Service Improvement Treatment Escalation Plans and Frailty

Student No: S5083397
SIP to ascertain whether training Frailty specialist

medical staff to complete STEPS (Somerset Treatment
Escalation Plan), would impact the quality of STEPS
1
Contents
Section 1: Implementation of the PSIP action plan/strategy Pg 4

Context Pg4
Situation Pg 4
Problem Pg 4
Intervention Pg 5
Aims, Choice and Design Pg 5
Operation Pg 6
Primary Data Pg 8
Sampling Pg 8
Method Pg 9
Questionnaire Pg 9
Design Pg 9
Interviews Pg 11
Organisational data Pg 12
Analysis Method Pg 12
Presentation of results and a discussion of key findings Pg 13
Questionnaire Pg 13
Chart 1 – Confidence to complete STEP Pg 14
Chart 2 - Q6. Confidence to Fill in Each STEP section PRE Training Pg 15
Chart 3 – Q7. Confidence to Fill in Each STEP section POST Training Pg 15
Results of Interviews Pg 16
Audit of STEPs Pg 17
Chart 4 - Pre & Post Training Audit of Frailty Patients STEPs Pg 17
Overall conclusions and future recommendations Pg 18
Section 2: Reflective discussion on the SIP activity Pg 20

Reflection on interview Pg 20
Key strengths Pg 21
Limitations Pg 21
Impact of Service Improvement Intervention Pg 22
Future Plans Pg 22
References Pg 24
Appendices
Appendix 1 - Participant information sheet Pg 28
Appendix 2 – Blank consent form Pg 31
Appendix 3 - Blank questionnaire Pg 33
Appendix 4 - Interview schedule Pg 36
Appendix 5 - Thematic and quantitative data from questionnaires Pg 37
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Appendix 6 - Thematic coding of interviews Pg 42

Appendix 7 - Pre-STEP Training Audit Pg 44
Appendix 8 - Post STEP Training Audit Pg 46
Appendix 9 – Gantt Chart Pg 48
Appendix 10 - Third Party Verification Pg 49
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SIP to ascertain whether training Frailty specialist medical staff to complete

STEPS (Somerset Treatment Escalation Plan), would impact their Confidence and
the quality of STEPS
Section 1: Implementation of the PSIP action plan/strategy (4378 words)
Context
The aim of the SIP was to ascertain whether training Frailty specialist medical
staff to complete STEPS (Somerset Treatment Escalation Plan), would improve
their confidence and result in an increase in the quantity and quality of STEP
documentation.
Situation
I am a trainee advanced clinical practitioner working within the frailty assessment unit
in a district general hospital in Somerset and I am the palliative care lead for frailty. We
take admissions either for a day assessment or for admission onto the frailty ward,
depending on the patient’s clinical presentation. Referrals are received from other
specialities within the hospital, including A&E, GPs or paramedics and results in
patients receiving a comprehensive geriatric assessment.
Problem
I identified that Somerset Treatment Escalation Plans (STEPs), were poorly completed
and often didn’t mirror the wishes of the patient, as predominantly the STEP wasn’t
discussed with them. Furthermore, the recorded information didn’t reflect their illness
trajectory, as without frank discussions a patient can’t be expected to fully understand
the implications of their choices. A CQC (Care Quality Commission) inspection in
2019 had highlighted this as a problem, but the hospital had not found a clear way
forward to rectify these omissions.
The bias in STEP completion pre and post COVID did change, which I’ll discuss
further in section 2. Nevertheless, STEP documentation remained poor post COVID
4
and patients continued to be omitted from the STEP process, with documentation
consistently completed inaccurately.
In my PSIP I discussed using the SPICT tool to help staff identify patients in the last
year of their lives. Subsequently it was felt by the palliative care team and myself that
time should be spent on building confidence in having difficult discussions with
patients and their families. Whilst the SPICT tool could be a useful addition to the
training, it could be too overwhelming to absorb information about this too. This would
be a pilot SIP, which if proved to be successful, could be replicated across the hospital.
For this service improvement project (SIP), I will be intervention led.
Intervention
Aims, Choice and Design

The aim was to improve End of Life conversations with patient’s so that their
wishes could be clearly explored and documented on Somerset Treatment
Escalation Plans, (STEPS). This would be achieved by delivering training to
increase medical staffs’ confidence to discuss STEPs with patents.
During the PSIP I had had several meetings with the palliative care consultant. He
and his team had been carrying out training sessions on communication within the
hospital and I wanted to ascertain if we could use their skills to improve
confidence to discuss end of life and STEPs within the frailty team. I involved key
stakeholders in the planning of the intervention, which was by way of email, face
to face discussions and meetings, (see stakeholder and Gantt documentation in the
appendix). I kept managers informed of my progress throughout the project and
had meetings with key individuals. Local approval was gained from the hospital to
carry out the service improvement project and gather informal audit data pre and
post the intervention. This comprised initially of a pre audit of STEP forms for
patients on the frailty ward and an informal meeting with the frailty team to
discuss problems they had encountered when filling in the STEPS. I met with my
manager to gain authorisation and the clinical service improvements manager to
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explore whether this SIP would be authorised by the hospital and no ethical
approval was required. Furthermore, I met with my education mentor and the
frailty consultants. I felt that the consultant’s agreement and enthusiasm for the
intervention would encourage the rest of the team to participate fully in the
training and could dictate the eventual success or failure of the intervention. I sent
emails to members of the frailty team and met with individual members to explain
what the training would involve.
The aim of my pre-intervention audit was to reveal any issues regarding the STEP
documentation. I audited twenty frailty patients’ medical files, focusing on their STEPs.
This revealed that only 5% of patients had a STEP in place. If they had one, it was
incomplete and, generally indicated a lack of patient or family discussion. Furthermore,
there appeared to be inappropriate decisions made on behalf of patients, such as a
gentleman with advanced lung cancer, who did not wish to have further investigations
or treatment, but who had a STEP that documented that he was to have “full escalation”
of care. Primary data collection was prior to the COVID situation, which did change
STEP documentation and I will discuss this further in section 2.
I arranged an informal meeting with all the frailty clinicians and presented these
findings via a powerpoint. I communicated End of Life information and the importance
of the STEP documentation to empower patients to make their own future care
decisions. I wanted to gain information about what their perceived barriers were to
accurate STEP documentation and this meeting revealed medical training barely
covered end of life care. Medics therefore did not feel adequately prepared to have
difficult discussions regarding planning for death and dying. They subsequently felt
that they lacked confidence in this area and staff intimated that difficult discussions
were sometimes avoided, in the hope that someone else would take responsibility for
completing the STEP forms. They agreed that it would be helpful to have these issues
addressed.
Operation
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This was an intervention led project whereby training would focus on how to
complete the STEP form correctly and building confidence to have difficult end of
life discussions with patients and their families.
During my meetings with the palliative care team, they shared that they had
commenced communication training with staff throughout the hospital to increase
confidence in having difficult patients and family discussions. This had received highly
positive participant feedback and I wanted to ensure continuity with this training. They
would use their successful training plan which utilised role play and integrate STEP
documentation, with the frailty medical team. A member of the palliative care team
would play a patient and the attendees would play themselves. There was to be a
maximum of six people attending the training to ensure that each person had an
opportunity to take part in at least two scenarios. I requested a date for the training and
ensured that the consultant and associate specialist geriatricians could attend. I then
emailed the members of the frailty team and where required discussed details of the
training with individuals. This clarified what would be included, in terms of theory and
role play and the benefits of attending. Once the training was confirmed, I notified the
service improvement and clinical managers.
Role play has been shown to help medical staff to increase their confidence in end of
life care, (Coyle et al, 2015, Addicott, 2010). Key limitations of this approach are that
not all scenarios that could be experienced can be covered in a role play session.
Furthermore, some staff can find role play to be intimidating, which could (and in this
case did) prevent some staff attending. The sessions only allowed for a maximum of
two role plays each and this may not have been sufficient time to embed these key
communication skills.
After a brief opening discussion, including reminding participants that they could leave
at any time, how to fill in each section of the STEP was recapped, which also
emphasised the importance of continuity across the STEP. Different scenarios were
introduced, and the palliative care team took it in turn to role play patients or family
members whilst the medical team took it in turn to play themselves. If they were not
sure how to proceed, the scenario was paused so that a group discussion could take
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place. Whilst 6 people attended, only 3 were Frailty Specialist staff, the rest of the
attendees were general medical staff.
I took the first role play and the palliative consultant made the scenario as realistic as
possible. Sometimes participants don’t want to be the first person to take part in a role
play and I hoped that my being first would reduce anxiety for the attendees and
encourage them to have a go. They took it in turns to participate in each scenario,
asking the “patient” what their wishes were regarding future treatments and care.
We wanted to make the role play as real as possible, therefore when there were
discussions about resuscitation, the “patient” stated “well, I don’t want to die”. We
discovered that if the discussion was not set up in the correct manner, it could easily
result in the “patient” feeling upset, threatened or concerned that the practitioner was
pressurising him into not having active treatment. It was important to allow the
participant to stop the scenario at any time if they were not sure how to progress the
discussion. This ensured that the training was non-threatening and there was time to
discuss any concerns or ask questions throughout the two-hour training.
Primary Data
 Sampling
A purposive sampling strategy was used, (McDermott et al, 2018), which focused on all
of the frailty training participants being asked to complete the questionnaire (3/3), all
three completed it and all agreed to be interviewed.
 Approval was gained from BU, the hospital, and participants, via the Participant Info
Sheet, and the Agreement Form, (see appendices). I ensured that consent was
consensual by advising the participants what taking part in the SIP entailed, (at the
PSIP meeting and later via the information sheet). They were reassured that their
interview transcripts and their questionnaire replies would be stored securely in a
locked cupboard and that no one would be made aware of their individual answers to
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ensure privacy. Furthermore, they could not be identifiable from the information they
gave me and they could withdraw their consent at any time.
Method
The primary data collection focused on Post STEP training questionnaires and semi
structured face to face interviews which took place with three medics. I chose these
people because they were the only members of the frailty team that attended the
training.
 Questionnaire
I decided to create a questionnaire as I felt that this could reveal information which I
otherwise would not be able to gather. I designed the questionnaire, (see appendix) and
liaised with the palliative care lead for the hospital to ensure that he was happy with its
content. One of the advanced clinical practitioners assisted me by testing it out prior to
its distribution to the rest of the frailty medical team. I did not find it easy to create the
participant questionnaire, with my first version being too simplistic.
I elected to use a questionnaire as they are cost effective and I felt it would allow
relevant data to be collected, (Wilson, 2010). After testing it with a colleague, I chose
the third version, aiming to establishing whether the STEP training had increased
participants confidence, (McClelland, 1994) and whether this could be translated to
better quality STEPs, that reflected the wishes of the patients. Some limitations of
questionnaires are that participants could withhold their true feelings and could skip
questions; questionnaires could be difficult to interpret and elicit superficial answers. I
was therefore mindful of these points when creating the questionnaire.
Design
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When formulating my questionnaire, I thought carefully about what information I

wanted to gain from it and how the questions flowed from one to the next in a logical
fashion, (Gilham, 2008). I used descriptive statistics for the closed questionnaire
questions and thematic analysis for the open questionnaire questions and the interviews.
The 1st question, which was a closed question, ascertained the date of training that was
attended and was included because some doctors had not attended the training,
therefore a second training was planned. Subsequently this was not possible due to the
second COVID wave. The group received their questionnaires a few weeks after their
training and I was concerned that a late request for feedback via the questionnaire
would result in a lack of quality information, I will discuss this further in the reflection.
I omitted to ask for the level of qualification on the form and gender. This is because
this information could have meant that I would have been able to identify who the
comments were from. Subsequently however the responders chose to speak to me when
they were filling in their form and I therefore knew who the replies were from. (I will
comment further regarding this in the reflection in section 2). The group was very
small, with a consultant, associate specialist geriatrician and one ACP other than me.
Furthermore, both the senior doctors attended the STEP training, whilst both the
foundation level doctors did not attend.
The bulk of the questionnaire focuses on the opinions of the attendees. I was interested
in what they hoped to gain from the training (Q2) and whether they felt these needs
were met (Q3). Open questions allowed the participant to free text and therefore their
answer was not limited by my assumptions, (Takamura, 2005), (Q2, Q9, Q10) and I
hoped to avoid bias. It is important to not have too many of these sorts of questions
though as they can be tiring for the respondent risking brief non insightful answers to
save time and possible analysis difficulties, (Reja et al, 2003).
During my PSIP fact finding meeting the attendees had expressed that the greatest
barrier to STEP forms being completed was their lack of knowledge, leading to a lack
of confidence. This lack of proficiency prevented their having vital discussions with
patients and consequently, completing STEP forms. I was therefore keen to gain insight
into whether their confidence had grown during the STEP training. Q4 and Q5 used a
10
rating scale, which allocated a value to the numbers, therefore putting their answers in
context, whilst Q3, Q6, Q7 and Q8 used an interval scale.
I broke the STEP form into sections as I hoped to highlight any areas where knowledge
to complete the STEP form was lacking and whether or not training met needs in these
particular areas. I hoped that this would lead me to understand where improvements
could be made for future STEP training. Furthermore, question 10 would help assess
whether the training had changed behaviour in practice and allowed a free expression of
opinion within the box supplied. I aimed to reveal new insights into the participants
thoughts about the training and how it had influenced them. The way I worded it could,
however, have given an expectation that there would have been a change in practice,
which could have caused bias, (Gillham, 2008, pg 26). I included open-ended questions
in the questionnaire, which helped to elicit information which closed questions
wouldn’t have provided. By contrast the closed questions were included to clarify a
point, (Q1), (Marcinowicz, et al. 2007) and the rating scales enabled a numerical value
to be given to responses. These could then be measured and the resulting data depicted
as a meaningful table.
Interviews
The interviews were carried out with the same three members of the frailty team that
had replied to the questionnaire. I hoped to expand on the questionnaire findings by
using a semi structured interview, with open questions, which allowed them to reply as
they wished and closed questions to clarify any specific points, (Gillham, 2000), (see
interview schedule appendix 4) and would elicit qualitative data. I used an introduction
question, which explored the interviewee’s aspirations for attending the STEP training
and then followed this with an enquiry about what they actually felt they gained, how
they found the role play, scenarios they felt would be helpful in the future and what
further STEP training they felt they needed. (Kvale, 1996 p.133-135). It was not
enough to just increase staff’s confidence, I wanted to explore whether this translated
into the Frailty specialist medical staff completing better quality STEPS. There were
some interview limitations such as a lack of anonymity, they were time consuming and
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there may have been a subconscious bias when I interviewed them. However, the only
thing I felt able to change was to make a conscious effort to avoid bias during the
interview.
Organisational data
I wanted to examine organisational data, to understand the extent of the STEP problem
on the frailty ward. This would give me informative information, which I could then
structure the training around.
Some fact-finding work involved my auditing of 20 patients’ medical files on the

Frailty ward and a number of meetings with the palliative care team. At the beginning
of 2020, very few patients had STEP forms or resuscitation decisions, despite this
having been highlighted as a problem during the 2019 CQC inspection.
Resuscitation decisions were not always completed in end of life patients and on
auditing the STEP forms on the Frailty ward at the beginning of 2020, this was
demonstrated to still be the case. Government guidance during the COVID 19
epidemic, (BMA, 2020), highlighted that resuscitation decisions were fundamental in
patient management and should be prioritised, but the frailty ward’s STEPs still had
inappropriate decisions and much of the remaining form was often left blank or filled
out incorrectly.
Post the training I audited 20 frailty patients’ medical files, both of day case admissions
and admissions into inpatient hospital beds. The method I used for my organisational
data audit was documentary analysis, by comparing pre audit and post audit patient
files, looking at end of life STEP forms.
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Analysis methods
There were two participants who attended the training from other hospital teams, but
when analysing the questionnaires, it was only important for me to gain the qualitative
data from the three people from the frailty unit. I grouped all the replies for each open
question together, (see appendix). This enabled me to analyse the results with thematic
analysis, (Q2, Q9, Q10) and to analyse the results statistically, (Q4, Q5, Q6, Q7). I
shortened the title of each section of the STEP so that the results could be fitted onto
the results graph as follows:- “What is important to me” (Important), For / Not for
resuscitation, (Resuscitation), “Hospital Transfer”, (Hospital), “Life prolonging
treatment”, (Prolonging), “Specific treatment options”, (Treatment), “Discussions with
Patients and / or families”, (Discussions), “Supplementary Information”,
(Supplementary).
When analysing the interviews, I broke the replies into a number of different themes
and placed all the replies onto one thematic document. This enabled me to highlight key
words and themes in each section, (see appendix).
 Presentation of results and a discussion of key findings
I am only going to show the key charts and will refer to others in the appendices.
Questionnaires
The thematic analysis of the questionnaires (see appendix), indicated that the
participants aspirations for attending the STEP training (Q2), were to enable
discussions regarding a patient or families wishes or concerns and to increase difficult
conversation skills. There had been no previous formal STEP training and therefore the
respondents highlighted that being taught to complete the STEP was imperative to
improving practice.
They all felt that the STEP training had either met their needs “fairly well” or
“completely”. Where it was felt that the training had only met the needs “fairly well”,
this was clarified by the need to have more scenarios in future training as the quantity
of scenarios per session was limited by time.
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Chart 1
Q3. Confidence to Complete STEP

10
9
8
7
6
5
4
3
2
1
0
Pre Training Post Training
Attendee 1 Attendee 2 Attendee 3
Prior to the STEP training, the attendees felt unconfident to fill in most areas of the
STEP, (Chart 2, Q6), other than the “Whats important to me” section. This
corroborated the findings of the PSIP audit of STEPs, which indicated that this section
was generally completed well, (audit may 2020, see appendix). After the training they
“agreed” or “strongly agreed” that their confidence to fill in all of the STEP sections
had been enhanced, (Chart 3, Q7). Furthermore, 100% of the attendees felt “Very
14
Prepared” to have difficult conversations with patients and their families about STEPs,
(Q8).
Chart 2
Q6. Confidence to Fill in Each STEP section PRE Training

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Important Resusitation Hospital Prolonging Treatment Discussions Supplementary
Strongly Agree Agree Disagree Strongly Disagree
Chart 3
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Q7. Confidence to Fill in Each STEP section POST Training

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Results of Interviews
I performed thematic analysis on the interviews, grouping statements together into

different themes, (see appendix 6). When discussing their feelings pre training, there
were feelings of fear about filling in the STEP documentation, (participant 1) and even
after the training there was a feeling that more training would be needed, more practice,
more scenarios and wanting to shadow the palliative care practitioner, so they “didn’t
get themselves into a hole”. They felt there was a need for a yearly refresher, a second
session and that this training should form part of the junior doctor training.
There was an acknowledgement that the patient should be the focus of all planning, not
medical options or their diagnosis and the vital importance of a STEP discussion with
every patient. There was a recognition that the patient may not feel ready to have a
discussion, but that this communication could be started in hospital and continue in the
community.
Confidence had clearly improved post training, with one participant expressing that
they felt “prepared for the (STEP) conversation” and another that they understood more
about what “language to use”.
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When I asked the participants to discuss the different areas of the STEP, they
predominantly felt they had prior knowledge regarding the “What’s important to me”
section, but hadn’t known how to use the form and in particular the “medical options”
section. They did not comment further on other specific areas of the STEP and I could
have asked more questions regarding this to gain more insight.
There remained some doubts about whether they had sufficient knowledge post
training, (Participant 1 & 2) and particularly in areas such as a potential transient
confusion, such as a delirium and how to communicate with patients and families who
have an “unrealistic expectation” . Furthermore, there was a request to have Advanced
Care Planning and SPICT training. Whilst this had been planned during the PSIP, not
including it in the SIP was affirmed to be the right decision as “it could have been a
distraction”.
Pre & Post Training Audits of STEPs
Chart 4 shows the effect of training on the completion of the frailty patients STEP
paperwork. Pre training 14/20, (70%) had STEP documentation in place, whereas Post
training 100% of the patients STEP documents were in place. A significant
improvement was demonstrated in the quality of the documentation, with the hospital
transfer, goals of care and ceiling of care documented in all post training STEPs.
Furthermore, there was a greater correlation in the goals of care and ceiling of care,
(85%), whereas pre training this was only 40%. The area of the STEP dedicated to
documenting the name of the nominated person to speak on the patients behalf if they
were unable to, remained low, (50%), but this was still an improvement on the pre
training documentation, (10%).
Chart 4
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Pre & Post Training Audit of Frailty Patients STEPs

120
100
80
60
40
20
0
ac
e us e es el
f er ar
e re n ip
s
cit
y
at M
is h rS sf Ca tio sh
pL St To fo an fC of la n pa
In
su
s nt of
W k Tr s o
ng rre tio lC
a
E P
rta ea ita
l al ili Co la ta
ST Re po on Sp sp Go Ce Re en
Im cti to o & M
fle le
H es
Re ab m
U n Na
Pre Training (%) Post Training (%)
In both the pre and post training audits, one STEP stated that a “Dr” had completed the
form, but this was not clarified with a grade.
Pre training issues such as a lack of discussion with the patient regarding their wishes
and multiple omissions of data in the required boxes improved, but there were still a
number of areas where documentation was not correct. These included repetition of the
resuscitation decision in a number of boxes such as the “What is important to me” box
and on one STEP multiple boxes ticked in the ceiling of care category. Furthermore,
there were some STEPs (15%), which had been annotated by a second doctor after the
initial completion, which led to a confusing STEP.
Mental capacity appears to remain an area where training is required. In the 25% which
had either no capacity, or the boxes weren’t completed, no mental capacity assessment
was found in the notes. There was one old STEP documentation in place, which meant
that there was no enquiry regarding Mental Capacity or the level of the practitioner
completing the documentation.
Overall conclusions and future recommendations
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The questionnaire bears out that 100% of the attendees felt “Very Prepared” after the
STEP training to have difficult conversations with patients and their families. They felt
that the role-play and discussion around different scenarios was “excellent”. Since the
training they had put new skills into practice and thought that the teaching had been
“embedded and consolidated” in their practice. The questionnaire could be changed
slightly particularly with Q6 & Q7, where Pre and Post should be bolded and in capitals
to ensure that questions are better understood. It would also be better to request
feedback immediately after the training. I did not feel I would change the interview
questions at this time.
The post STEP training audit of the patients being treated under the Frailty Team
demonstrated that 100% had STEP documentation in place. Furthermore, there was a
significant improvement in the standard of documentation, with most areas of the form
annotated correctly.
Future training should particularly emphasise that the need for contact details of the
next of kin or nominated individual, should the patient be incapacitated. Furthermore,
in the first audit there weren’t any STEPs which had been changed or amended by
another doctor, but in this post training audit three had been updated instead of a new
STEP being completed. It would be imperative for this practice to be strongly
discouraged as it could lead to mistakes.
Whilst neither the Frailty team’s staff grade or consultant completed any STEPs
themselves, they had a significant influence on their staff team by encouraging and
coaching to ensure that all the STEPs were completed to a significantly higher quality
than before the training. By contrast, there were two STEPs which had been completed
by other hospital consultants, where the quality of the STEPs reflected their lack of
training. Given the coaching influence of consultants with their junior staff, it would be
imperative that all staff who are expected to be able to fill in STEPs competently,
including consultants, attend future STEP training.
There are a number of elements which could be included to further enhance the
completion of STEPs. These include Advanced Care Planning conversations and the
SPICT tool. Furthermore, follow-up sessions which could expand the types of scenarios
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used within the role play, a yearly update and including STEP training in junior
doctor’s induction training could improve patient care. I will discuss these areas further
in section 2.
Section 2: Reflective discussion on the SIP activity (1100 words)
The PSIP work enabled preparation for the SIP to be realised. I had discussed the use of
the SPICT tool, (Supportive and Palliative Care Indicators Tool), which if included in
the training would have helped identify patients with multiple life limiting conditions. It
was omitted in the SIP, to increase focus on communication skills, with additional
SPICT training in the future.
When creating the questionnaire, I could have included questions to establish the
respondents’ gender, their grade and age. The group was small and such identifiable
information could have prevented anonymity and consequently participants honest
feedback, (Ove Sjöström & Dorthe Holst (2002), a finding disputed by Campbell and
Waters’ research, (1990). Subsequently the participants chose to complete their
questionnaire with me which may have resulted in a positivity bias, but equally their
positive pretraining motivation and organisational commitment, could also have
influenced their feedback, (Tannenbaum et al, 1991). I did use a scaled response, which
possibly elicited predominantly positive answers and consequently limited its
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usefulness to gather information, (Gutek, 1978). I avoided routing in the questionnaire

design, as I felt that this could cause confusion, (Zhou et al, 2012).
The group received their questionnaires a few weeks after their training as the training
took place prior to the questionnaire design. I was concerned that this would result in
paucity of feedback, but it didn’t and it enabled the participants to feedback after
putting their training into practice.
Reflection on interview
Plenty of information was gathered during the interview questions, with one
interviewee being particularly transparent regarding her pre training knowledge. By
contrast, the senior doctors may have found difficulty in divulging any omissions of pre
training knowledge, leading to a higher pre training score, (Table 1).
I was aware that interviews can become unfocused, (Denzin and Lincoln, 2000, p. 12)
and therefore was attentive to this. Furthermore, there can be a disproportionateness of
authority within an interview situation in favour of the interviewer, (Hannabuss, 1996)
although I felt the opposite when interviewing the consultants. I focused on a
qualitative interview to allow emphasis by the interviewee on what they felt was the
most significant aspect of the training. I felt this allowed the interview to flow and for
ideas and experiences to be expressed freely, (Martin and Turner, 1986).
Key strengths,
A fundamental strength of the training was the palliative care team, who’s knowledge
and delivery of the role playing was excellent, as reflected by the attendees’ feedback.
The SIPs success was aided by both the senior doctors support, enthusiasm, and
receptiveness to attend the role play training. They transmitted their knowledge to
clinicians who had not attended and utilised their influence to improve best practice in
patient care, (Schön, 1991, Tortoriello & Krackhardt, 2010). If they hadn’t attended the
STEP training, the hospitals hierarchical institutionalized boundaries could have
prevented this inter-professional transfer of knowledge, (Scott et al, 2000).
Furthermore, they could potentially influence other key hospital consultant’s future
attendance of training.
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Limitations
There were several issues which could have limited the effectiveness of the SIP. One
was that one foundation doctor was on annual leave, whilst the other rejected the
attendance of the training. Given the small frailty team (one consultants, one associate
specialist, two F1 doctors and two trainee advanced clinical practitioners), this
represented 33% of the team. Additionally, the F1 doctors would be responsible for
most of the ward jobs, (as the two trainee ACPs were responsible for the Frailty Day
Assessment unit). I wanted to explore the reasons why the F1 Dr refused to attend the
training.
Post qualification training is imperative for skill enhancement, whilst preventing

performance decline and ensures research based medical care, (Hulsman et al, 1999).
Some doctors don’t want to be told what training they should attend, (BMJ, 2019),
whilst others may be unconsciously incompetent, (Burch, 1970).
One foundation Dr indicated that he didn’t like role play, however, role play enables
participants to practice patient scenario skills within a safe situation where they can
discuss real life situations, which, if managed ineptly, could potentially cause distress to
real patients, (McCovoy, 1988). Role play can increase physician comfort and ability
to deal with difficult discussions around end of life (Ajzen, 1991, Walczak et al, 2016)
and is an effective learning tool, (Rogers, 1951). It is used extensively in medical
training, but prior experiences in his training may have adversely affected his
willingness to participate, (Nestel and Tierney, 2007). We must be motivated to learn,
(Bandura, 1977), therefore even if this training had been mandatory, there is no
guarantee that he would have participated fully.
Impact of the service improvement intervention

The STEP ensures that the patient, their family, GP and the hospital team understand
the ceiling of care and prevents investigations and treatments which could unwanted
and cause suffering, (Dorman et al, 2018). The STEP training significantly improved
both the quality and quantity of STEPs completed with Frailty patients, (Table 4).
22
100% of the Frailty patients had a STEP post training, a 30% improvement on the pre
training situation, whilst confidence increased by up to 70%.
Future Plans
The prevailing hospital “team-based approach” could prevent knowledge transfer from
the Frailty Team to other teams, (Currie & White, 2012). It will therefore be imperative
for intra-hospital STEP training. A strategic step could be to present the STEP SIP at
the hospital’s Clinical Governance meeting. However due to COVID, attendees are
limited, with most attendees viewing remotely but this could still be effective,
(Sitzmann et al, 2006)
The STEP training was delivered to a small group and this demonstrated a significant
improvement in both confidence and STEPs. The palliative care team could now
replicate this training throughout the hospital as training standardisation reaps rewards,
(McNortan, Barrows 1985). The drawback of this is the length of time it will take for
all hospital Drs and ACPs responsible for STEPs to be trained.
One trust is piloting both mandatory intranet training and patient focused information
leaflets, (Graham et al, 2018), and this could be an option for us. A yearly update event
and incorporating STEP training into junior doctor’s induction training and possible
including advanced care planning could also be a future initiative.
In conclusion I feel that the STEP training was a success, and this has now been
delivered to the A&E team. I am now planning with a senior frailty doctor and a
palliative care consultant to pilot the use of the SPICT and possibly the STOPP-Frail
tools (a medication deprescribing tool). For myself, SIP projects are now not as
daunting and I am inspired to do more, with the aim of improving patient care.
23
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Section 3: Appendices and 3rd party verification
Appendix 1
Participant Information Sheet
Service Improvement Project, (SIP) to ascertain whether training Frailty specialist

medical staff to complete STEPS (Somerset Treatment Escalation Plan), could impact
the quality of STEPS.
Invitation paragraph
28
You are being invited to take part in a project. Before you decide it is important for
you to understand why the data collection is being done and what it will involve.
Please take time to read the following information carefully and discuss it with others
if you wish. Ask us if there is anything that is not clear or if you would like more
information. Take time to decide whether or not you wish to take part.
The project manager is Juliet Pankhurst who a Trainee Advanced Clinical Practitioner
and is the Frailty Palliative Care lead.
Who is organising/funding the data collection/project? (If applicable)

There is no outside funding of the project, the data collection will be undertaken by
Juliet Pankhurst as the project manager.
What is the purpose of the project?

Early identification of patients likely to die in the next 12 months is key to
successful advanced care planning. Moreover, people in the last year of life have
increased use of services but limited effectiveness of treatments, therefore
identifying these patients is key. Medical staff have limited training in end of life
communication and this can impact confidence in completing Treatment
Escalation Plans with patients and or their families.
The aim of the project is to deliver a role play based simulation training in order
to increase medics confidence in completing STEP forms with patients and or
their families and therefore increase the quality of STEP documentation.
The project will be completed by March 2021.
Why have I been chosen?

You have been invited to participate in the service improvement project as you are a
member of the Frailty Medical Team. All the doctors and advanced clinical
practitioners will be asked to take part. It is hoped that this pilot project will
demonstrate that training in communication with patients increases confidence to
correctly fill out STEPs with patients. If successful, this could be replicated in other
areas of the hospital.
Do I have to take part?

It is up to you to decide whether or not to take part. If you do decide to take part, you
will be given this information sheet to keep (and be asked to sign a participant
agreement form). You can withdraw at any time, up to the point where the data is
processed without it affecting any benefits that you are entitled to in any way. You do
not have to give a reason. Deciding to take part or not will not impact upon/adversely
affect your work.
What would taking part involve?

You will be asked to fill in a questionnaire after your training which can be used for
data collection and may be invited to have a face to face or phone interview with the
29
project manager. This could take up to 20 mins and will be at a time and location
within the hospital, which is convenient to you. You will be asked to feedback about
your STEP training experience in a constructive manner, giving as much detail as
possible, so that the training can be enhanced for future groups.
What are the advantages and possible disadvantages or risks of taking part?
The training will be delivered by the hospital lead for palliative care (Rob Lutyens) and
will involve hypothetical scenarios of End of Life patients, who wish to discuss their
STEP. The attendees will take it in turns to role play a medic who is assisting the
patient to make choices that best suits their circumstances and wishes. There will be
plenty of support and the scenario can be paused at any time, to allow for a group
discussion and or advice to be given regarding a way forward. Some staff may find
discussions regarding End of Life uncomfortable and they will be given support to
discuss their feelings if required, either within the group or afterwards with the
palliative lead or the project manager.
Whilst there are no immediate benefits for those people participating in the project,
other than due to educational content, it is hoped that this work will enable future
training to be enhanced so that it can better meet the needs of the participants.
Will my taking part in this project be kept confidential?

All the information that we collect about you during the course of the data collection
will be kept strictly confidential. You will not be able to be identified in any reports or
publications. All data relating to this study will be kept for no more than 5 years on a
BU password protected secure network.
The data collected will be used in the service improvement project and if you would
like a copy of the published results please speak to the project manager. You will not
be identified in any report or publication.
What type of information will be sought from me and why is the collection of this
information relevant for achieving the project’s objectives?
It is important to gather information regarding your experiences of the STEP training.
This will help us to gain an impression of whether the training was useful or not and
how it could be adapted in the future to best meet the participants needs.
Will I be recorded, and how will the recorded media be used?
You will not be recorded
Contact for further information

Please contact
Project manager:
Juliet Pankhurst – Trainee ACP – Frailty Assessment Unit – 01935 384847.
s5083397@bournemouth.ac.uk
or
Unit tutor:
30
Lynne Rutter, Senior Lecturer, Unit Leader/Academic Adviser (PSIP/SIP) Tel:

07891106482, Email: lrutter@bournemouth.ac.uk
Complaints
In you wish to make a complaint.
Please contact Lynne Rutter, Senior Lecturer, Unit Leader/Academic Adviser (PSIP/SIP)
Tel: 07891106482, Email: lrutter@bournemouth.ac.uk
The participant will be given a copy of the information sheet and, if appropriate, a
separate signed participant agreement form to keep.
Thank you for taking the time to read through this information.
Appendix 2
Participant Agreement Form

Full title of project:
SIP to ascertain whether training Frailty specialist medical staff to
complete STEPS (Somerset Treatment Escalation Plan), could impact the
quality of STEPS.
Name, position and contact details of project manager:

Juliet Pankhurst – Trainee ACP – Frailty Assessment Unit – 01935 384847
Name, position and contact details of unit tutor:
31
Lynne Rutter, Senior Lecturer, Unit Leader/Academic Adviser (PSIP/SIP) Tel: 07891106482,
Email: lrutter@bournemouth.ac.uk Please
Initial
or Tick Here
I have read and understood the participant information sheet for the above
project.
I confirm that I have had the opportunity to ask questions.
I understand that my participation is voluntary.
I understand that I am free to withdraw up to the point where the data are
processed and become anonymous, so my identity cannot be determined
During the task or experiment, I am free to withdraw without giving reason and
without there being any negative consequences.
Should I not wish to answer any particular question(s), I am free to decline.
I give permission for members of the project team to have access to my

anonymised responses. I understand that my name will not be linked with the
data collection materials, and I will not be identified or identifiable in the outputs
that result from the project. OR
I give permission for members of the project team to use my identifiable

information for the purposes of this project.
I agree to take part in the above project.
____________________________ _______________
__________________________________
Name of Participant Date Signature
____________________________ _______________
__________________________________
Name of Project Manager Date Signature
This form should be signed and dated by all parties after the participant receives a copy of the participant
information sheet and any other written information provided to the participants. A copy of the signed and dated
participant agreement form should be kept with the project’s main documents which must be kept in a secure
location.
32
Appendix 3
SIP Questionnaire
STEP Training
Aim:- To ascertain whether the STEP training increased the confidence to fill out
STEPs correctly in a way which best reflects the patient and / or families wishes
1. What was the date of your STEP training?
33
2. What were your main aspirations for attending the STEP training?
3. To what extent do you think your needs were met by the STEP training?
Please tick one box.
Completely Fairly well Mostly A bit Not at all
4. Out of 10, where 0 is totally unconfident and 10 is extremely confident is what was your PRE training
confidence in filling in STEPS
5. Out of 10, where 0 is totally unconfident and 10 is extremely confident is what was your POST training
confidence in filling in STEPS
6. Please state how far you agree / disagree about your PRE training confidence to fill out each section of
the STEP.
Please tick one box for each section.
STEP Sections Strongly Agree Agree Disagree Strongly Disagree
I feel confident to fill out:-
What is important
to me
For / Not For

Resuscitation
34
Hospital Transfer
Life Prolonging
Treatment
Specific Treatment
Options
Discussions with
patient and / or
family
Supplementary
Information
7. Please state how far you agree / disagree about your POST training confidence to fill out each section
of the STEP.
Please tick one box for each section
STEP Sections Strongly Agre Disagree Strongly

Agree e Disagree
I feel confident to
fill out:-
What is important
to me
For / Not For

Resuscitation
Hospital Transfer
Life Prolonging
Treatment
Specific Treatment
Options
Discussions with
patient and / or
family
Supplementary
Information
8. How prepared or unprepared has the STEP training made you feel to have difficult conversations with
patients and their families?
Please tick one box
Very Prepared No Slightly Not

35
Prepared Chang Prepared Prepared

e
9. What elements could have been included in the training to increase this?
10. Thinking about the last STEPs you have filled out with patients (post training), please can you describe
any aspects of the process that have changed since your STEP training?
Appendix 4
Interview Schedule - Post STEP Training
1. Can you tell me what you aspired to gain from the STEP training?
2. Can you tell me what, if anything, you gained from the STEP training?
3. How did you find the role play? Do Drs have role play in their medical training?
4. Are there any particular types of patients that you feel you could benefit from further
training to fill in STEP forms with?
36
5. You said that you felt the training was 9/10, can you tell me more about why you
graded it that way?
6. Is there anything further you feel could help regarding filling in STEPS?
Appendix 5
Thematic and Quantitative Analysis - Questionnaires
STEP Training
Aim:- To ascertain whether the STEP training increased the confidence to fill out
STEPs correctly in a way which best reflects the patient and / or families wishes
1. What was the date of your STEP training?
Wednesday 8th July 2020 - All
37
2. What were your main aspirations for attending the STEP training?
To enable discussion
address patients wishes and any concerns,
having difficult conversations,
how to formalise/ complete the STEP documentation.
Clarity about STEPS & usage
3. To what extent do you think your needs were met by the STEP training?
Please tick one box.
Completely Fairly well Mostly A bit Not at all
  (Need
more
scenarios
)
4. Out of 10, where 0 is totally unconfident and 10 is extremely confident is what was your PRE
training confidence in filling in STEPS.
(P= Participant)
P 2,
1 8
P 9
2
P
3
5. Out of 10, where 0 is totally unconfident and 10 is extremely confident is what was your
POST training confidence in filling in STEPS
(P= Participant)
P1 9,
P2 9
P3 9-10
6. Please state how far you agree / disagree about your PRE training confidence to fill out each
section of the STEP.
Please tick one box for each section.
38
STEP Sections Strongly Agree Disagree Strongly

Agree Disagree
I feel confident to fill
out:-
What is important to me 
For / Not For 

Resuscitation
Hospital Transfer 
Life Prolonging 
Treatment
Specific Treatment 
Options
Discussions with patient 

and / or family
Supplementary 
Information
7. Please state how far you agree / disagree about your POST training confidence to fill out
each section of the STEP.
Please tick one box for each section
STEP Sections Strongly Agree Disagree Strongly

Agree Disagree
I feel confident to fill
out:-
What is important to me 
For / Not For 

Resuscitation
Hospital Transfer 
Life Prolonging 
Treatment
Specific Treatment 
Options
39
Discussions with patient 

and / or family
Supplementary 
Information
8. How prepared or unprepared has the STEP training made you feel to have difficult
conversations with patients and their families?
Please tick one box
Very Prepared No Change Slightly Not

Prepared Prepared Prepared
9. What elements could have been included in the training to increase this?
It would be good to see how this could progress to a conversation to assist in advanced care
planning for patients and I would welcome any further training in this valuable area of patient
centred care.
Another session on the SPICT tool and how to use it would be good.
None really (? Not time to fill in with all thoughts)
The role play and discussion around different scenarios was excellent. Following the training I
have had time to embed and consolidate the training in my practice, I would welcome a further
session on reflecting this practice and may be a follow up session would be good.
Clarification around level of competency/ who is able to complete STEP forms with patients, i.e.
practitioners able to complete or senior medical team.
10. Thinking about the last STEPs you have filled out with patients (post training), please can you
describe any aspects of the process that have changed since your STEP training?
I felt empowered to initiate what used to seem difficult conversations with my patients. Having
been able to initiate these conversations I have found that patients are generally pleased to have
discussed their TEP and have documentation to express their wants and needs regarding DNAR.
Pt wishes & outcomes – I am more aware of the process & what needs to be put in each box
40
Chart 1
Q3. Confidence to Complete STEP

10
9
8
7
6
5
4
3
2
1
0
Pre Training Post Training
Attendee 1 Attendee 2 Attendee 3
Chart 2
41
Q6. Confidence to Fill in Each STEP section PRE Training

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Chart 3
Q7. Confidence to Fill in Each STEP section POST Training

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Appendix 6
42
Thematic Coding of Interviews
 Fear – prior to training I felt “frightened to fill out STEP”
 After training – strongly more confident but need to practice more I still feel I could get
myself into a hole
Uncertainty
 Im not sure what level of expertise I should have (clarity because on hospital junior Drs
aren’t allowed to fill in DNARs), will my STEP be valid? Training brilliant but feel this is an
unanswered question
 Not 100% confident in some situations eg patient very unwell with suspected delirium.
Unrealistic expectations of patient or / and family towards STEP – handling these situations.
Sometimes I have to go back later on
 Hospital scenarios more difficult than at home
 more difficult in acute setting than community” as can get lots of background info from RIO
system in community
 Didn’t know how to use the form pre training
Confidence
 STEP well covered
 Medics do a lot of role play in their training. I don’t think people should object to this
 Concise and detailed
 I feel prepared to have STEP conversations with pts
 Training v important for ACP role in frailty unit
Language –
 How to do STEPs better – language to use, subtle ways of doing STEPs in a clearer way
Patient Focus
 Focus on what matters to the patient, not what’s wrong with the patient
 Its about what the patient wants not medical options
 Reminded of the importance of STEPs – should do with every patient
43
 Sometimes STEP is a process & journey they have to go on. We can sometimes only start this
with them because they might not want to discuss it at that time
Different areas of STEP
 What’s important to me – would normally get a feeling for this anyway
 Medical options, treatment & management didn’t have confidence pre training as
insufficient level of competency (Participant 1), concerned it should be a Consultant / senior
decision. After training felt I could have these conversations.
Specific Future Training
ACP
 Look at Advanced Care Planning (ACP)
SPICT
 Revisit using the SPICT tool – add into training
 Want session on using SPICT tool
 SPICT could have been a distraction to practical conversations in that session, but we need
to cover this too
Repeat
 Session length was good, shouldn’t increase that but need 2nd session
 Need to repeat it periodically
 It should be part of junior drs induction training as more likely to be discussing STEPs than
consultant
More Training –
 Gave 9 after training as still feel the need for more scenario training, need additional training
to consolidate practice, 1 session not enough
 Know about STEPs, more aspects to learn
 It was offered that we could shadow palliative care practitioner – I will organise time to do
this
Appendix 7
44
Audit - Pre STEP Training
STEP Audit: 15.5.2020
20 files audited
Does the patient have a STEP form? Yes No

14 70% 6
What is the resuscitation status? Do not attempt Do attempt CPR
CPR 8
6 30%
Is the ‘What is important to me’ box Yes No
complete? 10 - 50% 4
If yes, is this considered a reflection of the Yes No

patient wishes? 8 - 40% 3
N/A 3
Is the ‘unable to speak for myself’ section Yes No
complete? 2 – 10% 12
Is the hospital transfer section complete? Yes No

12 – 60% 2
Is the ‘goals of care’ section complete? Yes No

11 – 55% 3
Is the ‘ceiling of care’ section complete? Yes No

13 – 65% 1
Do the goals of care correlate with the ceiling Yes No
of care? 8 – 40% 6
Names and relationships of those involved in Yes No
discussions complete? 8 – 40% 6
Mental capacity section complete? Yes No
2 – 10% 12
If no, Mental capacity documented anywhere Yes No
else on the form? 0 N/A 8
7
If mental capacity documented as not Yes No N/A
present, has a mental capacity form been 2 12
complete?
Level of Dr completing the form: 1 No Grade

SHO 2
F2 4
SG 7
Con 0
If not consultant has this been countersigned Yes No
by a consultant? 0 0
Comments:
Examples of issues
Nothing written in rational for why CPR not to be attempted
Rational written in patient wishes box
Form suggestive that only DNAR was discussed in any depth and that pt probably wouldn’t want
degree of intervention stated on STEP if appropriate conversation had taken place
“Try to keep me alive unless I become brain dead” “want to be taken care of” “patient wishes”
“Needs discussion with NOK” but not happened, MCA not done. Team made aware of this omission
45
during audit process

Just “Sally” as NOK, no contact details or surname
Ceiling of care not in correlation with procedures listed
“Pt wishes to be resuscitated” / “Strong wishes to be resuscitated “in what is important to me box
No date, multiple omissions of boxes - redone as not safe for patient in discussion with them
46
Appendix 8
Audit - Post STEP Training
STEP Audit: 13/11/2020 – Frailty - 20 notes audited
1 Does the patient Yes = 20 (100%) No = 0

have a step form?
2 What is the No Not Attempt CPR Do Attempt CPR

resuscitation status
17 (85%) 3 (15%)
3 Is the “What is Yes = 15 (75%) No

important to me”
box complete? 3 (see comment)
4 If Yes, is this Yes 15 (75%) No

considered a
reflection of the (See comment)
patient’s wishes?
5 Is the “Unable to Yes = 10 (50%) No = 10 (50%)

speak for myself”
section completed?
6 Is the hospital Yes = 20 (100%) No

transfer section
completed?
7 Is the “goals of Yes = 20 (100%) No

care” section
completed?
8 Is the “ceiling of Yes = 20 (100%) No

care” section
completed?
9 Do the “goals of Yes = 17 (85%) No = 3 (15%)

care” correlate
with the “ceiling of
care”
10 Is the names and Yes = 15 (75%) No = 5 (25%)

relationships of
those involved in
the discussions
complete?
11 Is “Mental Yes = 15 (75%) No = 5 (25%)

Capacity” section
47
complete?
12 If no, “Mental Yes No N/A

Capacity”
documented 2
anywhere else on
the form?
13 If mental capacity Yes No N/A

documented as not
present, has a 2
mental capacity
form been
completed?
14 Level of Dr / Cons Reg TF SHO ACP

practitioner
completing the 2 (10%) 2 (10%) 2 (10%) 7 (35%) 6 (30%)
form
15 If not consultant, 0
has this been
countersigned by a
consultant?
Comments
Q3. Reason given for not resuscitating – patient unwell, low GCS, limited cardiac reserve
Resuscitation decision reiterated
Q4. Further reiteration of resuscitation decision.
Q9. 2 ticks in this column on one STEP
Q11. MC crossed out – no signature or tick put in affirming capacity box
Q14. Registrar included ST3 & middle grade. One STEP had no qualification stating just
“Dr”
Additional information
Annotations to original by another Dr – form not rewritten x3 - confusing
Last days of life and Not for Life Prolonging Treatment both ticked
Previous DNAR used to base new one – No MC ticked but no MCA found in notes
No supplementary information added eg PMH
1x old STEP form used which therefore omitted MC questions
Appendix 9
48
Gantt Chart
SIP – Increase STEP compliance
Jul Aug Sep Oct Nov Dec

Task
28th 2nd
Meeting with Ed Moore - SI Lead Hospital
23rd 28th 24
Meeting with Lynne Rutter
12th
Hospital Service Improvement Meeting
12th
Agreement & Consent Formulation
28th 16th
Bournmouth Uni Day SIP
1st , 8th 4th 27th 3rd

Meeting With EOL Lead Rob
21st 18th 9th

Meeting with Dr Rasheed
6th
EOL Steering Group
4th
Create Dr Questionnaire
15th
Create Interview Schedule
8th
STEPs Training
13th
Post Audit Data Collection
12th
Formal Data Collection
10/3/2021
Assignment Submission
Appendix 10
49
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Student No: S5083397

SIP to ascertain whether training Frailty specialist

Student No: S5083397

Section 1: Implementation of the PSIP action plan/strategy Pg 4

Section 2: Reflective discussion on the SIP activity Pg 20

Appendix 6 - Thematic coding of interviews Pg 42

SIP to ascertain whether training Frailty specialist medical staff to complete

Section 1: Implementation of the PSIP action plan/strategy (4378 words)

For this service improvement project (SIP), I will be intervention led.

Aims, Choice and Design

When formulating my questionnaire, I thought carefully about what information I

Some fact-finding work involved my auditing of 20 patients’ medical files on the

 Presentation of results and a discussion of key findings

Q3. Confidence to Complete STEP

Attendee 1 Attendee 2 Attendee 3

Q6. Confidence to Fill in Each STEP section PRE Training

Strongly Agree Agree Disagree Strongly Disagree

Q7. Confidence to Fill in Each STEP section POST Training

Strongly Agree Agree Disagree Strongly Disagree

I performed thematic analysis on the interviews, grouping statements together into

Pre & Post Training Audits of STEPs

Pre & Post Training Audit of Frailty Patients STEPs

Pre Training (%) Post Training (%)

Overall conclusions and future recommendations

Section 2: Reflective discussion on the SIP activity (1100 words)

usefulness to gather information, (Gutek, 1978). I avoided routing in the questionnaire

Post qualification training is imperative for skill enhancement, whilst preventing

Impact of the service improvement intervention

References for sections 1 and 2

Bandura A. Social Learning Theory. Englewood‐Cliffs (NJ): Prentice Hall, 1977.

Barrows H. How to Design a Problem-Based Curriculum for the Pre-Clinical Years.

BMA, (2020). COVID-19 - Ethical Issues. A Guidance Note. Available at:

Burch, N. (1970), “Conscious competence learning model: four stages of learning

Dorman, S. et al. (2018) ‘82 Treatment escalation plans – supporting individualised

Gillham, Bill. Developing a Questionnaire, Bloomsbury Publishing PLC, 2008.

Graham A, Ellis J, Yogalingam S, et al. Treatment escalation and resuscitation

Gutek, B. A. (1978) ‘Strategies for Studying Client Satisfaction’, Journal of Social

Jackson, J. L. (2005) ‘Communication About Symptoms in Primary Care: Impact on

Kissane, D. W., Bylund, C. L. and Banerjee, S. C. (2012) ‘Communication Skills

Kvale, S. (1996) InterViews : an introduction to qualitative research interviewing. Sage.

McAvoy, B. R. (1988) ‘Teaching clinical skills to medical students: The use of

McClelland, S. B. (1994) ‘Training Needs Assessment Data-gathering

McDermott, A., Kitchener, M. and Exworth, M. (2018) Managing improvement in

McNaughton, N. et al. (2008) ‘Psychiatric education and simulation: A review of the

Ludmiła Marcinowicz, Sławomir Chlabicz and Ryszard Grębowski (2007) ‘Open-

Schön, D. A. (1991). The reflective practitioner: How professionals think in action.

SITZMANN, T. et al. (2006) ‘The Comparative Effectiveness of Web-Based and

Sjostrom, O. and Holst, D. (2002) ‘Validity of a questionnaire survey: response patterns

TORTORIELLO, M. and KRACKHARDT, D. (2010) ‘Activating Cross-Boundary

Walczak, A. et al. (2016) ‘A systematic review of evidence for end-of-life

Wilson, J. (2014) Essentials of business research : a guide to doing your research

Zhou, T. C., Lyu, M. R. and King, I. (2012) ‘A classification-based approach to

Section 3: Appendices and 3rd party verification

Participant Information Sheet

Service Improvement Project, (SIP) to ascertain whether training Frailty specialist

Who is organising/funding the data collection/project? (If applicable)

What is the purpose of the project?

Why have I been chosen?

Do I have to take part?

What would taking part involve?

Will my taking part in this project be kept confidential?

Contact for further information

Lynne Rutter, Senior Lecturer, Unit Leader/Academic Adviser (PSIP/SIP) Tel:

Participant Agreement Form