Download - Stay and play: transforming healthcare delivery

CHILDREN & SOCIETY VOLUME 19 (2005) pp. 42–53Published online 3 March 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/CHI.818

Stay and Play: TransformingHealthcare Delivery

This paper provides further evidence to challenge the scepticism of

successful interprofessional working. It is a story of a project to

support families and children, more specifically, isolated mothers,

and the use of continuous quality improvement and action research

methodologies to engage a community and change service provision.

Based on exploratory group work Stay and Play child development

and learning sessions were set up for, and were well received by,

parents. The project group worked initially with uncertainty and

undefined needs; professionals involved eventually saw the benefit of

changing their practice to meet local community needs. Copyright#

2004 John Wiley & Sons, Ltd.

Introduction

Interprofessional working and education are central tenets ofUK public policy, particularly within health and social care.The New NHS: Modern, Dependable advocates interprofessionalworking as a means of achieving the modernisation agenda(DoH, 1997). Subsequent documents set the context and call forcommon learning programmes to improve services (DoH,1999b, 2000, 2001a, 2001b). Yet, ‘the empirical and theoreticalliterature is largely sceptical about the feasibility of effective jointworking between separate but related professionals’ (Hudson, 2002,p. 7). This paper provides further evidence to challenge thisscepticism. What follows is the story of a project to supportfamilies and children, more specifically, isolated mothers, andthe use of CQI (continuous quality improvement) methodol-ogy to engage a community and change service provision(Langley and others, 1996; Wenger, 1998).

RIPE (Regional InterProfessional Education Project, 1998–2001;Todres and Macdonald, 2001) was funded by NHS ExecutiveSouth West and based at Bournemouth University. Develop-ment work, agreed via consultation with local health autho-rities and NHS Trusts was undertaken in three practicesettings (elderly acute care, mental health, and child andfamily services). Project foci included service improvement,interprofessional learning and collaboration, and involvedboth academic and service agency partners in these practice

Copyright # 2004 John Wiley & Sons, Ltd.

Keith Brown* andNatasha YoungBournemouthUniversity, Institute ofHealth and CommunityStudies

Steven Keen

*Correspondence to: Keith Brown,

Head of Post Qualifying Social

Work, Bournemouth University,

Institute of Health and Commu-

nity Studies, Heron House, 8-10

Christchurch Road, Bournemouth

Dorset BN1 3NA, UK. E-mail:

[email protected]

Contract/grant sponsor: NHS

Executive South West Region.

settings. The overarching aim of the child and family services group was developed overtime and after further discussion with university staff, health visitors, local voluntaryorganisation play leaders, play workers, a community paediatrician, service manager andthe coordinator of a user group representing parents—and is stated as follows—‘toimprove services for parents with young children and to provide opportunities forinterprofessional education and learning’.

One of the outcomes of RIPE was to seek out factors that influenced interprofessionallearning and ways in which groups of professionals learned to work together to improvepractice. A further aim was to find out whether CQI provided a useful vehicle forinterprofessional learning. As such, the project was centred around a fundamental beliefin learner-centred experiential learning. Its evaluation was primarily viewed in processterms; this made it more complex. A cyclical, ongoing action research process was mostsuited to explore both project and research aims.

Methodology

Waterman and others (2001) note three main reasons for choosing action research: changefacilitation, a cyclical process related to change and participation; its strength lies inthe blend of participants and research with action and change. It is a style of research(and not a method; Meyer, 2000) that pursues action and research, and allows thesimultaneous achievement of change and understanding (Dick, 2002). Action researchprojects may draw upon both qualitative and quantitative data (Meyer, 2000). Multiplesources of information, the use of an iterative process and seeking out disconfirming ornegative evidence, enhance the quality of action research projects (Dick, 2002).

Action research involves ‘trying out ideas in practice as a means of improvement and as ameans of increasing knowledge’ (Kemmis and McTaggart, 1982 cited in McNiff and others,1996, p. 9). This process encourages members of a team, organisation or community todefine issues to be explored, share relevant knowledge, take appropriate action, reflect andlearn from the results (Chaiklin and Lave, 1996). There is often an open starting pointand no fixed end goal—the emphasis instead is on team learning, capacity building andcontinuous improvement. Action research also emphasises the importance of groupdynamics and the role of a facilitator who is present but not in control (Greenwood andLevin, 1998).

Dick (2002) describes a number of possible action research cycles, however, allalternate between some form of action and reflection; for example, Plan, Act, Observe,Reflect or Intend (reflect before action), Act (reflect during action), Review (reflect afteraction). Inquiries often engage in six to ten cycles of action and reflection (Reason andHeron, 1999).

The action research approach provides a framework of study, action and reflection but is

not a neat, orderly activity that allows participants to proceed step-by-step to the end of theprocess. People will find themselves working backward through the routines, repeating processes,revising procedures, rethinking interpretations, leapfrogging steps or stages, and sometimes makingradical changes in direction. In practice, therefore, action research can be a complex process(Stringer, 1999, p. 19).

Transforming Healthcare Delivery 43

Copyright # 2004 John Wiley & Sons, Ltd. CHILDREN & SOCIETY Vol. 19, 42–53 (2005)

Similarly, the core of a CQI cycle is the use of knowledge to identify changes, actionplanning and assessing the results thereof. It is based on the premise that quality is aboutmatching service to need; there is an implicit recognition that care will not improvewithout changing the processes by which it is delivered (Todres and Macdonald, 2001, pp.77–84). Therefore, CQI is partly about clarifying patient needs, current provision andidentification of areas for improvement.

The child and families group used a CQI model proposed by Langley and others (1996).This involved going through a number of learning cycles by asking questions such as whatare we trying to accomplish, how will we know that a change is an improvement,what changes can we make that will result in improvement? The answers to thesequestions focused and structure subsequent action in such a way to maximise any likelyimprovement. This project used the Plan, Do, Study, Act cycle and what follows mirrorsthis process interlinked with discussion from the literature. Project stages are condensedto form Table 1. Informal verbal ethical approval was maintained throughout each of thesestages by asking both users and group members if they were happy to continueparticipating in the process. The paper concludes with an assessment of projectoutcomes and methodological considerations and ends with a summary. Any verbatimquotations from users or group members use italics.

Plan

Initially, group meetings focused on how to identify isolated families and what serviceswere available to them. There were a series of questions around definitions of ‘isolated’people, or people in need who were not using services. Describing this group proveddifficult and prompted a good deal of multi-agency discussion. It was found that manyservices existed but the means by which an isolated parent could access them was

Table 1: Stay and Play project stages

Date Action Stage

September 1998 Initial group discussions. Identification of isolated families and what PLANservices are available to them

January 1999 Questionnaire developed. Two pilot interviews completed. DONine further interviews planned

April 1999 Data analysis—parents needed somewhere informal to go with their STUDYbabies to provide stimulation and support

June 1999 Stay and Play child development and learning session designed and enacted ACTJuly 1999 Initial sessions characterised by anxiety and uncertainty. Attendance increased STUDY

to six mothersSeptember 1999 Verbal feedback from these six mothers was very positive. But health DO

visitors and Stay and Play staff are unsure why they are there and what theyare getting out of it

January 2000 Attendance increased to 15 families. Health visitors are becoming more STUDYapproachable to parents. Attendance increased to 30 families by July2000—results of ensuing questionnaire are positive

September 2000 Further Stay and Play afternoon session to be organised. Health visitors PLANto be present from the outset and attend in blocks of three to four weeks

October 2000 Next Stay and Play sessions took place in a different locality DOJanuary 2001 Project momentum is strong. Two additional mothers join the group STUDY

meetings. Less support required from university staff

44 Keith Brown and others


piecemeal. Discussion also took place on what experience individuals in the group had ofisolated families within their areas of work, and possibly reasons for their perceivedisolation. It was decided to speak to parents directly.

Do

Parents of children born during a certain time period were asked how they felt aboutcurrent service provision. Names of ten families with children aged six months, two yearsand three years were randomly drawn from the birth register. A telephone questionnairewas developed and health visitors were to make contact with these families. Threehealth visitors agreed to ask one parent each to describe how useful they found existingservices, explore individual experiences of being a parent, and how they might identify‘isolation’. By January 1999 two pilot interviews with mothers of three month old childrenhad been conducted. The mothers were thought to be atypical of the proposed sample.Understanding and insight into what it meant to be ‘well supported’ emerged. Minoramendments were made to the telephone questionnaire. This early work progressed.Names of a further nine mothers with six month old babies were obtained in a randomfashion from the local birth register. Telephone interviews needed to be completed beforeApril 1999.

Although the CQI framework was in place to guide the way the group worked, there wasno specified end point beyond that of improving services to meet local need. At thebeginning of the project, meetings were exploratory and aimed at developing participativegroup processes and deciding on a course of action. This, for many, was a new wayof working. It created a certain amount of tension and anxiety. Having an abstract aimsuch as the improvement of services for a particular group, rather than, for example, thesetting up of a clinic, meant taking more risks than participants were used to doing in theirusual roles. At times they found it difficult to accept they could end up down several blindalleys before finding the right way forward.

Study

In April 1999 health visitors fed back their interview findings to the group. Over half thefamilies selected did not meet the sample requirement because of older children.Nevertheless the interviews provided some ‘very interesting and illuminating’ information.Despite these mothers being familiar with the parenting experience, they still consideredthemselves isolated. This challenged the assumptions made by some health professionals.Of particular note was that mothers felt isolated not because of socio-economic factors orhousehold location, but because they had few friends. This was especially true for motherswho had stopped working after the birth of their child. They had lost contact with their‘work’ friends.

They were saying things like they wanted to join a parent-toddler group but felt unable, unwilling,frightened to join a group because they were cliquey, or they didn’t feel confident enough to walk into agroup. One person had had a previously bad experience with professionals because of one of thechildren beforehand and therefore was very wary of professionals. Another person was saying howhard she found it being a mother of a child, [more] than she thought it was going to be and so [there was]a whole series of potential issues to consider. (Health visitor reflecting on parent interviews)



Act

It was clear that parents needed somewhere informal to go with their babies—somewherethat would provide stimulation for the babies and support and advice for parents. Thegroup wondered how could such a facility be offered within existing practice, or whetherpractice could be changed to meet parents’ needs. A scheme run by Partners, a localvoluntary sector organisation offered a possible working model.

The Partners project

Partners is based at an infant school in Hampshire. Set up in 1996, it aims to ‘supportparents in their role as the first providers for their pre-school child’s educational needs’.Initially the project involved home visiting, working with parents on their understandingof child development and learning through play. These activities were supported by atermly activity session, known as Stay and Play. The focus for these sessions was onhelping children to prepare for school attendance.

Starting up

The idea of having a Stay and Play session was the basis of the Andover group’s learningcycle. Sessions would be staffed by play leaders. Mothers would be able to attend withtheir children and be encouraged to explore different modes and media whilst playingwith them. Stay and Play workers would demonstrate and model these different playactivities. Sessions would provide opportunities for parents and carers to meet with othersand come into contact with resources able to meet their individual needs. Healthvisitors would also attend and provide an informal drop-in and information clinic. Thisnew Stay and Play group was aimed at parents of newborn to three year olds.

This cycle took place between June and July 1999. At the beginning it was characterised bya great deal of uncertainty. Information about the session was distributed, but theintended session was of a ‘drop-in’ nature. There was no idea of how many families toexpect during the first few weeks: would there be two, or would there be 20? There wasuncertainty about whether these sessions were actually required by the local community;whether they would make a difference; and whether they would be successful. Anxietyand uncertainty continued around the roles of those in the group. All concerned wereworking in different ways within the Stay and Play sessions than they were used to.

This was an issue for some project participants, that is, they had to think and work in waysthat were different to the usual ways their roles were perceived or enacted. The potentialconflict or unease of working interprofessionally is highlighted elsewhere (Easen andothers, 2000). Cultural differences in ways of working and different emphases on valuesare not always easily or quickly resolved. This can be a potential hindrance incollaborative efforts. In this project, health visitors in particular had to work in bothsubtly and explicitly different ways.

Health and social care professionals are being encouraged to work in different and moreinnovative ways to meet the needs of the population they serve (for example DoH, 1997,1999a, 1999b, 2000, 2001a, 2001b, 2001c). There is emphasis on increasing the public health



function of those who work in the community (Calman, 1998; SNMAC, 1995). Thisinvolves

care based on collaborative networks and community participation together with a recognition of theimportance of addressing the inequalities experienced by individuals and groups in terms of theiropportunity to access the means of achieving health (Plews and others, 2000, p. 138).

Study

Three mothers attended the first session and after four weeks this had doubled to six. Thisgood progress was achieved largely through word of mouth as mothers saw the benefits ofthe sessions and encouraged friends to attend. Although, with two staff and a healthvisitor present, the group wondered if it was the best use of time and resources. At severaltimes during the project, the question of ‘Why are we here and what do we get out of it?’ wasraised by the health visitors. Partners project staff asked the same, ‘We are doing all the hard,heavy work, using our limited resources, and what do we get out of it?’.

Do

The group felt that the most important question was ‘What do the parents get out of it?’. Thebest way to find out was to ask. Verbal feedback from six parents was positive and gavethe workers momentum to keep going. All that was needed was more parents andchildren. By December 1999 attendance had risen to ten families. When sessions resumedin January 2000 15 families attended, and by the second week back they had spread intotwo rooms. Field notes taken at the time show subtle changes in how health visitorsbehaved, for example, they joined in more activities. This made them more approachableto parents. Records were kept of health visitors’ comments at each session, which reflectedboth positive and negative thoughts. Sessions became more and more popular. By July2000 up to 30 families attended each week.

A questionnaire, distributed in summer 2000, was developed to obtain user feedbackabout the Stay and Play sessions. Responses were overwhelmingly positive, with mothersindicating personal benefits for themselves and their children. The popularity of the grouphad almost led to overcrowding within the activity area, and concern was expressed bysome mothers for the safety of young babies when many active toddlers were around. Theresponse to this was to arrange separate morning and afternoon sessions, the morningbeing for babies and the afternoon sessions for toddlers. This happened in September 2000.

Study

From this cycle a range of key learning points emerge:

� Health professionals learned the value of seeing children and their carers in a non-clinicsetting, and of having their professional expectations challenged. There was an evidentneed to be open-minded.

� Those in the voluntary agency learnt that they could work in partnership withprofessionals and have an equal voice and value.



� Professionals often do not know what their clients’ needs are.

Plan

The group agreed that health visitors would be present from the outset at the next round ofStay and Play sessions. This way they would feel more a part of the group and not a ‘bolton-extra’. However, some health visitors still questioned whether it was the most effectiveuse of their time. It had been agreed inadequate for health visitors to attend just a singlesession. Therefore, they agreed to attend a block of three to four sessions to buildcontinuity and relationships.

Health visitors planned their next phase of activities, constructing them around a seriesof themes: the role of the health visitor; accident prevention; sleep; meningitis; and health.As the project evolved it appeared that the issue for the health visitors was not merelyabout planning their time alongside other members of the group and the mothers withtheir children. It was about their use of this time in a new context. Practice is context-bound and plans to use that require adaptability and flexibility. For the health visitors,learning to work differently was initially a complex, slow and tentative process, and atfirst there appeared to be resistance. For some health visitors it was easy to be accessiblefor the young mothers on an informal basis; others were not comfortable with this.

Do

The next Stay and Play sessions took place in a different locality. Planning for the nextlearning cycle included actions for off-line collaboration and activities. Leaflets about theStay and Play were distributed to parents via health visitors. An information exchange hadbegun in this embryonic collaborative practice. In the eyes of one service manager it wasimportant that health visitors saw for themselves the nature and quality of provisionwithin the voluntary sector. Health visitors were able to recommend the sessions to fellowprofessionals.

Study

There were periods during the project when it seemed that nothing was happening. Workset for subsequent meetings was not done owing to other work commitments andenthusiasm for the project’s direction or non-directive ways of working was not alwaysforthcoming. Despite the fragility of the project at times, by the end of 2000, a certainmomentum had been gained and less support was required from the university team, asone group member put it; ‘All of a sudden now it’s just happening and everyone’s doing their bitand it’s going OK.’

A health visitor commented in relation to this momentum:

Well, the main thing is what is achievable. What is achievable if people actually sit down and say, let’sall get together, let’s think about this and let’s put it into action, so it’s the achievement, how things canbe achieved when, as opposed to talking about them and writing about them, how they can actually beachieved [so] that people can actually follow them up and put them into action.



Further, the fact that personnel were not consistent over time also impacted on groupworking. Ovretveit (1997a) describes different types of interprofessional teams. Thoseinvolved in this project could be described as a ‘network meeting team’ since theycomprised a collection of individuals from different professions with different clientgroups and management structures, who worked in the same service or client area. Somemembers of the group were involved from inception to completion (the service manager,one member of the university team, and a play leader). Others left as their role changed.Or group membership changed due to a personnel change for a particular role. In a ‘fast-changing situation, and for some purposes, an open network with changing attenders is the mostappropriate mechanism for communication and co-operation between agencies and professions’(Ovretveit, 1997a, p. 16). Changes in attenders slowed and frustrated progress. Thisconcurs with research conducted by Easen and others (2000). They suggest that continuityof personnel over a three year time period is essential for effective multiprofessionalcollaboration. The consistency of the university based facilitator helped alleviate this issueto some extent.

Plan

Initial project focus centred on ‘isolated’ parents. This service development was entirelyexperimental, and as planning took place, it was uncertain whether there was any demandfor what they sensed was necessary. This presented another tension; an uneasy, uncertainchallenge when much current practice was oriented towards pre-identified objectives. Itwas unknown whether three or 30 mothers might attend the Stay and Play sessions.

Parents attending Stay and Play sessions extended their social support network. Theycontinued to meet socially for mutual support and activities such as swimming. Someparents had put their child’s name down for playgroup. The popularity of the Stay andPlay sessions generated further critical questions to be addressed by the project group.Given their success, how could new parents be trained to help in the activity sessions, andhow could the project be developed further? Two mothers started attending project groupmeetings. Both spoke of improvements in their children, and the opportunities offeredwithin these sessions. For some women it had been the first chance to meet with otheryoung mothers.

User involvement in projects is an increasingly important part of UK public policy. Thereis an acknowledgement in documents such as The Expert Patient (DoH, 2001c) that patientsor service users have a great deal of knowledge and need to be consulted if services are tobe tailored to needs of the patient. In addition, service user or community involvement isone method of empowerment which, it is argued, leads to an increase in social capital andreductions in social exclusion. Targeting social capital and social exclusion indisadvantaged groups or communities is in turn advocated as one way of decreasinginequalities in health (Duggan, 2002).

However, engaging the community is not easy. Many development projects which takeplace in communities have funding from national bodies or government to target aparticular issue. This may not fit with either local interests, or with the philosophy ofcommunity development (Standish, 2002) thus creating possible tension and lack ofengagement. There are also issues around communication between professional and lay‘cultures’.



Increasing participation can mean anything from information giving to decision makingpower being wholly assumed by patients or clients. Participation is thought to have anumber of benefits including organising a service in a way which is more suited topeople’s preferences. This increases the usage, support, effectiveness of and loyaltytoward a service (Ovretveit, 1997b). Within the Stay and Play project parents wereconsulted through interviews which were designed to elicit their experiences and viewson what would have made things better for them. Services were designed based on thisfeedback, and altered as a result of the continuing cycles of action and reflection. Over thecourse of time participation was increased through the attendance of two mothers fromthe Stay and Play group at project meetings.

Outcomes

The focus for this project was on method and process. The only outcome specified was thatthere should be an improvement. By focusing on interprofessional education andworking, everyone involved could concentrate on building services with the user at thecentre. This both reduced tension between professionals and meant that the pressure tomeet pre-prescribed (usually illness) targets was not apparent. According to the womenattending the group, the main reasons for attending the Stay and Play session were thedevelopment of both child and parent play skills, and a commensurate reduction inisolation. The group also became a contact point for mothers who would exchangetelephone numbers and later set up social meetings.

The informal session style with easy access to information was appreciated by users; it wasabout reassurance. This informal approach, with health visitors making personal contactwith mums, was also appreciated. Conversely, formal health visitor clinics wereconsidered an unsuitable forum to ask questions. One user explained that, in the informalStay and Play setting, a request for advice from a health visitor would not lead toindividual feelings of failure if a particular strategy was unsuccessful with a baby, becauseanother health visitor could be asked. Health visitors were thought a useful resource.

The community paediatrician attended one meeting and recognised the value of workingwith mothers at very early stages of attachment and bonding. This is in direct contrast tolater stages of development (children aged two to three) where problems can be alreadyapparent.

Project outcomes have been plentiful and include gains in confidence for mothers andchildren, increased communication skills, the establishment of social networks, anddevelopment of a repertoire of social and communication skills for use with children. Therichness of this experience is not captured within simple outcome statements. Crucially,social isolation, as identified by a number of individuals at the beginning of the project hasbeen, in part, addressed. A positive, inclusive model of working with different disciplinesand with the community has developed.

Also there has been the rich learning of starting out on a project with no identifiedoutcome measures at the beginning. Living with the uncertainty of ‘Will it work?’, ‘Willanyone come?’ taught the participants the value of using the CQI model and also aboutbeing bold and brave together. The absence of a clear outcome measure at the beginning



meant that any actions had to meet the needs of the users, as they were ‘their outcomes’ andnot professional outcomes.

This powerful learning experience reminds us how difficult it can be to change practiceand systems (Wenger, 1998). At times it felt like health visitors would never understandthat a change in the way they used their time could be of value. But the constant andpowerful feedback from the mothers gradually won them over until they too began to seethe value of their contribution within the ‘Stay and Play’ setting. There are now fiveseparate sessions across the town each week. News of the good practice has spread, withvisitors from other areas seeking to emulate the ‘Stay and Play’ model.

Although this highlights the possible transferability of this work, one of its limitations isthe extent to which given the same process the same outcomes would result in anotherarea. The project is context specific and care must be taken when applying its methodologyelsewhere. Nevertheless, the methodological quality of this work is enhanced by the use ofmultiple sources of information. Telephone interviews, informal verbal feedback, fieldnotes, health visitor session comments, involvement of mothers within the project groupand written questionnaires provide the triangulation of evidence needed to answer thegroups’ questions. Pursuit of disconfirming or negative evidence via such questions as,‘What are the users and professionals getting out of these sessions?’ also increase theproject’s methodologically quality. Finally, a sincere attempt has been made to reportthese choices transparently (Reason, 2003).

Summary

Overall, ‘Stay and Play’ tells the story of how isolated mothers were supported and helpedand how professionals changed their practice by listening to their clients. It shows howpower and responsibility can be shared to enable all to grow and develop. It illustrateshow a CQI model may be used to facilitate interprofessional learning, and how an actionresearch approach may be complementary to the reporting of this process. The ‘Stay andPlay’ work continues without the external facilitation of Bournemouth University staffdue to the process of empowerment that occurred during the three years of the RIPEproject. It was a lengthy, and at times, anxious and frustrating journey yet is a goodexample of how community development initiatives can work. Through workingtogether and listening to clients, health visitors and other professionals challenged theirassumptions and practice. The positive response to the ‘Stay and Play’ sessions and theirongoing success is testament to the utility of this approach. Importantly, this adds to thegrowing body of evidence that multi-agency working is key to improving the quality ofservice provision (Easen and others, 2000) and counts against scepticism disparaged byHudson (2002).

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Contributors’ details

Keith Brown is currently Head of the Post Qualifying Social Work department at BournemouthUniversity. He has professional qualifications in social work, nursing and teaching and academic



degrees in social work, nursing and management. Previously a senior manager of a social servicesdepartment he has practised in a variety of social work and nursing positions. He facilitated andmanaged the Stay and Play project from beginning to end.

Natasha Young has been a Research Fellow at the Institute of Health & Community Studies,Bournemouth University since 2002. Her research centres on post qualifying social work educationand its impact on practice and practitioners. With a background in psychology she is also involved inteaching on various courses within the Institute. Natasha supported Keith in his management of theStay and Play project.

Dr Steven Keen has a broad based social science background applied to research in the fields ofhealth and social care. After six years as a Research Fellow at the Nuffield Institute for Health,University of Leeds he moved to Wiltshire with his family. He has worked as an independentresearch analyst ever since.



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