An emergent theory of clinical engagement in relation to implementing Quality Improvement methodology. A grounded theory study in intensive care units in Scotland.

It is well recognised in the quality improvement literature that understanding context is essential to successful quality improvement. Yet, there is a lack of evidence within the Quality Improvement (qi) literature describing a definition of context. Additionally, clinical engagement is offered as another important influence on successful implementation of qi and achieving aims. This study set out to understand if there was a relationship between staff perceptions of clinical engagement when reducing ventilator associated pneumonia and how this relates to the System of Profound Knowledge framework central to the model for improvement methodology? Utilising a constructivist grounded theory approach, 18 nursing, medical and managerial staff were interviewed in four Scottish intensive care units to understand their perceptions of clinical engagement and whether it influenced their ability to achieve the Scottish Patient Safety Programme (SPSP) Ventilator associated pneumonia (VAP) reduction aim. This study has made it possible to develop a working definition of Clinical engagement which resonates with staff working in intensive care units. Staff in all units, irrespective of achieving the SPSP VAP aim, described clinical engagement in a similar matter, highlighting the requirement to actively engage all staff groups. Where staff responses differed between the units was in the language used when referring to each other – in non-achieving units there was increased reference to person dependency and evidence of decohesion within teams. The use of a constructivist grounded theory approach can support intensive care staff to share their perceptions of clinical engagement and facilitate the development of a working definition which has meaning in practice for staff. It is also possible to develop operational definitions of context as described by staff and to use this to inform the four lenses of the System of Profound Knowledge