Acceptability of the AI intervention
Participants discussed aspects of the AI intervention that they liked and areas for improvement related to both the AI process and AI sessions.
Views on the AI process: A refreshing approach to change
Participants liked the AI process, enjoyed participating in it, and found it a valuable way to approach practice change. The AI process was considered distinct from typical change initiatives and appealing in its atypicality:
It's usually, 'here's what we're working with, what can we change' as opposed to 'this is what you guys are doing and doing well, how can we expand and make it better...than what it already is'. It was actually for a lot of us, I think it was quite exciting to have this sort of study being done as opposed to the usual ones that we do. (Interview 09, p. 1, lines 22-25)
Some participants indicated that they would readily participate in another AI intervention or that it would be fitting for other interventionists to assume an AI approach. AI was considered a clinically useful intervention because it was applicable to other areas besides pain. It was characterized as a refreshing approach to change due to its positive approach, democratic nature, and focus on expanding on existing practices.
The positive approach of the AI process
It's good in the way that it acknowledges what we're doing right and the strengths that we have and then it just helps us to strengthen whatever it is that we're already doing well into something better, and I really like that part of the whole process. (Interview 05, p. 1, lines 12-14)
Participants repeatedly praised the positive approach of the AI process, which included giving attention to strengths and successes in their unit related to pain and other clinical areas. Engagement in AI was described as rewarding, motivating, and empowering. Although the group liked holding a positive focus through the AI sessions, this task was not necessarily felt to be effortless; it was perceived as a novel approach in a context (i.e., society and work environment) that was more attentive to the negative. Acknowledging issues and challenges was considered important to avoiding negative sentiments around maintaining a strictly positive focus:
Like even though we were talking positive, positive, positive but we were looking at all the negative aspects and trying to make that positive. So I don't think that anybody in the group actually felt anything different or felt negative about only talking about positive and not the negative aspect of what we do on the floor. (Interview 08, p. 2, lines 6-9)
The democratic nature of the AI process
There was widespread enthusiasm about the democratic nature of the AI process amongst participants, but especially from the staff nurses. Staff nurse participants often contrasted the AI process to the more dictatorial approaches to change (speaking explicitly about being 'dictated to') that they were accustomed to in the unit:
I don't know of any other [approaches to change] other than being sort of told what we should do. And this was a nice, refreshing approach to collecting information. I think it worked well because like I said, I was very impressed with it because I guess a lot of times when we're the ones that are actually doing the work, we're not the ones that are asked questions about what we should be doing or how we should do it-we're being told what we should do, right? And it's nice to be able to give the input because a lot of us, like I said have many years of experience and knowledge behind this stuff...and it does support, you know, the changes, you know? (Interview 06, p. 6, lines 28-45)
Staff nurse participants discussed their appreciation of being involved in the AI intervention from the outset and the equal participation of staff nurses and nurse leaders alike. Being leaders of the change was relished, and the experience of working together as equals in a group was described as fun, exciting, and rewarding. Implementing the action plan in their unit without outside assistance was considered empowering; overall, a continued relationship with the facilitators was not desired, as participants felt they had enough support amongst themselves to enact the plan. The nurse leaders spoke of the benefit of involving staff nurses in the change initiative, including the value of gaining contributions from those who would use the practice, their ideal position in the unit to defend the change to their colleagues, and the positive influence on their professional esteem.
Despite the increased workload associated with this approach, some of the staff nurse participants remarked that it felt less burdensome relative to more dictatorial initiatives; the load of change was lightened by the fun associated with their involvement in the initiative, not being told what to do and how to do it, and working with their colleagues and the nurse leaders. However, one of the novice staff nurse participants noted that the responsibility of implementing the plan was challenging to manage due to time constraints. She used protected time from another role she assumed in the unit to implement her audits and felt that, although it was likely not practical and might be unacceptable to others, implementing the action plan outside of work time might be easier.
A focus on expanding on existing practices
Expanding or improving on existing unit practices, rather than implementing something entirely new, was viewed as a practical and realistic way to approach change. Overall, participants noted that expanding on existing practices eased and supported their implementation of the action plan as an independent group; they were already doing the practice and were therefore confident about the change they were putting forth. However, another participant noted disappointment around the topic choice of pain assessment documentation for this very reason, stating that it 'wasn't a far stretch to implement it on the unit' (Interview 02, p. 3, line 5). The prospect of implementing a new practice, while not impossible, was seen to be a bigger challenge that could be facilitated by the positive approach:
I think the biggest, the most key thing in this whole study was that it was an actual positive approach. It was...no matter what it was or how familiar we were with it or unfamiliar or how new or old, I don't think that matters. I think the fact that we've taken something that we're already doing whether it's something fairly new or something that we've, you know...done forever, taking that and just expanding that no matter how big or how little, I think it's that positive approach to change that makes the difference. (Interview 09, p. 6, lines 27-32)
The AI process was also considered a means to build on existing ways of practicing in the unit. Participants purposefully developed pain assessment documentation audits that were delivered colleague-to-colleague. Informal interactions with their colleagues were considered a natural and usual way of addressing practices in their unit. As one participant said, 'Just talking about improving practices and that kind of thing, like we do it everyday' (Interview 05, p. 13, lines 18-19).
Views on the AI sessions
Participants' views on the AI sessions were organised into three themes, including the structure of the sessions (i.e., number, frequency, and duration), nature of the group (i.e., group size, mix, and dynamics), and facilitator partnership.
Structure of the sessions
Overall, participants liked the number, frequency, and duration of the AI sessions. The duration of the AI sessions was cited as generally satisfactory and an important element of the intervention design, with one participant stating, 'I felt comfortable sharing my thoughts and views and I don't think that would have been possible if it felt very rushed' (Interview 07, p. 15, lines 32-34). An exception was the AI session addressing the Design phase, which participants felt required more time due to the nature of the activity; everybody had contributions to the Provocative Proposition (Table ), and the group was intent on creating a statement that was an accurate reflection of their thoughts and intentions. Participants suggested that a practical solution to accommodate the need for more time was to add an AI session, rather than lengthening each one.
There was general disagreement around the acceptability of the full-day AI session that covered the Discovery phase in the morning and the Dream phase in the afternoon. Some participants thought it was a good day because, 'It focused on what we did well and wanted to do better' (Interview 05, p. 8, line 16); they felt the material was fresh in their minds, and they liked reducing the number of session days. More commonly, however, participants found it to be a long day, tiring, and not as productive as a result. The nurse leaders found the full day to be too long because they were also working during the AI sessions.
Keeping the sessions closely spaced was considered essential to maximizing continuity and minimizing disassociation from the content and process of the AI sessions. Emphasis was placed on the cumulative nature of the AI sessions. Overall, participants indicated that they liked completing the AI sessions within a two-week period and felt that decreasing the frequency to even one session per week might make it too long and compromise their productivity. However, there was a tension between the theoretical preference for closely spaced sessions and the practical realities imposed by the work environment:
[The spacing of the sessions] was good that way because it didn't...we didn't have much time between each session which was the good part because all the stuff that we talked about in the session before, it was quite fresh in our minds. I think if we had done once a week it would have taken us a little bit longer to get back to where we were...when we did the previous one. On the other hand, having them that close together is hard because you have to do it on your days off. And it's hard to get...I mean it's a pretty big group and it's hard to get everybody off at the same time without compromising...the unit. (Interview 09, p. 15, lines 13-22)
Nature of the group
Overall, participants were satisfied with the size of the group. A fine balance was noted between group size and productivity, with a recurrent view that the size was at its maximum in terms of effectiveness: More people would have meant more opinions, which might have become unmanageable. Based on the plethora of opinions expressed during the AI sessions, one participant felt that the group size was too large. She acknowledged that the larger group was helpful for implementing the action plan but that a smaller group could have selected a smaller area for change. However, it was more commonly noted that there was strength in numbers, which was important for bringing the change to the unit.
And they knew quite a few of us were interested in it so I think having us act as leaders and being involved and interested, it showed that 'why are they interested in that? Well maybe I should be too.' And I don't know, I think it really...that sort of thing works well on our unit - just having the numbers sort of speak for themselves. (Interview 12, p. 8, lines 44-46; p. 9, lines 1-3)
The value of the relatively large group size was often discussed in the context of group mix. The diversity of experiences and professional roles in the group was considered an asset to the AI sessions and potentially compromised by involving fewer participants. Several participants noted that the group dynamic was one of equality with open communication. Techniques used by the Process Facilitator were felt to promote this dynamic, including individual, paired, and group approaches to activities and addressing the quieter participants by name. Staff nurses highlighted the value of the positive focus for easing discussion around their practices and unit in the presence of nurse leaders:
And the way that everybody framed the sentences also was again to reflect more the positive than the negative because as [the Process Facilitator] kept on saying...'think about the positive aspects, we are not here for the negative ones'. So that again influenced the way we brought information out to the table without having to fear that my [nurse leader] is sitting here or my [other nurse leader] is sitting here. (Interview 08, p. 14, lines 19-23)
The partnering of the Process and Content Facilitators and their distinct roles were emphasised as being essential to the AI sessions. An important aspect of the Process Facilitator's role was her provision of theory-based information on the AI process in simple language. The Content Facilitator was viewed as contributing pain-related information and, as one participant articulated, 'a practical sense of what we do on the unit' (Interview 10, p. 22, line 5). Their partnership was valued because they contributed different perspectives, ideas, and experiences to the group. Their good and complementary relationship was considered influential to group functioning and the prevention of conflict.
In light of the group size, one participant noted the value of having a back-up facilitator who could focus on recording the results generated in the group discussions. Recording results on large sheets of paper in real time was considered a valuable design feature of the AI sessions as it facilitated the development of ideas, focused the group, provided reminders of material covered, and gave an overview of the contributions of the team. Other facilitator-led features of the AI sessions that participants felt enhanced productivity were the Process Facilitator providing summaries of the activities before the sessions and handing out synopses of the discussion points from the previous session to start the next session.
Fidelity of the AI intervention
Consistency of intervention implementation with the elements of the AI process
The Process Facilitator delivered all 23 activities (100%) outlined in the intervention manual as designed over the four 3-hour AI sessions. Beyond delivering the essential elements, the Process Facilitator repeated and clarified explanations and instructions around the AI process, answered participants' questions related to AI, and facilitated the development of ideas.
Nurse participants' perceptions of the factors that interfered with intervention implementation
Participants described several barriers that adversely affected their participation in the AI sessions and the implementation of the action plan in the unit, including change overload, logistics, busyness, and a lack of organised follow-up. There was often a divide in perspectives on barriers between the staff nurses and nurse leaders. Overall, participants stated the implementation of the action plan was a discrete event limited to the outlined tasks that was implemented in full and as planned.
The thing is when we were trying to implement it, it was a really tough time because there were so many things on the unit that were changing...[the] IV pumps, the whole change of the computer system. It was just everyone was going through change overload. (Interview 05, p. 6, lines 1-3)
A context of change in the unit during the implementation of the action plan was attributed to several concurrent hospital initiatives, including the introduction of new intravenous pumps and a computer system, as well as staff nurse orientees. While some staff nurse participants indicated they felt no effect of the hospital initiatives on the implementation process, the widespread sentiment was that they slowed their progress; however, this was largely attributed to the impact of the changes on a nurse leader, rather than on themselves:
And I think that's where we ran into that issue about not being able to get our [education module]...the email sent out on time...because whoever was doing that was dealing with IV pumps and it was just ...it was a bit too much from that end I think but from our end because we weren't all...all of us were not that involved with the IV pumps, I think you know if we got the email out we would have been able to stick to [the timeline]. (Interview 09, p. 24, lines 13-17)
In spite of this transient context of change, participants noted that the long-standing culture in the unit was one of 'passion for pain management'. In general, they felt this culture facilitated their participation in the intervention sessions and supported their implementation of the action plan in the face of contextual barriers. Other cultural features outside of pain considered to make their unit a favorable setting for the AI intervention included a sense of curiosity in the unit around new initiatives consequent to it being a teaching hospital; the fact that it was a 'fairly young unit, a kid's hospital, we like to have fun and stuff like that, and people are fairly positive on the unit anyways' (Interview 02, p. 13, lines 26-27); a dynamic of equality and teamwork; and a sense of autonomy amongst the staff nurses.
Organisational details, like summer holidays, were cited as interfering with the implementation of the action plan. Staff nurse participants mainly discussed the effects of a delay resulting from a nurse leader delivering late on an early phase of the action plan. This caused mild frustration on the part of some staff nurses, who felt it decreased their momentum. Others expressed understanding that the delay was a function of the nurse leader's workload, which was compounded by the unexpected leave of a participant meant to be her support for the task. One staff nurse participant noted that this delay was a judicious decision given the context of change:
There were so many things all at the same time... that I think that's why [nurse leader] decided to hold back ... because otherwise you do get, you know people not doing it...there's not compliance, they don't care, you know it's just too much all at one time, yeah. (Interview 06, p. 23, lines 7-9)
Ultimately, some staff nurses reported that they pushed forward with the plan in spite of this delay to stay on target with their deadlines. Conversely, the nurse leaders tended to focus on the logistical barriers of their professional roles and practice. They indicated that the structure of their schedules and nature of their responsibilities made it difficult to free up the time for the AI sessions. For example, one nurse leader noted,
From my perspective it was kind of hard to be away from what I had to do because it was different...like for the staff nurses it was actually off-days. So they came in on an off-day to do it...where as I would have to leave my stuff, my duties for that day to go and be away for a period...I couldn't stay for the whole [full-day session]. I had to leave for a bit of it. Because it was part of my workday and it was just...I tried to see if I could free myself up for that time but I couldn't. (Interview 10, p. 8, lines 39-42; p. 9, lines 25-26)
They discussed the inconsistency of their participation with some frustration, and one nurse leader emphasized that it was unfair to the staff participants. A staff nurse participant echoed this sentiment and felt that all participants should be expected to maintain an equal and full level of participation in the AI sessions.
Participants' discussed their perceptions of juggling their work with the implementation of the action plan, within the time limits of their day. In general, staff nurse and nurse leader participants differed in their views related to this theme. Some staff nurses mentioned the adverse impact of a busy day on their efforts to complete their audits, as patient care was the priority of their daily work. Overall, however, the work of the action plan was considered feasible due to its concrete and realistic nature. The 'doable' nature of the action items and deadlines facilitated the timely implementation of the plan, despite their clinical demands. They achieved their goals by consciously including them in their daily work:
I think we find a way of just implementing it as part of our daily routine. And once you get organised and you know that that's what you're gonna do...and you put it down there, like it's on your worksheet and it's on your...[daily agenda]. (Interview 03, p. 21, lines 15-19)
The availability and accessibility of pain management resources helped their efforts, including the pain service, pain assessment tools, and pain policies and guidelines. Human resources were considered a valuable support to their practices; colleagues were a trusted source of and expedient means to information in light of their daily busyness.
Conversely, the nurse leaders noted a stronger effect of everyday busyness on their efforts to implement the action plan. Amidst juggling their administrative or clinical tasks, the implementation process was discussed as challenging. As one nurse leader stated,
I know I didn't get to all the [audits]; I was supposed to do it and it was just other...other...priorities that got in the way...Just busy, you know just everyday like stuff going on the floor and whether or not I took time so then I kept thinking 'well I should do it, I should do it' and then I just never did it and forgot about it. (Interview 11, p. 19, lines 10-11; p. 20, lines 4-6)
Lack of organised follow-up
The lack of organised follow-up postimplementation of the action plan was recurrently discussed by participants as impeding their continued efforts to improve pain assessment documentation in their unit. They desired a group discussion around what was implemented and how it worked, which would also have provided a conclusion:
I think we're missing that part...what's happened after you had the audits and what came out of it. Like to go back and just give feedback as to what people [felt] came about in their little, you know practices that they had to do on the unit so that everybody feels like there is some sort of closure, yeah. (Interview 03, p. 12, lines 19-22)
In the final remarks of the last AI session, the Process Facilitator emphasized that the group was to implement the action plan in their unit and use AI to continue to improve this practice area or other areas of interest. Positive momentum for change is a theoretical outcome of participating in the AI process and an aspect of creating an appreciative learning culture [11
]; however, there was notable confusion amongst participants regarding who was responsible for organising a follow-up discussion. As stated by one nurse leader,
I think that maybe if we'd had another opportunity to go back as a group, that might have helped just keep the momentum going. And I don't know whether that's something that maybe the [other nurse leader] and I should have done formally or we should have utilised [the facilitators] to help with that, I'm not sure...but I think that would have helped. (Interview 11, p. 2, lines 44-45; p. 3, lines 1-2)
This confusion was linked to the democratic approach of the AI process: Because the group dynamic in the AI sessions was one of equality, when the group went forward without the guidance of the facilitators, there were no identified leaders to assume organisational roles and direct the progression of the practice change. Despite their preference for implementing the action plan without continued facilitator involvement, several participants indicated that they were relying on the facilitators to organise a follow-up meeting, rather than taking charge of the situation as a group.