This study was the first to explore the use of VRIII in a Vascular Surgery Unit using VRE. The results of this study demonstrated that VRE methodology uncovered the actual and potential hidden complexity in everyday work that encompasses various types of tasks and clarified how it was handled in situ. Engendering healthcare practitioners’ reflexivity helped the researcher to explore how and why some tasks were accomplished in particular ways and to align more closely with the reality of everyday work, the result being a better understanding of WAD while using VRIII. Various methods had previously been used to explore WAD and resilience in healthcare, e.g. field observation, interview, and focus groups [24,25,26]. These methods can partially capture an approach to understanding WAD. However, no studies had been conducted to explore WAD in the use of VRIIIs using a VRE methodology in which healthcare practitioners are involved in reviewing, analysing, and reflecting on their work.
Exploring the use of VRIIIs using VRE
Although the study findings were obtained on the basis of video-recordings of two patients and 10 healthcare practitioners, the use of VRE provided data that enabled analysis of VRIII use, and in turn recommendations to improve its use. A range of strategies to ensure the delivery of patient care was observed being used in the system. These included strategies based on the Safety-I approach (e.g. relying on guidelines) for VRIII, as well as strategies derived from the Safety-II way of thinking (e.g. context-dependent adaptations such as delegating the CBG monitoring task to colleagues when the nurse was busy). Practitioners reported that strategies from the Safety-I approach (e.g. independent verifications) were crucial while using VRIII. They also appreciated the importance of context-dependent adaptations (Safety-II) as a strategy for dealing with unexpected situations to ensure patient safety. This finding broadly supports the work of other studies demonstrating how adaptations are required in everyday work to provide safety improvements and resilience in the system [27,28,29]. It is imperative to highlight that the RHC concept has often been misconstrued, as adaptations have been regarded as being opposite to control, the implication being that the two cannot coexist [30, 31]. This study found that participants used a comprehensive approach based on two principal strategies (Safety-I and Safety-II) to strengthen systems and enhance their resilience and safety.
Previous studies highlighted the impact of using VRE in various clinical settings by demonstrating achievements such as enabling participants to be explicit about their own practices and problems in healthcare-associated infections , developing meaningful solutions for problems in an intensive care unit , and enhancing team capacity to enact person-centred care to improve dementia care . In this study, VRE helped healthcare practitioners to be reflexive and explorative of challenges, acknowledging that the work may need changing and suggesting practical solutions tailored to their work.
The use of VRE highlighted some of the challenges experienced by healthcare practitioners when using VRIII. These related to a lack of clinical knowledge and experience when prescribing the appropriate IV fluids, failure to appreciate the necessity of continuing to administer long-acting insulin, or lack of awareness of the type of fluids available. Rickard et al. identified that 64% of the IV fluids prescribed with VRIII did not have the recommended potassium concentration . This is consistent with what was observed in this study where there was a discrepancy between the fluid prescription and patients’ clinical status. Another challenge identified in this study was the use of the ePMA to prescribe VRIII and IV fluids. This finding is likely to be related to the fact that, prescribers rotate from other organisations, so the ePMA system might be new to them. This explanation matches the conclusion reached in other NHS Trusts, where the initial implementation of the ePMA system was more time consuming than the paper method, although as staff became more familiar with it, the process of prescribing, monitoring, and administering became more efficient .
The study hospital used different ways to improve staff knowledge and enhance patient safety, however, some participants said there was no specific training on VRIII use or its complications. The healthcare practitioners stated that completing the diabetes e-learning module with a pass did not necessarily mean they had gained the practical benefits expected with completing the module. With this in mind, some suggested that face-to-face in-house diabetes and VRIII-focused training sessions, tailored to the practical aspects of their work, would be more effective than e-learning.
Monitoring CBG every hour proved hard to achieve given the increased workload and shortage of nurses. One suggestion could be around providing clearer guidance on an acceptable window for BG monitoring frequency based on the patient’s case and the stability of their BG readings. For example, monitor BG every hour; if four consecutive readings are within the target range, then reduce the frequency of monitoring to two-hourly and return to hourly monitoring if BG moves outside the target range . Therefore, it is crucial that healthcare practitioners themselves define the scope of their work with the clarity needed for harmonised, tailored training and development plans . Understanding WAD and the needs of healthcare practitioners may ease the demand on system resources as well as satisfying healthcare practitioners’ needs.
Given the complexity that was found in the use of VRIII and how unpredictable situations emerged, it is vital to think about using methods focusing on engaging healthcare practitioners to explore the taken-for-granted work, e.g. VRE , in order to understand and investigate complexity in everyday work. Translating these methods into healthcare is difficult to achieve with the resources currently available. The NHS needs a clear shift in its safety strategy towards embedding safety professionals who are aware of the depth and breadth of these methods and are able to act as part of a healthcare system in which they are able to learn from adaptations and adjustments, suggest more context-related solutions and interventions, and engage in system design which will in turn help in realigning WAI and WAD and decreasing the gap between the two [39, 40].
Strengths and limitations of the study
Quality and safety improvement initiatives cannot be understood outside their context, and initiatives can only influence work when healthcare practitioners agree that strategies proposed for implementing these initiatives will improve their work . The novelty of the present study’s use of VRE methodology lies in the fact that its innovations arise from within established work (exnovation), and from within practitioners’ collective sense-making of their work.
This study identified several strategies that might enhance safety in the use of VRIII in the study hospital, including improving electronic prescriptions by providing preparatory training sessions for senior and junior doctors; face-to-face training; and teaching sessions on VRIIIs focused on the practical needs of healthcare practitioners. CBG monitoring and independent verification of prescribing and administering VRIIIs are important strategies for enhancing safety, meaning that attention should be directed towards investing resources in ensuring the consistency and continuity of experienced staff over time. The study’s findings could potentially be discussed with healthcare practitioners, NHS safety professionals and diabetes guideline developers, with a view to exploring the applicability of the suggested solutions and assessing how they might influence future VRIII guidelines and policies.
Patient and public involvement is recommended as best practice. Although there was no patient involvement in this study, healthcare practitioners were proactively involved in the study conduct and analysis, engaged in designing ways to video themselves and patients as well as analysed their work in the reflexive meetings, a process revealing opportunities for improvement by learning lessons from the everyday work that would otherwise remain undetected.
The small number of patients engaged was one of this study’s limitations. Conducting applied research in a busy tertiary teaching hospital was challenging and recruitment relied on the occurrences of acute patient cases, their prompt identification and notification by the study collaborator and the pharmacy team to the researcher.
Reflexive meetings in reported VRE studies were usually attended by a group of participants who had been involved in the video clip [42,43,44]. A hallmark of an effective study is that its method can be adapted as and when necessary to achieve the most promising results [45, 46]. In this study, adaptation needed to be made in relation to conducting the video reflexive meetings because of the COVID-19 pandemic. Although there were initial concerns that having only one healthcare practitioner in each reflexive meeting might limit the depth of the discussion, it was found that healthcare practitioners were very keen to discuss the video clips, openly analyse their work and suggest solutions for improving the delivery of patient care.
Although the number of participants (patients and healthcare practitioners) was considered low, the use of a mixed method approach to explore a specific phenomenon, i.e. the use of VRE in a Vascular Surgery Unit, along with engaging participants in analysis of their own work, enhanced the credibility and transferability of the study findings.
A key concern with using video approaches is the effect they may have on practice and on the communication between the participants and the patients on one hand, and between the participants and their colleagues on the other. Existing literature confirmed that there is no evidence video-recording causes significant alteration to the way participants usually behave [23, 47]. Although at the beginning of the study some healthcare practitioners made some adjustments to their work because of the mere presence of the researcher’s handheld camera, the prolonged presence of the researcher in the field unit helped the healthcare practitioners get accustomed to the camera. Using a chest-mounted camera would likely have made the recording more efficient by enabling hands-free recording and filming from a different angle, without making healthcare practitioners conscious that a researcher was observing and filming their work.
We are aware that the current findings of this study provided snapshots of how VRIII was used to treat elevated CBG. Future work should focus on collecting more data to develop a richer and deeper view of the use of VRIII. Additional studies using VRE need to tap into a wider range of patients and healthcare practitioners across many units in the same hospital used for this study and across different Trusts, to build a more comprehensive understanding of WAD in the use of VRIII and thus better inform policy making and clinical work.