Scaling up an intervention to protect preterm infants from neurodevelopmental disabilities: findings from a qualitative process evaluation comparing standard with enhanced quality improvement support packages for maternity units in England

Sabi M Redwood*, Christalla Pithara-McKeown, Tracey J Stone, Emma J Treloar, Jenny L Donovan , Karen Luyt

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

3 Citations (Scopus)
28 Downloads (Pure)

Abstract

Background
A quality improvement strategy (PReCePT) was used in a standard and enhanced format to scale up a clinical intervention (administering magnesium sulphate to women in preterm labour) across all maternity units in England to protect prematurely born infants from neurodevelopmental disabilities. Formal evaluations reported the effectiveness of the standard package alone in increasing the administration of magnesium sulphate. In this paper, we focus on the findings of the process evaluations, using normalisation process theory to explain how different implementation contexts generated the observed outcomes relating to normative and relational restructuring and sustainment.

Methods
Interviews were conducted with key individuals in implementation of leadership positions nationally and locally. Interviews were analysed initially using the framework method. We then engaged recursively with NPT constructs to generate generalisable insights with pragmatic applicability in other settings.

Results
In total, 72 interviews were conducted with good representation from units across England and staff from the National Academic Health Science Network. We found that all units irrespective of whether they received a standard or enhanced QI package were successful in the ‘normative restructuring’ of their setting to enable magnesium sulphate to be administered. This suggests that this implementation outcome is necessary to achieve improvements. However, it may not be sufficient to sustain the changes once additional resources have been withdrawn. Sustainment, our findings suggest, required ‘relational restructuring’ to accommodate altered workflows and facilitate the sharing of responsibilities and tasks in daily practice. Relational restructuring was more likely to have been achieved units receiving enhanced QI support but also happened in units with standard QI support, especially in those where perinatal team working was already well established.

Conclusion
Unlike other large QI-focused spread-and-scale programmes which failed to show any impact on outcomes, the PReCePT programme in both the enhanced and standard support packages led to improvements in the uptake of magnesium sulphate. The findings suggest that QI programmes interact with the enabling factors, such as strong interprofessional team working, already present in the setting. A standard package with minimal support was therefore sufficient in settings with enabling factors, but enhanced support was required in units where these were absent.
Original languageEnglish
Article number19
Number of pages11
JournalImplementation Science
Volume18
Issue number1
DOIs
Publication statusPublished - 24 May 2023

Bibliographical note

Funding Information:
We would like to thank all the participants who contributed to the evaluations. We also owe a debt of gratitude to BLISS, a support organisation for mothers experiencing preterm births, and two mothers, Elly Salisbury and Monica Bridge, who had experienced preterm births and were involved in the delivery and evaluation design of PReCePT. We acknowledge the Health Foundation and the West of England Academic Health Science Network (in particular Natasha Swinscoe and Ellie Wetz) for their support and guidance; the AHSN Network (in particular Gary Ford for leadership and guidance); Anna Burhouse for her continued input and inspiration; QI coaches Noshin Menzies, Vardeep Deogan and Hannah Bailey; Jo Bangoura for producing the PReCePT QI toolkit; and all local implementers in maternity units in England. This work would not have been possible without the expert evaluation project management from Elizabeth Hill and Pippa Craggs who we thank for their support.

Funding Information:
The National PReCePT evaluation was jointly funded by the National Institute for Health Research Applied Research Collaboration West (NIHR ARC West, core NIHR infrastructure funded: NIHR200181) and the AHSN Network funded by NHS England. The Health Foundation funded the PReCePT study (Funder’s reference 557668). This research was also supported by the National Institute for Health Research (NIHR) Applied Research Collaboration West (NIHR ARC West, core NIHR infrastructure funded: NIHR200181). The views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Publisher Copyright:
© 2023, The Author(s).

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