Abstract
The authors believe there is a need for novel ways of enhancing professional judgment and discretion in the contemporary healthcare environment. The objective is to provide a framework to guide a discursive analysis of an ongoing clinical scenario by a small group of healthcare professionals (4–12) to achieve consensual understanding in the decision-making necessary to resolve specific healthcare inadequacies and promote organisational learning. REPVAD is an acronym for the framework’s five decision-making dimensions of reasoning, evidence, procedures, values, attitudes and defences. The design is set out in terms of well-defined definitions of the dimensions, a rationale for using REPVAD, and explications of dimensions one at a time. Furthermore, the REPVAD process of application to a scenario is set out, and a didactic scenario is given to show how REPVAD works together with a sample case. A discussion is fleshed out in four real life student cases, and a conclusion indicates strengths and weaknesses and the possibility of further development and transferability. In terms of findings, the model has been tried, tested and refined over a number of years in the development of advanced practitioners at university healthcare faculties in two European countries. Consent was obtained from the four participating students.
Keywords
Introduction
REPVAD is an acronym for the five decision-making dimensions: reasoning, evidence, procedures, values, attitudes and defences, and it may be defined as a framework-guided discursive analysis of an ongoing clinical scenario by a small group of professionals (4–12) to achieve consensual understanding in the decision-making necessary to resolve specific healthcare inadequacies and promote organisational learning.
The five dimensions provide a framework for clinical healthcare decisions or assessments of situations. A problem or perceived problem in professional practice is often not easy to ‘solve’, and simple solutions to complex problems often do not have the desired result, so the problem will resurface. Therefore, it is quite often the case that actions and measures are ineffective. A shared and accurate scenario-based overview, with an open-minded and shared analysis, and the dialogical formulation of objectives are worthwhile before measures are taken. Sharing is the means and consensus is the aimed-for outcome. This step by step approach operates by following the framework of six analytic guidelines. Only then – on the basis of consensus – are conclusions, objectives and measures formulated, implemented and evaluated.
Rationale for REPVAD
The REPVAD model may be regarded as a response to the closed procedural thinking of industrialised healthcare. 1 It is a tool in what the first author (G.H.) has previously designated ‘Engaged Ethics’. 2 It is not itself intended as another procedure but instead challenges a superficial ‘proceduralist’ approach with ethical and critical thinking. It provides a facilitative approach or tool for opening up honest group exploration of ongoing clinical scenarios which have had less than optimal outcomes for patients. By this means a deeper group understanding of such scenarios is achieved and understanding on how to enhance specific aspects of care from a communicative and consensual point of view. With this approach it is seen that organisational learning is a matter of not only resources and procedures but also deeper consensual understanding, cooperation and ‘community’ of carers and cared-for.
It is to be noted that REPVAD does not reject procedures but embraces them as one dimension among five. What REPVAD addresses is proceduralism, that is, giving to procedures a sole role or overwhelming prominence in decision-making. G.H. has discussed this point elsewhere. 3 The reason that a REPVAD approach is now required in healthcare, and possibly other public sector institutions, is that the mangerialist and cost-cutting trend has reduced the scope for professional and team discretion and substituted it with quick rule-based approaches. 4,5,6 The aim of the REPVAD model is to help free up healthcare professionals to discuss in an open, trusting and interactive manner and achieve a better balance between a constraining top-down management culture and a ‘free-wheeling’ bottom-up approach. An over-emphasis on procedure-following tends to leave individual professionals in unthinking isolation. REPVAD aims to be professionally empowering.
It may be said that REPVAD is itself a procedure. This is true but it is of a higher order for it does not try to dictate the content of decision-making but provides a form which liberates consensual professional judgement. There are in the conclusions of each student example in this study evidence that indicates that REPVAD does actually achieve the stated aim to a large extent. This effectiveness was also manifested in the original development of REPVAD (see ‘Acknowledgments’ below). The more often that REPVAD is used in the healthcare setting, the more its effectiveness can be tested and more opportunities for its development will arise. The authors hold the hypothesis that a strength of this particular group-centred approach to decision-making compared with others is its professional–ethical basis in values and the psychological dimension of attitudes and defences. 7
The five dimensions
The five dimensions are designed to work together for the professional group to not only ‘interrogate’ the chosen scenario as an ‘objective event’ but also lead to group self-questioning about the role of the professional participants: their assumptions, habits of mind, ethical understandings and misunderstandings, and the overlooking of significant human detail especially when under pressure. The dimensions do not pretend to be a comprehensive list but are chosen precisely because of their potential for the self-searching ethical animation of professional team decision-making.
The authors envisage that REPVAD would be most fruitfully used on a regular basis (perhaps once a month) by a group of staff most of whom will actually be involved in a scenario perceived as being less than optimal in outcome. The group could be created in response to different situations along a spectrum from an unexpected critical incident to an apparently ‘intransigent’ problem that has continued for years and seen perhaps in a fresh light by a newcomer. The group could change with circumstances or have a core of some individuals – this core changing more slowly over a longer period of time.
It is suggested that training in REPVAD could be initiated in the educational environment, where there may be more time for discussion, and/or developed in the clinical setting where there are live and pressing issues needing attention.
Reasoning
The aim of reasoning is to arrive at a preliminary overview of the balanced or unbalanced reasoning and assumptions and pre-conceived ideas among the staff actually involved at the time in the scenario. 8
There is a brief retrospective overview of what the case or scenario is about and why the decisions and outcomes appear to have been unsatisfactory, at least on the face of it, from the point of view of the patient and/or the patient’s family and/or the healthcare professionals involved. The emphasis here is not on the deeper explanation or justification of intentions, actions and omissions but on what happened, who was involved (in terms of roles rather than personalities) and why the actors would have quite reasonably thought at the time that they were doing all the ‘right’ things and how it turned out that (arguably) they were not. This preliminary discussion pays attention to the actual reasoning process (or lack of it) at the time and how there may have been certain assumptions, unquestioned habits and routines, rule-bound actions, extreme positions taken, lack of attention, miscommunication and failure to communicate, role-confusion and so on.
One should be aware that there may be a tendency to get ‘bogged down’ at this very first dimension. The facilitator must ensure that this stage is an overview of what happened on the face of it and why certain actions or omissions may have been thought reasonable at the time (see the ‘didactic example’ below). After about 10–15 min in this dimension, the group should move on. Any attempt to apportion blame or ‘pull rank’ should be kindly deflected by the facilitator.
Evidence
The aim of evidence is to collect and present the most important and current objective information relevant to the scenario.
The group now discusses all the ‘hard facts’ involved in the case. This is not about opinions, or behaviour or procedures but about such matters as directly experienced observations, what has been established by science and techniques, the medications and therapies involved, measurements, statistical data, the facts stated in reports whether internal or external, evidence-based practices and so on.
It may be necessary for the facilitator or some designated person to research some relevant facts before the meeting, and the meeting itself may result in a search for more up-to-date facts. In any case, those involved in the case need to first state the hard medical, nursing and healthcare facts as they perceived them at the time of the case and (if relevant) preceding it, and then what they may have learned subsequently.
Procedures
The aim of procedures is to collect and present all current rules, protocols, contracts, regulations, guidelines and mission statements that are especially relevant to the scenario.
The group now turns its attention to the procedures that were in fact followed in the case and then consider those that might be followed and/or ought to be followed. Again, some broad research may need to be done before or after the meeting. What is meant by ‘procedures’ covers a range of types of rules, for example, clinical protocols, procedures embodied in policy documents, ‘good practice’ guidelines from relevant regulatory and professional bodies, technical instructions for equipment, national and European directives, prescriptions with indications and contra-indications, health and safety rules, contractual terms and job descriptions and so on. Obviously, one should not try to be completely comprehensive, but only choose what is especially relevant to the case under discussion.
Values
The aim of values is to manifest and agree on the crucial positive moral, ethical and aesthetic values that are believed to underlie, or that should underlie, the scenario (e.g. compassion, team harmony, consent, patient-centredness and dignity).
Values are the criteria or standards that a person, professional, organisation or society deploys to pass judgement as good or bad, right or wrong, fair or unfair and so on This judgement is of a moral, ethical or legal nature and may be positive or negative. For the patient some values will be aesthetic, that is, concerning what is personally attractive or comforting or not so. Moral judgements concern individuals such as honest/dishonest, patient/impatient, kindly/callous and sensitive/insensitive. Ethical judgements concern a specific professional role, such as respecting confidentiality/breaching confidentiality, seeking client consent/acting without client consent, and maintaining one’s professional knowledge/failing to maintain professional knowledge. Legal judgements (putting aside criminal matters) concern organisations and organisational roles, such as competence/incompetence, giving due care and attention/acting negligently and accountability to stakeholders/lack of accountability. Of course, these domains often overlap and health carers are expected to observe certain values at all levels.
Where do we seek values? Values may be virtues or vices embedded in a person’s character, may be part of a culture or sub-culture (social or organisational), may be stated in good practice guides or mission statements, and found in professional codes of conduct, human rights declarations, contracts of employment and elsewhere. 9
The vocabulary of values would include concepts such as compassion, fairness, respect, responsibility, helpfulness, transparency, integrity, beauty, comfort and care. Without apportioning blame, the group should be prepared to measure acts and omissions in the case under study by referring to good practice, codes of conduct, mission statements, the patient’s expectations and so on. Of course, the group will sometimes wish to recognise that what morally ought to be done is often constrained or obstructed by organisational issues such as poor communication, lack of human or material resources or inappropriate skill mix.
Attitudes
The aim of attitudes is to honestly bring to the surface, without blame, the individual attitudes or possible attitudes which may have contributed negatively to the scenario or contributed (or should have contributed) positively.
This dimension and the previous one require a degree of confidence, mutual trust, respect and self-honesty within the group (see ‘ground rules’ below).
The group will now explore how individual, professional and organisational attitudes impacted and/or constrained – whether implicitly or explicitly – the decision-making in the case study. We define an attitude as a pattern of reactions (or non-reactions) that is personal, internalised, relatively stable and repetitive. If you like, it is a mind-set, a character, personality, disposition, stance, posture or outlook. An attitude is not rationally acquired (not consciously) but is the cumulative outcome of one’s genetic and everyday experiential learning over a life-time.
To give example, a person may have a tendency to being suspicious, resentful, optimistic, helpful, defensive, naïve, cynical, bullying, arrogant, humble, empathetic, hostile, generous and so on. An attitude runs deep and is difficult to change, but significant changes can be made if there is a willingness for self-understanding on the part of the person concerned. 10
It is often, but not always, the case that a scenario may at least in part be due to the personal and/or professional attitudes of one or more of the carers and managers and, of course, of the patient and family. There is no easy solution with this dimension, but respectful, tolerant and sensitive discussion can go a long way.
Defences
The aim of defences is to bring to the surface, without blame, the personal or professional psychological defences (such as denial, buck-passing, blame, possessiveness, rivalry and anxiety) that may have blocked better and more sensitive care for the patient.
The group will finally zoom into a particular professional and organisational attitude that, paradoxically, becomes all the more difficult to discuss or even mention the more it is the source of certain systemic problems in healthcare, namely, defensiveness. Chris Argyris’ seminal book ‘Overcoming Organisational Defences: Facilitating Organisational Learning’ is now 25 years old but should be compulsory study for all healthcare professionals, especially those with managerial or specialised roles. 11 Good decision-making is blocked and bad decision-making thrives where a certain threshold of defensiveness is surpassed in a team or organisation. 12
Defence is a psychological/behavioural strategy and tactics, usually unconscious, by which a person defends himself or herself against threats and attacks (real or perceived). There may be a perceived threat to their own identity, status, role, power or reputation (morally, personally, culturally, physically and economically). Defence is also used to shun responsibility, if something is not done that should have been done. Defence is a psychological stance whereby a person can be removed from a controversial event (‘I was not sure’, ‘I knew nothing about it’, ‘It wasn’t my fault’, etc.). It is a way of warding off responsibility or commitment. 13 An admission by a professional or manager that they have been acting defensively in some way could ‘break the ice’ and lead to a more open discussion of how to improve decision-making.
REPVAD process
The REPVAD process is as follows: Facilitator. A group facilitator is appointed and familiarises herself or himself with this process and the five dimensions. Another person is appointed as a note-taker. The facilitator should be someone trusted and fair-minded in the eyes of the group. Ground rules. The facilitator’s first step in opening the meeting is to reassure everyone that the meeting is intended only for the improvement of patient care, and that it is a ‘safe environment’ in which sensitive issues can be discussed with honesty and without blame.
14
The facilitator distributes to the group a one-page list of the REPVAD dimensions with a brief definition of each. Case selection. A case or scenario is selected and presented at a REPVAD meeting. Consideration is given to who should make the selection and what criteria of selection are to be used, for example, critical incidents, high-risk actions or a long-standing issue. The meeting should not be less than 45 min and not more than 90 min. Decisions will have to be made about how many people will be present, and who are the appropriate participants. Process rules. Clarification is provided that the aim of REPVAD is the enhancement of patient care, consensual understanding, team building, practical resolution of issues and organisational learning. It is not a talking shop, nor is there always a well-defined ‘solution’. The focus is always on the specific scenario and improving by learning. Presentation. An appropriate person presents the case and answers brief preliminary questions for clarity. This should not take more than 3–4 min. Once the group has an initial grasp of the ‘problem’ or ‘issue’, it moves on quickly to the analysis. Dimension guidance. Most of the meeting is taken up with a step by step application of the five REPVAD dimensions. The facilitator states the dimension, initiates discussion with some brief remarks and points for discussion are contributed by those present. The facilitator then re-presents to the group a summary of each case-dimension for agreement or ‘ironing out’. Lessons learned. Individual blame is avoided. By means of group reflection an attempt is made to summarise lessons learned, by individuals, by role adjustments and the organisation and by generalising from this case as appropriate. Action plan. The group may decide to keep an anonymised record of the outcomes or not to do so. Patient confidentiality is respected. Possible policy changes may be considered and some lessons may need to be taken to a higher management level.
Didactic scenario
We will not expand our REPVAD definitions here, since we can provide a more useful context-driven understanding of these concepts by showing how they may be applied in practical cases. We begin with a didactic scenario. A didactic scenario is one that is aimed at training the REPVAD facilitator. Here, there are self-conscious comments on the working of the method of analysis. This particular scenario is drawn from the lived experience of a teacher of REPVAD (second author (C.M.)), which will serve the purpose of animating and clarifying the five REPVAD dimensions for use by REPVAD facilitators.
After that, we shall present summaries of how the model was actually applied to four further real-life cases by master’s degree student nurses at four different Swiss hospitals, where the nurses work while studying part-time. The students were guided by a trained facilitator on a master’s level course, called ‘Scholarship’, which was devoted entirely to teaching and using REPVAD. In these student cases it is assumed that the reader is now grasping how the analysis is performed and can evaluate the student responses to the REPVAD method in their attempts to apply it in group discussion. These four cases emphasise reflection on the benefits of REPVAD. Also, each student study ends with a brief didactic comment on the study. This should further manifest the model’s utility, enable its further development and transferability and demonstrate how it should be used in new cases by the reader of this article.
It should become apparent that the model’s five dimensions provide a ‘frame of reference’ by which one can ‘prise open’ the scenario and reveal which dimension or dimensions mostly determined or influenced the problematic outcome. 15 The way in which one dimension facilitates or hinders another dimension also starts to show up. The group-interactive approach engenders a negotiation of viewpoints and fresh self-questioning. It should also help empower the individual professional by giving them an equal voice. One can then specifically address such dimensions from a new vantage point, even if at first this creates some discomfort.
The didactic scenario is taken from practice in a nursing home with 47 residents. It promotes the Eden Alternative®, which emphasises the quality of life. 16,17 Here, standards of care have been developed that empower staff to deal with stressful situations, and there is a prohibition of physical restraints except in emergencies to protect the patient from imminent and serious harm and always followed by in-house expert care. The scenario was used in the course ‘Scholarship’ as an example for the students to become familiar with the REPVAD dimensions.
Sample case history
One resident with dementia had risen a few times in the night and fallen. On one occasion this happened at about 23:00 h when the regular round was in progress with one qualified nurse accompanied by an assistant. The two members of staff found themselves under pressure when the resident fell and began screaming. She was unhurt and taken to the toilet and then helped back to bed. On the third day the resident was provided with a night light and the bed rails were pulled up. However, on the morning of the fifth day the day-shift staff reminded the staff concerned that bed rails were not allowed.
Consequently the care expert was called in because the team could not find a solution to the high risk of falling. The night light had not helped and the resident had tried to climb over the bed rail. The result was that the resident then fell heavily scattering the bedside lamp, radio, telephone, cards, flowers and chocolates and she lay on the floor wet and in a confused mental state. The incident was distressing for everyone concerned and very time-consuming for the busy staff.
Using this case study, we may ask, for training purposes, what an ideal application of REPVAD would look like. The facilitator would follow the process given above and then non-obtrusively guide the discussion along its lines, so that the following kinds of questions would arise. We emphasise that this is an ideal, since it is important not to force the viewpoints expressed but only empower and facilitate.
Reasoning
The facilitator tries to tease out answers to the question of whether the actors were or thought they were acting reasonably at the time, and what it is that now feels unsatisfactory about the outcomes on the day of the scenario. For example, was it reasonable to think that a night light and raised bed rails would help? Why would one think that, and why would one question it now? Were there underlying unquestioned assumptions, for example, that a bed rail would prevent rather than exacerbate a fall? Are the right connections being made between one action or event and another? Was a routine being followed without much thought? But, it might be said, ‘Don’t staff have to follow routines’ to work efficiently and harmoniously. Was there dogmatic thinking at some points, or jumping to ‘easy solutions’, or extreme conclusions? Did the resident herself provide any reasons for the incident? Is this just an inherently ‘unreasonable situation’ with no way out?
Evidence
The facilitator, while allowing everyone to contribute, actively empowers everyone to look at the bare facts and search for new facts. For example, why does the resident often get up at 23:00 h? Answers might be found by the group in terms of urinary tract infection, too much fluid intake in the evening, going to bed early and so on. Has there been a urine dip-stick test for infection? What is the resident’s medication regime and is it somehow connected with her behaviour? The group would now be motivated to seek out new evidence from actual practice. What is the research evidence concerning the effects of bed rails on certain classes of patients? Are there published articles or new guidelines for the care of the older people subject to falls? 18
Procedures
The facilitator now moves to the procedures involved. Is the restriction on physical restraint such as ‘no bed rails’ a rule that is good in all circumstances? If it is to be applied does special care have to be taken, and if so what exactly? Can a bedside table, or some of its items, be moved away from the patient at night? Is there any special device or equipment a patient could use for getting up at night? Are there other health and safety regulations, or good practice guidelines or policies that might be helpful? Are there remediable communication gaps concerning implementation of the rule against physical restraints?
Values
The facilitator reminds the group of the Eden Alternative® mission statement and its ethical values of autonomy, dignity and integrity. How are these values enacted in the case of using or not using bed rails? Is there sometimes a conflict of values, such as dignity versus safety (risk), and how are these resolved? Whose values are most important? How does the ethics of ‘consent’ work out in this actual scenario and in this kind of setting?
Attitudes
The facilitator reminds the group that they should now honestly consider the helpful and unhelpful attitudes or general dispositions of those involved. Avoiding blame or belittling anyone the group is first asked to identify positive attitudes, those which helped to acknowledge, confront and resolve the difficulties, such as good communication, working as a team, encouraging others, taking an initiative and looking for alternatives. Then the facilitator could ask the group to identify hindering attitudes, such as failure to communicate, feeling futility about improving care, discouraging others, being too confrontational with others or refusing to take initiatives. It is natural to feel hesitant about acknowledging the negative attitudes, but it can ‘break the ice’ if someone has the courage to admit that their own attitude could have been more positive in some respect. For example, one or more staff can sometimes develop the attitude that at night not much happens so one should do the round quickly and with the least effort so that one can sit down and chat. What in fact is the general attitude of staff to a resident who is much more ‘difficult’ than the others?
Defensiveness
The facilitator has to be quite perceptive to notice when a member of staff or a group is providing excuses in order to defend themselves against blame, loss of reputation or power, or against taking on new responsibilities. The facilitator should be compassionate and patient in raising such issues, for example, the discussion of taking or avoiding responsibility, proposing a new responsibility, minimising or evading responsibility, pushing responsibility onto someone else (so-called ‘passing the buck’), interpreting a role too narrowly or perhaps too broadly, or being ‘absent’ when difficulties arise, or appealing to one’s role boundary unjustifiably, and acting in one’s own interest rather than that of the resident. In the scenario, questions may occur to the facilitator such as whether responsibility for the safety and comfort of the falling resident was perceived as too difficult to take on and best to avoid if one could.
Results of REPVAD analysis
The main action points resulting from the group discussion following the framework were as follows. It was not unreasonable to have tried a night light and bed rails as a ‘quick-fix’ solution but this was not based on any further inquiry into the resident’s circumstances. It was discovered that she did not go to bed earlier than usual and did not drink more at night than usual. The group could now see that it was easy to check on the resident at about 22:00 h and, if she was awake, to offer to take her to the toilet. The staff had learned to loosen up their attitude that they already knew what the basis of the problem was and what the solution would be and that therefore there was no need to actually find out and try something new.
More evidence was sought concerning possible medical causes. A simple test proved that she did not have an infection. The group also decided to establish whether there had been a change in drug regime that might have affected the resident’s behaviour. The drug regime was examined closely. The patient was being given 4 × 1 g of Paracetamol©, because of back pain, also 1 Tbl of Omeprazol© to protect the stomach, so this meant that in the morning the resident had to take nine tablets. Talking with her more deeply she told the staff that she treated the tablets in the same way she had as a seamstress in the past organised her buttons and so on. She sorted the tablets in size and took the large ones in the morning, the smaller ones at lunch and the smallest with dinner. After all, explaining this to us she was living out the Eden Alternative® value of ‘participation’. Her clever re-organisation of the drug regime put in doubt the diagnosis of ‘dementia’, and some further inquiries revealed that she had never been formally diagnosed with that condition.
Finally, all became clear when it was revealed that since the smallest tablet was Torem©, the diuretic, she took it just before sleeping – hence the urgent need to get up. Following the required changes in the order of medication the resident slept throughout the night without trying to get up.
Benefits of the analysis
Both patient and staff benefitted from the REPVAD analysis. The time spent on REPVAD brought larger gains in time and resources saved as well as less stress for everyone concerned. The risk of an adverse incident from falling was now greatly minimised, the communication of staff-staff and staff-residents improved and the value of discovery and openness was brought into line with the Eden Alternative value system.
Real-life student cases
Here are summaries of the four real-life scenarios as analysed with REPVAD by Master’s students. This gives us an idea of how those new to REPVAD respond. Each concludes with the participants’ responses to a request to reflect on ‘the use of REPVAD, your gains in learning in your role as an academic nurse and gains for the hospital’. These conclusions also indicate an enabling of REPVAD development in differing circumstances or professional groups.
These illustrations are to some extent context-specific, actor-specific and time-specific. By this we mean that a different discussion on the same incident, even if it involved the same actors, would have some differences in perceptions, agreements and disagreements. Furthermore, interventions and medications change with time and locality. Thus, the reader may find themselves at certain points disagreeing or feeling they would have made a different intervention. This is not a weakness of REPVAD but a strength, since it does not seek unanimity or the ‘perfect solution’ but consensual understanding and piecemeal healthcare improvement.
Scenario 1
Introduction
In a private clinic most of the critical incidents reported are medication errors. Management and staff assumed that this is due to short staffing. I tried critically to examine these reports and go beyond the explanation of ‘too few staff’. The literature identified multiple causes of medication errors which cause avoidable suffering and waste money. The analytical process was done together with three experienced staff nurses.
Reasoning
Analysis of how in fact the nurses reasoned about their medicating actions revealed that there was not enough knowledge about medication and too many assumptions were made about the knowledge of other health carers. They often did not dare to ask physicians when their prescriptions were unclear. Doctors write prescriptions by hand, nurses transfer them later into the electronic health record, but it was not being considered whether this might be a source of errors. Nurses may assume that physicians are aware which medications clients take before they enter the hospital.
Evidence
A review of the local evidence concerning medication showed that it was the top error in the critical incident reporting system. There is no standardisation of physicians’ updating of the medication dosages of previous medications that patients brought into the hospital prescribed by their general practitioner (GP). Three new medical specialties were added to the hospital in the past year, and everyone brought their own specialty-medication regimes with them. On questioning, nurses are saying, ‘I don’t know this medication’. The evidence revealed that handwritten and scanned medication records had discrepancies.
Procedures
The medication administration process was newly defined by the management and declared to be implemented in 2013. Nurses were not familiar with new electronic records. Medication is often written down on a piece of paper and not directly put into the electronic record. Input is often not double-checked. Nurses rarely ever use the 6-R-rule: right patient, right medication, right time, right dose, right application and right documentation.
Values
The professional and ethical values of careful attention, diligence and non-maleficence were not given sufficient weight. Medication management was not seen as especially important. Knowledge about it was sometimes missing, such as changing from intravenous to oral application and vice versa. Medication prepared by a colleague in an earlier shift was not double-checked using the 6-R rule.
Attitudes
Concerning a responsible attitude, patients were assumed to be responsible for their own previous medication. Hospital doctors were often not interested in the previous medication of their patients. Short staffing is believed to be the main culprit for the occurrence of errors, and the prevailing attitude was, ‘distribute the medication, it needs to be done, it doesn’t matter how’. Nurses are used to short staffing and accept the way it is. Double-checking the medication using the 6-R rule is generally neglected.
Defences
Nurses often displayed defensiveness of their time and energy, assuming that responsibility lay elsewhere. They were reluctant to double check with physicians whether their handwritten prescriptions are unclear or not legible, possibly thinking, ‘It’s not my fault if it is unclear’. Many errors were reported in critical incident records but not acted upon. The new medication administration process needed more time than the old process and was therefore never fully accepted.
Reflection and action plan
The general reflection was that there was insufficient responsibility and attention at every stage from noting previous medication to administering, recording, liaising with medical colleagues, double-checking and asking questions or making recommendations, and lack of capacity and/or willingness to learn from mistakes. All topics were highlighted and addressed by a strategic implementation plan at nurse and at management and quality assurance level in 2015.
Personal and organisational benefits
The topic of medication errors was revived at management and ward level through the structured approach using REPVAD. The added value for me and the hospital was as follows: (1) knowledge of the REPVAD method; (2) reflection on the prevailing thought-style in the hospital: mostly routinised and minimalist experiential knowledge instead of professional, analytic and reflective thinking; (3) seeing the importance of including all stakeholders, so using their ‘swarm intelligence’ in analysing and remedying the problems; this was included in the year 2015 strategic goals of the nursing department; and (4) the education of nurses about medication management and their over accountable role in it.
Scenario 2
Introduction
A 65-year-old woman was ‘contact-isolated’ because of an MRSA/ESBL (methicillin-resistant Staphylococcus aureus/extended spectrum beta-lactamase) contamination in her groin and thus in her urine. Wearing a protective coat and gloves was mandatory when caring for her in order to avoid contact with body fluids. For other tasks in the room a correct hand-disinfection was sufficient. A door sign indicated the isolation situation and a rack outside of the room had masks, gloves and protective coats ready. In the beginning the patient had lots of visitors but they dwindled away over time, and only her daughter still visited. The patient became more depressed and said that visitors stay away in fear of contamination and infection.
I observed that the nursing staff dressed up fully in protective gear when entering the room for other than direct contact activities. Her daughter was told to do the same. I asked myself why the nurses used such exaggerated hygiene precautions, which were not correct and had a detrimental emotional effect on the patient, used too much time for them to dress up every time they entered the room and was also wasteful using too much of the disposable gear, gloves and masks. A group REPVAD analysis followed.
Reasoning
It seemed perfectly reasonable that nurses, and visitors, would fear a dangerous infection and there was an obligation not to spread it. It was also reasoned that nurses might not be able to distinguish between contact and no-contact isolation procedures. It was acknowledged that it must be hurtful for the patient to be only touched with gloves, and that she might feel cut off from the world, stigmatised and become depressed.
Evidence
The effects that isolation measures have on the experience of patients and their families were researched. Studies confirmed that patients are visited less often in cases of isolation. In addition, one could observe a relationship between isolation and affective changes such as higher anxiety and depression. 19 In isolated patients, life satisfaction decreases greatly and there is severe restriction of mobility. Feelings of stigma associated with the protective clothing of staff and the isolation alarm at the door were found.
Procedures
The internal procedures explained and gave clear directions on what needed to be done in different isolation cases. As soon as a patient is diagnosed with MRSA or ESBL, a computer alert goes out to the internal infection control experts who visits immediately and gives advice to the nurses. In fact, the hospital guidelines did not support the manner in which the procedures were actually implemented in this case. However, it is known by everyone that ESBL is spreading and is due to lack of effective antibiotics. This would explain why the nurses were over-extending the procedures in an insensitive way. It was agreed by the group that the procedures should be highlighted in the computer system and easier to find.
Values
Ethical values like ‘role model care, engaged care and respectful care’ are endorsed by the nurses but are not always put into practice for one reason or another. For example, time pressure prevents them studying the procedures if they are not familiar with them, so they prefer to copy a colleague’s practice. In this way mistakes may be made and wrong practices creep in.
Attitudes
The nurses are often under pressure, so stopping to reflect on a procedure may be regarded as time-wasting or unnecessary. It then becomes the attitudinal norm to just get on with work, to copy colleagues’ practices and to risk engaging in faulty practices. Therefore, reflective sessions and discussion of case studies are important in shifting attitudes and in the long run save on time and resources as well as help patients.
Defences
Taking shortcuts in hectic work becomes the defensive norm against a feeling of being overwhelmed. Simply functioning and coping with the daily heavy workload become a priority.
Reflection and action plan
Reflection of the REPVAD analysis and discussion showed up a need to address the nurses’ anxiety about contamination, avoid stigma and feelings of isolation for the patients by implementing the right measures in the right way to the right degree, update the nurses on the most recent literature on Evidence-Based Systematic Reviews (EBSR) in short and digestible form, make the procedures more visible and accessible on the computer, initiate better communication with the infection control specialist in order to receive more support, make sure family members are being instructed correctly about the right procedures by the nurses and provide an information leaflet clarifying the rationale for special measures in cases of MRSA. A detailed action plan with a timeline to put the above into practice was devised.
Personal and organisational benefits
Reading the literature on ESBL can indeed be frightening and it became my goal to help nurses to deal with their anxiety in a professional and well-informed manner. I needed to observe risky situations and support them to put the correct procedures into practice and to give them motivational feedback once they have done so. It was very rewarding to use the REPVAD model to analyse this complex situation and to navigate solutions on all levels supported by evidence from the literature. REPVAD provided a helpful structure for critical and reflective reasoning. The nurses experience less stress through my support and save time by not overdoing the protective gear, and this also saves money and helps support the patient emotionally.
Scenario 3
Introduction
Newborn babies and toddlers often develop diaper dermatitis due to the use of disposable nappies. 20 This can lead to skin damage, itchiness and fungal infections. It is painful for the children and treatment is often prolonged and healing is slow. This problem is well known in the paediatric clinic and guidelines on how to avoid diaper dermatitis include detailed instructions. Practice shows that these guidelines are either ignored or only partly put into practice. The REPVAD model has been used to identify the reasons for this.
Reasoning
The actual reasoning behind the inadequate use of the guidelines was that the guidelines are too long (nine pages) and not easy to find on the computer. Care procedures are time-consuming and need to also be implemented at night when the children are sleeping. The materials and products to be used are many and the right choice might be too time-consuming and too complicated. Even if the assigned nurse chooses the right materials there is no guarantee that the following shift will do the same, and they often change the procedures without consulting with the assigned nurse.
Evidence
Generally, there is a lack of awareness of the necessary evidence. The team where the student works is inexperienced and only possesses rudimentary knowledge about the consequences of diaper dermatitis. They do not realise that non-compliance with the recommended procedures is doing harm to the child-patients, and there is rarely consultation with the specialised wound-care team in the clinic. The nursing team is then confronted with very sick children and complex care. They would rather ‘survive’ their shifts and thus do not want to put any effort into consulting the guidelines.
Literature indicates that diaper dermatitis accounts for between 25% and 50% of skin conditions in babies and toddlers, which is very painful and can lead to secondary infections. 21 Risk factors are diarrhoea, insufficient diaper-change frequency and a change from liquid to solid food. Most effective is targeted prevention, which includes a 3-h diaper change, non-alcohol containing wet-tissues, application of zinc-ointment and exposing the diaper area to fresh air.
Procedures
The published internal guidelines are evidence based and binding. They contain detailed applicable procedures for prevention. They also contain a pictorial list including all materials. The clinic’s mission includes a statement that the wellbeing and the dignity of the children should guide all actions. Safe and professional care is espoused as well as cooperation with the parents.
Values
All nurses would verbally subscribe to the mission statement values of mindful, high-level and meaningful care. The team is respectful in the company of parents and children and good care is important for them. However, in hectic everyday work, these values are only partly present or practised, and insufficient connection is made between the ethical values and the clinical procedure and evidence.
Attitudes
Team attitudes depend very much on the labour intensity and leadership of the particular shift. Normally the nurses work diligently and support each other. There are days where only the basic necessities of care are carried out, so that the team can meet and share thoughts. When the unit manager is present, they all do as they are told, and they keep quiet even if they have differing opinions. If the manager is absent, there is more openness to discussing how to resolve difficult situations. The nurse manager of the unit does not support evidence-based practice, and everyone is aware of her attitude. Since the care of the children is often carried out in the presence of the parents, it is possible that the parents have differing opinions and thus the correct care might be ‘diluted’ by their wishes and opinions.
Defences
The focus is on getting the physician-ordered work done, because this prevents the nurses being criticised by the doctors. If there is time left, then care tasks like correct diaper changes are carried out. It is difficult for young nurses to take full responsibility for the whole care process when parents are present around the clock. They may experience the questions of the parents as a threat to their competence. Some team members avoid taking responsibility for complex procedures so that they cannot be criticised for their inadequate implementation.
Reflection and action plan
In this unit, a culture of problem-solving is underdeveloped and communication is poor. Instead of asking others for advice nurses engage in habitual and outdated practices, and modern evidence-based practice is not on their horizon. Nurses often engage in fruitless discussions with parents, and as they cannot assert their professional stance the correct process of care is often interrupted. The action plan includes retraining nurses in round table discussions and at the bedside on the correct and evidence-based procedures to prevent diaper dermatitis, familiarisation with relevant studies supporting the written guidelines, and every child will have the guidelines printed at the top of their records. Guideline updates will involve instruction and questions in detail in the future and not just pinned to the wall, consultation with the wound-specialist team in the clinic on how their expertise can be used more and the inventory of available products will be simplified.
Personal and organisational benefits
REPVAD has helped me to develop habits of analysis, seeking evidence and communicating. I reflect much more on everyday practice and increased critical and ethical thinking helps me to dissect all the facets of practice. I also learned how helpful it is to include my course colleagues from different disciplines to analyse practice and to reach suggestions for improving daily nursing.
Scenario 4
Introduction
A new evidence-based guideline to minimise sudden infant death syndrome (SIDS) was introduced to a maternity unit. This included no toys, no safety-pins, bed-sharing only with a parent who has to be awake and strictly no co-sleeping. The SIDS guideline exists not only in many Swiss hospitals but also in many hospitals throughout the world. In this particular unit the guideline has not been put into practice. Co-sleeping and bed-sharing were still encouraged by the staff. In contrast, the paediatrician attached importance to an immediate implementation of the guideline and not only insisted in the implementation but also instructed the new parents. This inconsistency of two different approaches at the same time made the new parents feel insecure.
The replacement of the head of the paediatricians made demands for the strict implementation of this guideline on this unit. This caused an uproar in the team, especially the breastfeeding instructors, who perceived the guideline as a threat to their ‘legacy and life accomplishments’ which included rooming-in, bonding and a breastfeeding-friendly hospital. They felt threatened and even went into active opposition, forming a group with the goal to change the mind of the leading paediatrician to preserve the status quo.
Reasoning
Since the issue was very emotionally charged, it was difficult to dissect the reasoning behind the disagreements. The anxiety was palpable, but what was causing it? Misunderstanding, dogmatism, extreme positions being taken, habitual patterns of thought, reliance on anecdotal experiences? Do the breastfeeding instructors fear for their (informal) leadership role? Do different players have different and conflicting goals? Where does the unit manager stand, what is her role and is she visible? Where is our overall goal of best care for the newborns and their families? Where is the notion of ‘safe care’? Do the nurses also have informal manipulative power?
Evidence
International studies support the view that SID interventions have an influence on reducing the mortality of newborns. 22 Feedback from parents show that inconsistent information makes them insecure and doubtful. 23
Procedures
An internationally acknowledged guideline document exists, based on up-to-date evidence. Locally there are also a written clinical mission statement and written clinical guidelines and goals that support the principle of the best interests of the patient (or, in this case, the baby). But were the procedures being studied and discussed in a rational manner with the baby’s interest coming first?
Values
The top ethical value here was the ‘best care’ for the patients embodied in the mission statement and it was obvious, according to the mission statement already accepted by all, that the patient is always the centre of our work. It was also a verbally accepted value that practice should be evidence based.
Attitudes
Personal attitudes and anxieties were in danger of overriding the wellbeing of the patients. It was assumed that healthcare professionals must ‘know what’s best for the patient’. Some staff members were strongly feeling attachment to a certain professional group, rather than seeing themselves as contributors to an integrated healthcare team. It often seemed that a personal parenting experience was overshadowing scientific clinical judgements.
Defences
Some staff members were defending their own professional status and power. They were feeling threatened, and clinging to outdated practices, showing an avoidance of critical discussion of attitudes, with attachment to locally developed and unreflective expertise, based on anecdotal experience, not on evidence.
Reflection and action plan
The application of REPVAD in group discussion revealed that the key to the issue was that the breastfeeding instructors were experiencing status anxiety. This fed their resistance and led to a paralysed situation in decision-making. A plan for gradual attitude change and reassurances unfolded. Subsequent talks with the instructors and their involvement in creating pictograms and information letters for parents eventually made them partners in implementing the new guideline. Further attitudinal issues, up to leadership level, still remain but it is envisaged that the development of a team culture of helpful self-questioning will dissolve those issues.
Personal and organisational benefit
I now realised that the implementation of new guidelines or changed practices needs analysis of the cultural context in advance, in order to be sustainable. REPVAD showed me how important an inclusion of values and attitudes is, especially in difficult situations. A shared value base is an important part of the quality of care on a unit. With REPVAD the issues could be discussed on a factual, not personal basis. A structured analysis also facilitated communication of the problem to outsiders (in this case my peers) and facilitated resolution by providing valuable ‘outsider views’.
Conclusion
The consistent application of REPVAD is a means of empowering cultural change in healthcare and creating the evidence-base in everyday practice. 24 It also shows that practically engaged nursing education at Master’s degree level can foster culture change in everyday nursing practice.
The subtleties and tensions of dialogue cannot, of course, be caught in the summaries above. It is the lived experience of REPVAD in action that is important. The model works best when its application strikes a balance between being directive and being spontaneous and creative. For this reason it is probably best if the REPVAD facilitator is not the unit manager. The root idea of REPVAD is to sketch out a discursive space for the participants to reflect, discuss, search for honesty and truth in a minimal structure – but not so minimal that the discussion is lost in irrelevance and blame.
Its great strength is that it provides systematic and objective (non-personalising, non-blaming) guidelines for the secure and cooperative analysis and self-analysis of the misunderstandings, mental blockages and lack of evidence that are at the root of so many real-life healthcare difficulties. However, it is not a panacea and its fruitful deployment depends on a sufficient degree of willingness of the team involved to be honest and trusting.
Its weakness is that it does not always lend itself fluidly to situations in which the over-arching difficulty is a high degree of managerial or leadership failure and/or lack of material resources. However, even then an attempt to apply REPVAD may unexpectedly open up leverage for the changes needed. Strong leadership may be needed in situations of entrenched perceptions and a reluctance to change. Given its dynamic and interactive nature the model is always open to further development both in its formal structure and in its application.
Footnotes
Acknowledgements
REPVAD was devised by Prof. Geoffrey Hunt at the University of Surrey, Guildford, UK, from 2002 to 2004 and he acknowledges the invaluable feedback and discussions from the ‘Advanced Practice’ (MSc) student nurses in the classroom and in their portfolios. He is also grateful to Christine Merzeder (Hunt’s student in 2004), who continued to apply it up to the present day in her educational post delivering diploma courses for nurses in Switzerland, Austria and Germany. REPVAD has been taught at MScN level since 2009 at Kalaidos University of Applied Sciences, Zürich in its Department of Health Sciences, but not previously published. The authors gratefully acknowledge the vital contributions from Yvonne Frick, Silvia Fux, Yvonne Liebert-Keller and Sabine Trautmann. Iren Bischofberger also enhanced the tool with theoretical considerations.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.