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UBC Theses and Dissertations

Appreciating the ethical implications of quality improvement implementation and relational safety : a qualitative study of patient/family experience Sawatzky-Girling, Brenda Margaret


Improving the quality of care and reducing preventable harm to patients/families are important obligations for health care professionals and institutions. Despite quality improvement’s (QI) significant contributions to health care, interventions that involve patients at the point of care raise ethical questions about heretofore unexamined wider impacts on patients. This qualitative empirical study challenged the assumption that QI is necessarily a benign and beneficial extension of routine medical care. The research questions focused on ethical and practical implications of patient/family experiences of a pilot QI intervention that gave patients a new opportunity to improve the quality and safety of their own care. Relational inquiry and ecological systems theory framed this ethical (values-based) analysis of moral agents in context. Using interpretive description methodology, I explored two hand hygiene QI interventions on two hospital units. Over 12 months, I observed patient care and staff meetings (~140 hours), interviewed/shadowed patients (n=25), families (n=8), providers/ volunteers (n=21), other staff (n=17), and analyzed documents. Findings about patient/family experiences of the QI interventions (what I term Work-as-Experienced) showed that a multifaceted set of perceptions and behaviours occurred at once. My thematic analyses centred on the value patients/families place on positive connections with their providers and health care settings. Contextual features of implementation showed disconnects between how quality leaders imagined the QI intervention’s success, how it was operationalized, and how patients/families experienced it. In interpreting these findings, I developed a Relational Safety Framework to explain how relational connections result from interactions with others and are potentially grounded in relational safety (feeling safe and valued). When people in vulnerable, uncertain circumstances have a sense of relational safety, they move towards connections with others, fostering trust. In this study I emphasize the importance of relational connections and shared meanings of quality/safety initiatives. Furthermore, evaluation is critical to assess the impact of QI on patients’/families’ lives. I recommend a stronger appreciation of the ethical implications of QI implementation, and strengthening relational safety through adopting a relational, multi-level perspective to foster ethical conduct of QI in health care. Relational safety is a new, ethically-based, values-added strategy to advance health care system improvement.

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