Table 3 Contextual factors for successful implementation and sustainment
Contextual factors | NPT constructs | Successful implementation and sustainment | Supporting quote |
|---|---|---|---|
Organisational buy-in and leadership support | Strategic intentions Reframing organisational logics Collective action: Contextual integration | Organisational buy-in and ongoing support for triage as a standalone department | “I think we’ve done some very bold statements around ringfencing staff, providing medical staff, specifically for that area. So it’s a good demonstration of the support that the organisation is offering to make sure that it works, and I think those things are pretty key.” (Director of Midwifery, site 9) |
Reframing organisational logics Cognitive participation: Legitimation | Senior and middle level management presence in triage, harnessing the hybrid manager role through monitoring and role-modelling | “As a senior leader I do walk through triage daily, if not twice a day, to say, “How’s things?” And when you see the board filling up… And actually I will go and work in triage as part of escalation. So again, rolling your sleeves up, getting in there, just doing what you were told to do – you know what I mean – do another CTG. It helps you to understand. And I think that appreciation with the staff then, that you know how bad it can get… so I think those variety of things have helped with the engagement with the staff.” (Director of Midwifery, site 2) | |
Negotiating capacity Adaptive execution | Releasing resources to enable BSOTS to be implemented | “We’ve obviously been able to get extra staff, we’ve got an MCA [Maternity Care Assistant]. But it wasn’t just given to us, we had to prove it, and we had to go back and get the data to.. It wasn’t just like “We need you to make it better and here’s all the money to do it”. We still had to prove why we needed them and how it was going to improve our data and stuff like that.” (Triage Lead, site 4) | |
Identity of Triage | Reframing organisational logics Negotiating capacity • Collective action: Contextual integration | Clear identity of triage department with protected resources and staffing | “Now we have senior buy-in, the way in which triage is perceived, and the way in which it needs to be protected, redeployed, the staffing challenges… Triage would be the last place that you would take staff from, because that is your front door – you deplete that, you’re opening up risks all over the place. So it’s that shift in understanding, of what is maternity triage. It’s now got its own floor space, its own staffing, its staff are on a separate rota, it’s got its own identity, quantifiable standards that we measure against, to hold it to account. It’s got a matron lead, so that has changed a lot.” (Director of Midwifery, site 2) |
Reframing organisational logics Adaptive execution Negotiating capacity | Moving non-triage activity away from the department | “We’re moving towards, moving with the day care facility – that is moving off, that is in transition as we speak. So that was with us. We also have had the elective work for theatres on here in the morning – that has gone. We also had ladies with a certain condition called hyperemesis here below 16 weeks pregnant – that has moved off to the wards. We still have pre-labourers coming in, and we still have the uptake (if other departments are restricted), labourers as well. And we also have ladies that can’t fit in antenatal clinic for appointments, we have the overflow for that. So at the moment I’m trying to separate everything, because the Maternity Assessment Unit should be a triage area, everything else should not be there. So, I’m getting there.” (Triage Lead, site 3) | |
Reframing organisational logics Collective action: Contextual integration & Legitimation | Triage added to obstetric ward round | “So some of the things we’ve done as early part of our journey is that they start their ward round in triage before they do their delivery suite ward round. That has to be the focus. So raising the priority of triage within the day-to-day running is achieved by doing that.” (Director of Midwifery, site 4) | |
Reframing organisational logics Cognitive participation: Legitimation Collective action: Contextual integration | Clear escalation policy | “I’ve noticed is, just that they take us more seriously. When we say we need help, they take us seriously. Whereas it used to be a sympathetic smile and a “I know it’s busy but you’re doing your best”. Whereas now, if we say “No, we’re breaching” then they prioritise us, and they will get us a midwife from somewhere.” (Triage Midwife, site 4) | |
Capacity and resources | Negotiating capacity | Adequate number of midwifery and obstetric staff to meet the demand/volume of women | “I think the frustration is that we can’t fully implement it because of the shortfall we have in the staffing gaps – and that’s midwifery and medical staffing gaps.” (Matron, site 6) |
Reframing organisational logics Negotiating capacity | Triage telephone being located outside of the clinical area and separately staffed | “The phone is within the clinical area and is picked up by the clinical midwives that are working in the area. So again, that’s another barrier. I know that should be outside of the clinical area and answered via a designated midwife, which hasn’t been something that’s happened.” (Triage Lead Midwife, site 6) | |
Reflexive monitoring: Systematisation, Communal appraisal & Reconfiguration Cognitive Participation: Legitimation | Routine audit and feedback to staff on key implementation indicators and senior leaders responding to the issues identified | “There’s always room for improvement. But I think the audit numbers, in terms of how quickly we’re seeing women and how well we are adhering to the fidelity of the system, are better now than they were. And I think the staff seem definitely happier than they were. And we’re doing a lot better about more continual engagement.” (Obstetric Triage Lead, site 2) | |
Collective action: Interactional workability & Contextual integration | Digitalisation of BSOTS and integration with electronic patient record system | “When it went onto BadgerNet [Electronic Patient Record] – ground-breaking. You opened your care record, you put a triage BSOTS in, you tell them what the complaint is that has brought them in, and it’s all right there by you. You put in everything that you need, and you just have to glance on the side. And it essentially RAG rates them for you. You can just look at what colour they are. Way easier. It works much better with your brain when you’re busy. So it has made it much easier to use.” (Triage Lead, site 2) | |
Increasing Capability | Coherence: Communal specification Cognitive participation: Enrolment, Activation Collective action: Interactional workability & Skill-set workability | Established and trained core triage team with clear roles and responsibilities | “So, for us, I feel like having our core team has been a game changer, and we try and make sure we have one core member on every shift. So that if we’ve got a rotational member of staff or a bank member of staff or whoever else it may be, that they’ve got somebody who really knows how it should work.” (Triage Lead Midwife, site 4) |
Coherence: Communal specification Collective action: Skill-set workability | Obstetric team trained prior to working in triage | “Since the relaunch you could actually say to any doctor now, because they’ve been made to do the training, and be like “She’s orange” and I’ll know what they mean, it means… Pre the relaunch, you wouldn’t even bother, because you know they wouldn’t… it doesn’t mean… it didn’t mean anything to them. We knew, and we would action it, but you couldn’t say to someone “Oh I’ve got three oranges and a green” because they’d be like “What?” Yeah, so again, only recently now it’s complete sense to someone and they’d actually know what to do.” (Triage midwife, site 7) | |
Triage environment | Negotiating capacity | Sufficient clinical space and number of rooms | “So, our space is reasonable. We’re lucky, we have seven rooms, and they’re seven individual rooms. But there are times that we overflow from that, probably, as I say, once or twice a week. And I don’t think at the moment there’s any way to extend or expand that from just where we are on estates point of view. There just isn’t a practical way to grow it anymore. But we have grown – we used to have four rooms and we’ve now got seven, so they’ve acknowledged the need for space.” (Triage Advanced Clinical Practitioner, site 2) |
Negotiating capacity | Appropriate waiting area for women | “So, literally, women and their partners or families will come in, check-in to reception, go through to the room to be triaged, and then wait in a waiting area, which is now observed continuously. So that’s quite a big piece of work from the environment perspective.” (Director of Midwifery, site 3) | |
Negotiating capacity Collective action: Interactional workability | Adequate equipment and IT systems | “Again, it was just nice to have a focus on MAU [maternity assessment unit] and realise that this is important too. Not that it wasn’t, but it’s just nice to have the spotlight and have a bit of focus on that area … We had a bit of a focus on new equipment, more equipment, better printers for requests. And it’s all been a bit of a change the past 12 months.” (Triage Midwife, site 7) |