry-led or Intervention-led proposed choice and justification Primary data input: question, method and analysis proposed choices and justification Expected impact

Notes:Intervention led to fully evaluate the intervention and to inform future recommendationsStill encompassing its key aims but taking clinical supervision away from the work place