Re-envisaging Infection Practice Ecologies in Nursing (RIPEN) through Arts and Humanities Approaches

Lead Research Organisation: Glasgow School of Art
Department Name: School of Design

Abstract

Antimicrobial resistance (AMR) and its consequences pose serious threats to health and welfare globally. Across the world nurses constitute the largest professional healthcare workforce and typically nurses have numerous daily interactions with healthy and ill individuals, family members, community groups and other care professionals. As such nurses have huge potential to make every contact count to reduce inappropriate prescribing and demand for antibiotics, and to enhance the effectiveness of those prescribed. However evidence on nursing's engagement with AMR indicates that the profession has not yet leveraged its potential to prevent AMR advancing or to countenance the consequences of failure.

Within this context the invisibility of pathogens and related AMR processes in everyday practice make AMR a relatively abstract issue. Based on our cross disciplinary research work involving contemporary visualisations of the pathogens, people and places that constitute practice ecologies, and on our historical research detailing eras of infection control practice in hospital settings, we believe that there is significant opportunity to enhance the meaningfulness of AMR for practicing nurses through expanded application of arts and humanities approaches. Thus we will address the main question:

How can relevant arts and humanities based approaches help nurses to re-envisage their infection control practice ecologies in response to antimicrobial resistance?

In doing so we will investigate four subsidiary questions:

1) How do groups of hospital and community based nurses understand and respond to the priorities and consequences of AMR within the context of their everyday working lives?
2) How can co-design and visualisation based approaches help these nurses to identify and construct sets of meaningful practices that optimise present prevention of AMR?
3) How can co-design, visualisation, history and other relevant arts and humanities approaches help nurses to re-imagine and re-envisage their infection control practice ecologies in a future with minimal or no effective antibiotics?
4) What priority issues and other questions does this initial enquiry raise, and how can these best inform policy and planning, education and further research?

Following a preparatory phase the main qualitative research will engage a group of hospital based nurses in Glasgow and a group of community based nurses in London. Structured around four sequential workshops with interim activities, these respective "Labs" will each address questions 1-3 using and evaluating different combinations of methods. The final phase of the research will involve a "Policy Lab" where the research team, advisory group and an invited range of policy experts and art and humanities academics will address question 4.

Through these means this novel study will produce the following deliverables:

a. Project outputs (e.g. journal publications) that demonstrate enhanced understanding of the nature and scope of nurses' engagement with AMR in a range of built environments including hospitals, GP surgeries and people's homes
b. Sets of prototyped AMR-related prevention practices that nurses believe they can meaningfully enact within these practice contexts
c. Project outputs in a variety of possible formats (written, visual, web-based) that demonstrate how nurses can re-envisage their infection practice ecologies in a future with minimal or no effective antibiotics
d. Identification of a set of priority issues and other key questions that arise from the enquiry and will inform a policy brief
e. An overarching analysis of the challenges, strengths and added value of deploying particular arts and humanities approaches within a health services research context

These will be of value to clinicians, the public as health service users, managers, planners and academics, and will yield potential for further practice, policy, research and educational developments.

Planned Impact

In addition to the benefits for academics detailed elsewhere in this application, the RIPEN study has been designed to generate five deliverables of potential direct benefit to a range of important stakeholder groups. These are now summarised:

Demonstration of enhanced understanding of the nature and scope of nurses' engagement with AMR in a range of built environments (including hospitals, GP surgeries and people's homes) will be of particular benefit to nursing and allied healthcare professions and health and social services managers. Few in-depth studies of this engagement exist and the application of arts and humanities approaches can illuminate this from a different angle, enabling more informed and nuanced planning and delivery of services. The production of sets of prototyped AMR-related prevention practices that nurses believe meaningful for practice contexts can bring added value for these clinical stakeholders.

Looking further ahead, project outputs in a variety of possible formats (written, visual, web-based) will demonstrate how nurses can re-envisage their infection practice ecologies in a future with minimal or no effective antibiotic therapies. There is a dearth of such thinking within nursing and other health services at present so this study can provide an exemplar to stimulate engagement. This will be of particular relevance to health and social policy planners and the general public as participants in health and social care. Impact will be enhanced through the fourth deliverable: identification of a set of priority issues and other key questions that arise from the enquiry. In drawing together the main findings and related questions there is the potential to inform these key stakeholders, and the relevant professional practitioner groups, in a compelling way that enables preventative actions to be identified and progressed.

The final deliverable entails producing an overarching analysis of the challenges, strengths and added value of deploying particular arts and humanities approaches within a health services research context. This will yield particular insights into processes involving models, methods and materials. This may be of interest to all stakeholder groups but will be of specific relevance to practitioners, especially those with integral research and education remits. In this way practice, education and research can be enriched to enable further methodological developments and learning gains.

These stakeholders will be reached through: direct involvement in the study (nurses, allied health professionals, lay members, and invited arts and humanities experts) and in the creation and dissemination of its associated outputs; the involvement, advocacy and networks of the six Advisory Group members who are ideally placed to engage key members of the practice, managerial, policy, education, and service user group/lay communities; the "designing-in" of a Policy Lab facilitated by King's College Policy Institute in order to harness the main findings and leverage further influence with key policy groups; the planned dissemination programme involving journal publications, conference presentations and public outreach events; the extensive professional activities and networks of the cross-disciplinary research team; and the easy accessibility of the project's website which will serve as a window on the progress, processes and key outputs of the study.

Publications

10 25 50
 
Title Re-envisaging Infection Practice Ecologies in Nursing 
Description This 9 minute film was made during one of the project's workshops in order to give insights into the processes involved for healthcare participants and to explain the main purpose of the project. The video includes an original poem. 
Type Of Art Film/Video/Animation 
Year Produced 2019 
Impact The film has been made available on the Glasgow School of Art website since October 2019. It was played in full to participants at a high profile workshop event on AMR at The Royal College of Nursing Headquarters on 4th October 2019. It has been viewed 61 times since release through Vimeo. 
URL http://vimeo.com/368059130
 
Description To date nursing hasn't leveraged its full potential to help address the advance of antimicrobial resistance (AMR). There are many reasons for this but four relevant aspects which have not received adequate research and development are (i) the meaningfulness of AMR for practitioners in the context of their everyday work (ii) the relative invisibility of AMR (iii) how to usefully develop optimal AMR practices from the perspective of nurses and other health professionals, and (iv) the need for nurses and others to envision future development of their practices and work contexts in a future world where effective antibiotics may be very limited/non-existent.

The RIPEN study addressed these issues by exploring the use of a number of arts and humanities (A&H) approaches (especially design/visual methods) with 20 participants (a mixture of 18 hospital and community based nurses; a doctor and a public/patient representative). We found that the methods were very useful in giving rich insights into how participants understood and acted on AMR in their daily working contexts (and to some extent within their personal lives). In this regard visual methods such as storyboards (with associated discussions) added particular value by making tangible the various contexts, conceptions, individual roles, team activities, materialities, fluid boundaries, power relations and uncertainties that tend to characterise individual and team practices. Moreover they elucidated the extent to which infection prevention and control (ICP) practices are differentiated from AMR -related practices. The many systemic influences on professional and personal behaviours relating to antibiotics were also explored during the project, notably through use of macro, meso, micro and nano level depictions. Some examples of findings are reported in a recently accepted journal article (Journal of Research in Nursing) and in a briefing paper to be found on the outcomes page of the project website ( https://www.ripen.org.uk/outputs.html ).

The latter source also reports a selection of the priority ideas nurses had for meaningful individual and team practice developments. Participants co-designed some of these ideas into policy and practice proposals and these informed a national Policy Workshop held at the Royal College of Nursing (RCN) in London. We then synthesised the findings from these processes into An Agenda From, and For, Nurses and their Policy Allies, entitled Envisage and Act on AMR. This was featured at a recent (2020) Westminster Health Policy Forum event and is informing refreshment of the RCN's guidance on AMR. Envisioning of practice ecologies in 2030 was also undertaken and some examples are available in the briefing paper mentioned above. Finally we plan to make a visually engaging report on the project's methods available on our website later in March 2020 so that stakeholders can learn about, and adopt/adapt the approaches we have explored. Key points and recommendations are made in this document. A film of workshop processes is also available via the project website. Overall we believe our study is a novel contribution in the field of nursing and AMR, yielding new perspectives on practice and policy by starting from participants' own practice and using engaging, visual-based methods to facilitate co-design work. Moreover it is a useful exemplar of how different disciplines can work productively together to address a clear need.
Exploitation Route Firstly, the insights generated about nurses' work around AMR and their related ideas for improvements and future ecologies will be of use to clinicians, practice developers and managers looking at how best to leverage the nursing imagination for progressing work in this field. This would be applicable within the UK and beyond.

Secondly, the methods used will be of relevance to educators, researchers, practice developers and managers working in infection prevention and control (and beyond). The report on the methods will share ideas and recommendations on this for future applications. In particular the RIPEN project shows how interdisciplinary approaches (design, nursing, history, policy, health services research) can be usefully developed and learnt from.

Thirdly, the policy agenda developed through RIPEN in conjunction with key UK stakeholders including the RCN, posits five main areas for policy and practice development. These can be used to inform the thinking and priorities of government, regional/local health and social care organisations, and professional bodies.

Finally the RIPEN project has also highlighted that nurses and other healthcare professionals have multiple identities, not least as potentially influential citizens in promoting optimal approaches to AMR. As the largest health profession globally, the power of nursing to influence can be further enhanced.
Sectors Communities and Social Services/Policy,Education,Environment,Healthcare,Government, Democracy and Justice

URL https://www.ripen.org.uk/outputs.html
 
Description As of March 2020, the project has just finished and it is early to assess its non-academic impact. However, the project has already had the impact of raising awareness of nursing's actions and potential in this field. Specifically, during the project, some of the emergent ideas were worked up into policy and practice proposals and developed at a national Policy Workshop held at the Royal College of Nursing (RCN) in London. This was attended by around 40 participants drawn from clinical practice, policy making, national organisations, education, research and the charitable sector. We then synthesised the resultant findings into An Agenda From, and For, Nurses and their Policy Allies, entitled Envisage and Act on AMR. This was featured at a recent (2020) Westminster Health Policy Forum event which was attended by around 200 delegates and was addressed by the UK Special Envoy on AMR. The RCN's Professional Lead for Infection and Control also addressed the event and featured RIPEN's work which in turn is informing refreshment of the RCN's guidance on AMR. In this way the project is already having some national impact in terms of policy influence.
First Year Of Impact 2020
Sector Communities and Social Services/Policy,Healthcare
Impact Types Policy & public services

 
Description Commentary feature about RIPEN on the Fresh Approaches to Antimicrobials in Society (AMIS) website (London School of Medicine and Tropical Hygiene) 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This engagement activity comprised an invited commentary feature about RIPEN on the Fresh Approaches to Antimicrobials in Society (AMIS) website (London School of Medicine and Tropical Hygiene). The website is a hub primarily for social scientists studying antimicrobial resistance and advocating strategy to better address it. It has international reach and is of interest to students in the field. The purpose was to promote knowledge of our study and the work being doing in nursing and the arts and humanities. It emphasises the value of interdisciplinary work. This has led to us discussing need for future initiatives with the LSHTM team.
Year(s) Of Engagement Activity 2019
URL https://www.antimicrobialsinsociety.org/commentaries/
 
Description RIPEN and RCN Policy Workshop (4/10/19) leading to a policy agenda for nursing and AMR that was shared at Westminster Health Forum Conference on AMR (20/2/20) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The RIPEN study has been working closely with the Royal College of Nursing (RCN) who are in the process of refreshing their guidance on antimicrobial resistance and nursing. The joint Policy Workshop held at RCN's London Headquarters on 4/10/19 brought together around 40 key policy leaders, academics, educators, researchers and clinical practitioners from across the UK. Prior to the event a briefing paper about the findings from the RIPEN study (see publications) was shared so that this could inform the workshop prioritising ideas for a policy agenda. The event was very successful and, following analysis of its outputs, a policy agenda called Envisage and Act was created. This agenda from, and for, nurses and their policy allies was synthesised into a leaflet that was given to all the 200 or so delegates at the Westminster Health Forum Conference on AMR held on 20/2/20. This high profile event, addressed by the UK's Special Envoy on Antimicrobial Resistance (Professor Dame Sally Davies), brought together key policy makers from all sectors. Rose Gallagher, Professional Lead for Infection Prevention and Control at RCN, also addressed the conference and highlighted RIPEN's work. The RCN will continue to draw on RIPEN's work to further develop policy and practice in the UK.
Year(s) Of Engagement Activity 2019,2020
URL https://www.ripen.org.uk/outputs.html