Implementing person-centred key performance indicators to strengthen leadership in community nursing: A feasibility study.

AIMS
To explore the utility and feasibility of implementing eight person-centred nursing key performance indicators in supporting community nurses to lead the development of person-centred practice.


BACKGROUND
Policy advocates person-centred health care, but few quality indicators exist that explicitly focus on evaluating person-centred practice in community nursing. Current quality measurement frameworks in the community focus on incidences of poor or missed opportunities for care, with few mechanisms to measure how clients perceive the care they receive.


METHODS
An evaluation approach derived from work of the Medical Research Council was used, and the study was underpinned by the Person-centred Practice Framework. Participatory methods were used, consistent with person-centred research.


RESULTS
Data were thematically analysed, revealing five themes: giving voice to experience; talking the language of person-centredness; leading for cultural change; proud to be a nurse; and facilitating engagement.


CONCLUSIONS
The findings suggest that implementing the eight person-centred nursing key performance indicators (KPIs) and the measurement framework is feasible and offers a means of evidencing person-centredness in community nursing.


IMPLICATIONS FOR NURSING MANAGEMENT
Person-centred KPI data, used alongside existing quality indicators, will enable nurse managers to evidence a high standard of care delivery and assist in the development of person-centred practice.


| BACKG ROU N D
In a move to broaden perspectives of quality in global health policy, there is an increased focus on humanizing health care, foregrounding patient and carer experiences (Picker Institute Europe, 2014;World Health Organisation (WHO) 2016;Department of Health, 2016).
This has positioned person-centredness alongside safety and efficiency in many national and international policies and recognizes person-centred care as a core competency in the health care workforce (Nursing & Midwifery Council, 2018;WHO, 2005). Evidencing quality care in community nursing services has become a leadership imperative; however, it is little explored (Maybin, Charles, & Honeyman, 2016).
In the UK, current quality measurement frameworks in the community focus on incidences of poor or missed opportunities for care (e.g. falls, pressure ulcers, infection rates), generated through national data sets, perhaps accounting for the invisibility of community nursing reported in the literature (Maybin et al., 2016;Queens Nursing Institute, 2017). This narrow view of quality standardizes practice across health care organisations and disciplines, often without incorporating individual experience of care (Foot et al., 2014;Horrocks et al., 2015;Kaehne, 2018). Rather than capturing person-centredness, quality indicators serve to create a negative view of evaluation within community nursing. To add to this, less robust reporting mechanisms in the community, when compared to hospital settings (Foot et al., 2014), mean data are not locally owned or used to improve care experiences for service users, consistent with new service models.
Community nursing does not always lend itself to clear-cut short-term clinical outcomes in the same way as a defined episode of care for an acute illness, and consequently, Horrocks et al. (2015) proffer indicators cannot be used 'off the shelf'. Care is often long term, aimed at prevention or promotion of health and well-being.
New models of care rely on strengths-based approaches, tapping into and promoting social capital. Models such as the 'House of Care' (Coulter, Roberts, & Dixon, 2013) encompass person-centred thinking, purposefully moving away from traditional ways of working, often viewed as reactive, fragmented models of care. However, more proactive, holistic and inclusive perspectives of care are difficult to measure. Finding ways to evaluate person-centred practice in the community must therefore be prioritized.
An alternative set of eight nursing key performance indicators (KPIs) was developed by McCance, Telford, Wilson, MacLeod, and Dowd (2012) that were sensitive to the unique contribution of nursing and focused on improving patient's experience of care. The eight KPIs, which are presented in Table 1, are considered novel in the context of the existing evidence base and are different from the other quality indicators generally used. The eight KPIs were also person-centred in their orientation as evidenced by their align-

| ME THODS
The overall aim of this study was to explore the utility and feasibility of the eight person-centred nursing KPIs and measurement tools in supporting community nursing teams to lead the development of person-centred practice in community contexts. More specifically, the objectives were to: • Strengthen collective leadership of community nurses through the implementation of the KPIs.
• Establish how the KPIs can be used to support community nurses in using evidence to inform their practice.
• Establish views of key stakeholders on the appropriateness and relevancy of the evidence generated by the KPIs as a measure of quality of service provision.
• Test the usability and feasibility of the iMPAKT App for data collection in community contexts.

| Setting and sample
Teams from different community settings were invited to participate from two health care organisations in the UK, using purposive sampling. Clinical partners, who were co-researchers, disseminated study information and were available to discuss the study. A total of seven nursing teams from different community settings were recruited on a voluntary basis comprising three district nursing teams, two health visiting teams and two family nurse partnership teams (Table 3).
In order to test the KPIs and feasibility of the iMPAKT App, the study was designed to involve the recruitment of patients/clients, partners and carers. Given the potential vulnerability of patient/ clients and children within these community settings, there was detailed discussion with the participating teams on the inclusion and exclusion criteria for the purposes of this feasibility study. It was agreed that there would be no involvement of families where there were any active child protection issues or patients who were at the end of life.

| Data collection methods
Participatory methods consistent with person-centred research were used, emphasizing that knowledge is not linear and causal but co-created through the relationships we engage in as human beings (McCormack & McCance, 2017). This method was chosen because it promotes a co-operative approach to evaluation, working with people rather than on them, and is based on the premise that the involvement of key stakeholders will develop ownership of the process. Active participation and co-creation were evident in the four phases of the study, which are presented in Figure 1.

TA B L E 3 Overview of participating sites
Data were collected until saturation of common themes was reached.
Feedback from the preparatory workshops led to a revision in two of the measurement tools within the iMPAKT App. The first related to the language within the surveys, which was revised to suit clients being cared for by the different teams; and the second to the observations of practice, which were developed as an activity log, recording time spent in direct client contact, either as a home visit or as telephone contact. Agreement was also reached on the data collection timeline and focus: the timeline for one cycle of data collection would be over a 6-week period where teams would gather a minimum data set of: 20 patient surveys; three patient/family stories (undertaken by the researchers); 10 record reviews; and completion of five activity logs for five members of staff over 5 days. During the second phase of the study, teams decided how and when they would collect data, with support from the research team. During the evaluation workshop, they generated their own action plans following their own analysis of the data. Data generated during each of the collaborative phases and also from the cycle of data collection using the iMPAKT App were included in the analysis.

| Data analysis
Data generated over one cycle comprised a total of 170 surveys, 11 activity logs, 20 record reviews and 11 stories. All the data were uploaded from each clinical setting using the iMPAKT App, and reports related to each of the KPIs were generated and downloaded. An inductive approach was used to analyse the data from the evaluation workshops, aligned to Braun and Clarke's thematic analysis (2006).
The study involved a considerable volume of data of high quality, and the data were sufficient to address the research question. Data comprised both the workshop reports and transcriptions from both focus group sessions. Analysis was undertaken within the project team across both sites. Members of the project team reviewed both workshop reports and transcripts individually, then as a group. Following critical discussion, themes were agreed, which are discussed in Results section.

| Ethical considerations
Key ethical considerations for this study focused on: ensuring voluntary participation and gaining informed consent; assuring anonymity and confidentiality for participants where appropriate; dealing with any unforeseen ethical issues such as disclosure of poor or dangerous practice; and protecting those who are vulnerable through, for example, the use of exclusion criteria and development of a distress protocol. The ethical approval process was led by one of the principal investigators in their jurisdiction, and research governance processes were followed to secure governance approval in each clinical site.

| RE SULTS
Some teams experienced difficulty in collecting a full data set during the implementation, which was explored further during the evaluation phase and is considered in Limitations section. Participants revised the measurement framework during the initial preparatory phase, and this contributed to increasing the level of consensus on the appropriateness and relevance of the eight KPIs. Participants' experiences of implementing the person-centred KPIs using the iM-PAKT App, the usefulness of the data to develop practice and the overall experience of being involved in the project were articulated through the identification of five themes: giving voice to experience; talking the language of person-centredness, leading for cultural change; proud to be a nurse; and facilitating engagement.  There was agreement between participants that they wanted to continue using the iMPAKT App. They discussed how they could help other community teams facilitate this work, to share the potential of implementing the person-centred nursing KPIs and the value in sharing responsibility for developing practice.

| Leading for cultural change
I would say we could even maybe go out to DNs and help to support them and say 'listen we have done this and we are also lone workers and we thought it was going to be really hard but look at these benefits'. We could help to support colleagues in different fields and say you know it really isn't that hard or as difficult as you think.

| Proud to be a nurse
Practitioners' sense of pride emerged strongly, and they talked of feeling proud to be a nurse. Staff felt valued by their team and importantly by clients and families. Seeing the complete data reports gave teams a real 'boost', and it was affirmation they were making a difference to people's lives. An example from one team's report is provided in the snapshot from the App in Figure 2 below.
As a nurse and as a manager you know seeing that report it actually makes me feel really proud to be a nurse and also for pride of the teams as well you know so we need to acknowledge this and keep the momentum going. Even if the feedback wasn't that positive, it still gives you the chance to fix things and discuss with the rest of the team it will also give us the chance to bond and come together with a shared purpose.

Box 1 Action planning
• Take the KPIs away to put up in the office for everyone to see.
• Use this as a philosophy, that is what we are about.
• See the potential in this work, but we understand that we need to build up the team to see the same buy-in.
• Take the findings/report to our next team meeting.
• Try and do some stories ourselves? Monthly? Open questions on paper and get clients to complete?

| Facilitating engagement
Participants initially felt apprehensive in commencing data collection. There was a general feeling of nervousness, with staff feeling the research could potentially become extra work for them, amongst other competing priorities. Ongoing support from both the project team and fellow peers within practice allowed participants to engage in data collection using the iMPAKT App.
At the start it was quite scary but with practice and the right support it has been very good and as you say it's been like a journey and one which I would be happy to repeat.

(FG2 FNP2)
External facilitation was necessary to help teams feel comfortable with using the iMPAKT App. Common themes arising from both the preparatory and evaluation workshops included the following: panic about technology; challenges in accessing the Internet; and not receiving reports in real time. There was also discussion on the relevance of the four measurement tools, which is summarized as follows: • Surveys and stories were considered appropriate and useable.
• Record review questions were considered more appropriate for recording nurses' knowledge of what was important to service users, but less so for consistent delivery of care against identified need.
• The activity log was considered very insightful, but would be enhanced if the iMPAKT App could take account of communication by text (evaluation workshops).
Journeying through the chaos was how participants described their own story of progressing through the project. What made it possible was adopting a team approach, finding ways of integrating data collection into their working day. As they felt enabled, they began to place value on the process.

| D ISCUSS I ON
The primary aim of this study was to explore the utility and feasibility Evidence, leadership (as part of context) and facilitation were recognized as key elements to bringing about changes in practice by Kitson, Harvey, and McCormack (1998)  There were significant challenges for some teams who were unable to collect the required amount of data, despite agreement about the usefulness of the KPIs and the iMPAKT App. This also links to how the implementation process was supported. Although facilitating engagement suggests the support offered to participants was key to the success of this project, little attention was paid to facilitation expertise in the teams. Facilitation is viewed as the active ingredient in the iPARIHS framework that operationalizes the implementation of evidence. This is planned in response to the focus of the innovation or change matched with the needs of the recipients of that change, whilst acknowledging the context in which the change is being implemented. Whilst as facilitators we were able to determine the needs of participants in the context of the change being implemented (i.e. the use of the iMPAKT App), we had little ability to influence the contexts in which the App was being implemented.

| Limitations
The small-scale nature of this feasibility study suggests that results should be generalized with caution. The lengthy ethical and governance approval process alongside issues with the readiness of the iMPAKT App reduced the time participants had to participate in the research. Not all teams managed to collect the required amount of data, although representatives from all teams agreed about the usefulness of the KPIs and the iMPAKT App. Only one cycle of data collection was possible, and the reports were not available in real time due to ongoing technological issues. There was an issue with the activity log component of the iMPAKT App where data did not save accurately to the master dashboard; however, teams kept a paper log of their activity for this component.

| CON CLUS ION
This study, conducted as part of a larger programme of research, has further shown the utility and robustness of the person-centred nursing KPIs and the measurement tools for use in community nursing. By adopting a collective leadership approach, teams were able to work together to decide on the data relevant for their practice area. There is potential for the iMPAKT App, which is considered user-friendly and easy-to-use, to help teams gather a range of data, privileging the voice of the service user. Facilitation is an important ingredient in strengthening leadership, which is central to enabling teams to work together to improve person-centred practice. In conclusion, this feasibility study provides many positive insights into the process of implementing the KPIs and accompanying measurement framework using the iMPAKT App, and provides a basis for considering a larger scale testing in the future.

| IMPLI C ATI ON S FOR N UR S ING MANAG EMENT
Person-centred KPI data, used alongside current quality indicators, provides an added layer of knowledge demonstrating how teams are working collectively to enhance the experience of care. The data generated can assist in the development or evaluation of new service models ensuring teams are working in line with key national policies surrounding person-centred care. It will allow nurse managers across different contexts to illustrate to key stakeholders how teams are working to deliver a high standard of care to people and how this care is being perceived by clients. Involving and engaging nurses at all levels in service development has been shown to enhance morale, teambuilding and leadership, creating the conditions for a flourishing workplace environment.

ACK N OWLED G EM ENTS
The authors wish to acknowledge all the staff across the participating organisations who committed time and energy to ensure the success of this study.

E TH I C A L A PPROVA L
Ethical approval was sought and granted in line with research governance framework requirements across all jurisdictions. The ethical and governance approval process was led by Ulster University for all sites within the UK (Ulster University Ethics Committee,