Photo credit: Creative Commons 0, Public Domain, via Pixabay.
Judith Dixon is a nurse and health visitor for the National Health Service Tayside in Angus, Scotland. She and a team of nurses conducted a QI project through the IHI Open School Quality Improvement Practicum as part of the Early Years Collaborative, a partnership between IHI and NHS Scotland, to improve rates of play among parents and babies in their district. I asked her a few questions about what she learned. (Learn more about the Open School Practicum, which is now available to professionals as well as students, here.)
How did you first become interested in QI?
In the nursing profession, we’re always encouraged to reflect on our practice and make improvements that will benefit our families. So I think it is something that is an inborn part of me!
But I hadn’t really had the opportunity to learn and implement PDSA cycles and quality improvement before taking part in the Early Years Collaborative (EYC). It was really inspiring to attend the kick-off events in Glasgow and hear from other practitioners about how small changes in practice can have such a dramatic impact on children’s lives — as well as how important the early years are.
How did you come up with the idea for your project?
I came up with the idea at one of the EYC events in Glasgow. The team from Angus, Scotland, was talking about the number of resources that are given to new parents by health visitors. We wondered how well parents were using resources such as play@home, which is a kit of play activities for parents to do with babies and toddlers.
This led me to question my own practice in distributing play@home. At that time, I would normally have given the resource at the first home visit. This would be just after the baby is 10 days old.
Reflecting on this, I realized that this is a time when new parents are often overwhelmed with anxieties, such as feeding and settling baby. A significant amount of important health promotion materials are given at this time. How could I expect parents to fully take in the purpose and benefits of play@home at this first visit?
This led me to look at an evaluation of play@home by the University of Wolverhampton in January 2013, which in fact showed that some parents could not remember if they had been given play@home and very few vulnerable parents had been given additional support to use it. The evaluation recommended that the role of the health visitor might be to distribute and monitor play@home. So this is exactly what I decided to look at within my locality.
What were your ideas about changes that might lead to improvement?
The first thing that I decided to do was to wait until I felt that parents were ready to engage before I would introduce play@home. This varied between three to six weeks after the baby was born, and I really used my professional judgment on the timing. There was no point in introducing the resource if parents were completely consumed with anxieties or by lack of sleep.
Then I started to think about how I could introduce the resource in a meaningful way to interest parents. I had just completed a training on the importance of brain development and attachment, so those issues were forefront in my mind. I realized that play@home is such a great resource to promote this.
I decided to develop a tool to introduce play@home — a fact sheet to generate discussions around baby brain development and attachment by highlighting some key statements and questions. For example:
- As a new mother, have you thought about baby’s brain development and how you can help it?
- Do you think nature or nurture has the most important impact on a baby’s brain development?
This question led to interesting discussions around how baby brain development is like building a house, and how play@home can be used as the building blocks.
I then invited parents to look at play@home and choose some activities that they would enjoy with their baby.
At key points in the child’s first year — six weeks, three months, and eight months — I returned to the discussion points. I would discuss the benefits of play@home again, but more importantly I found that parents really took pride in their baby’s development and telling me what play activities they enjoyed.
What was the biggest surprise in doing the project?
Small changes in practice can really make a big difference. Sometimes we are so busy that we forget to step back and really think about what we are doing!
What did you find most gratifying about the work?
It was really gratifying to see how well the parents engaged in using play@home and how parents enjoyed playing with their children.
But I also enjoyed learning new skills around data collection. I can now format a line chart. I scored parental knowledge and use of play@home depending on the number of play activities they were carrying out from the resource. It was really rewarding seeing the data from the project on a run chart, which demonstrated the effectiveness of a new approach to delivering play@home by health visitors.
What did you learn from working on an interprofessional team?
We are all striving to improve outcomes for children. By working together, the impact of any quality improvement intervention should be greater. We cannot achieve anything by working in silos!
The play@home project has highlighted the resource to other professionals. For example, some physiotherapists have reported they are now promoting activities within the resource to improve children’s gross motor skills. Perhaps this will becomes the next test of change.
If you had the chance to start your project all over again today, what would you do differently?
It’s difficult to say as it has been such a learning process all along the way. Sometimes it felt like taking three steps forward and two back.
I think before embarking on any project I would now think much more carefully about data collection. It’s not always easy to show evidence of improvement on a run chart. But it has made me realize that it is really important that quality improvement has evidence to support it.