Chemical Literature Review project
Chemical Literature Review project – Guidance
The description below is in addition to the General Guidance Document provided for this
module on Learning Central.
A Chemical Literature Review should provide an in-depth description of important topics in the
chemical sciences. It should give an account of the subject matter and a balanced assessment
of the current primary literature. The implications of recent developments for the wider
scientific community should be discussed and emphasised. A literature review does not
contain unpublished research.
Good sources of information for a chemical literature review are review articles, such as in the
Chemical Society Reviews and Chemical Reviews journals, as well as other sources of the
primary literature.
Report (50%) – Advice on writing the report should be sought from supervisors. The headings
under which your report will be marked are described below along with the weighting of marks
each category receives.
Abstract/Introduction/ References: 30 marks
Outlook/ Conclusions: 20 marks
Discussion: 40 marks
Quality of Presentation: 10 marks
Total: 100 marks
The following structure for the report is suggested. If you feel this structure is inappropriate
you must discuss the matter with your supervisor prior to adopting an alternative report
structure. This structure is recommended for your guidance but also gives your assessors a
standard by which reports in different areas of the subject may be judged.
The following should be used as a guide during the preparation of your report. You should consult
with your supervisor on the finer details as different areas of chemistry require different styles of
presentation (cf. synthetic organic chemistry vs computational chemistry). The report should
contain the following sections:
Title page – This has been prepared for you and should be downloaded from the module folder
on Learning Central. Insert your name, your supervisors’ name(s), and your project title in the
spaces indicated. The section indicated should be filled with graphical representation of your work.
This could be a reaction scheme, an image or model of a compound, or a relevant graph.
Table of Contents/Acknowledgements/Abstract – The abstract is the first part of your report
that your assessors and readers will see. It will help them to quickly get an idea of the subject of
the report. Therefore, it is important that it clearly and concisely summarises the main discussion
points of the report and why they are important.
The abstract is a single paragraph which should:
• Be no more than 200 words; concise and easy to read with recognisable words and
phrases. For representative examples of abstracts refer to papers relevant to your field.
• Set out the main objectives and results of the work; it should give the reader a clear idea
of what has been achieved
• Emphasise (but not overstate) the potential impact of the research and why it is important
(compared to other research in its field)
• Avoid including detailed information on findings; this should be described in the main part
of the report
Introduction – An introduction should ‘set the scene’ of the work. It should clearly explain both
the nature of the problem under investigation and its background. It should start off general and
then focus into the specific research question you are investigating. Ensure you include all
relevant references. All literature must be suitably referenced (see below).
Results and discussion – This is arguably the most important section of your report. Your
findings should be organised into an orderly and logical sequence. Only the most relevant results
should be described in the text; to highlight the most important points. Figures, tables, and
equations should be used for purposes of clarity and brevity; they should be your own
reproductions and not directly copied from the literature source. Data should not be reproduced
in more than one form, for example in both figures and tables, without good reason.
The purpose of the discussion is to explain the meaning of your findings and why they are
important. You should state the impact of the work presented and relate it back to the problem or
question you posed in your introduction. Ensure claims are backed up by evidence and explain
any complex arguments. The style adopted in the papers used for your introduction will act as a
guide.
Outlook – Based on the current literature presented in the main part of the report, an account of
the possible future developments of the subject under review should be included.
Conclusions – This is for interpretation of the key results and to highlight the significance of the
presented work. The conclusions should not summarise information already present in the main
part of the report or abstract.
References – All references listed numerically in the sections above (as superscripts) should be
given in RSC style, i.e.
- J.Bloggs and U.T.Cobbley, Angew. Chem., Int. Ed. Engl., 1999, 38, 666.
Project Report Style: Type written on A4 single-sided paper (margins top/bottom/left = 2.5 cm,
right = 2 cm), font no less than 11 pt, one and a half line-spacing, pages numbered. Chemical
structures should be prepared in ChemDraw (or equivalent). All spectra, graphs etc that are
included, irrespective of whether they are in the main body of the report or the appendix, should
be clearly and carefully labelled, in type. Spectra should also be labelled with a structure of the
compound used.
Project Report Length: The Introduction/ Discussion/Outlook/ Conclusions sections should be
in the order of 25 to 30 typed pages, excluding spectra and appendices, etc but including diagrams
and tables. Please note this is a guideline, if the nature of the project is such that a longer report
is thought to be necessary, then advice should be sought from supervisors.
How to Implement SAP SuccessFactors Software
W.1 Project
A Study on How to Implement SAP SuccessFactors Software – Employee Central Module, in Human Resource Function to Improve Efficiency and Standardisation
An empirical project submitted in partial fulfilment of the requirements for the degree of
Master of Arts in Human Resource Management
at the Westminster Business School of the University of
Westminster, by
SubDeclaration
I declare that the research conducted for analysis and discussion on this dissertation has been solely composed by myself. Wherever references have been made of others’ discussion adequate references and credits have been given to them in the relevant sections.
No part of this research has been submitted for grant of academic credit of any other research.
1 Acknowledgements
This research has been possible because of the valuable guidance of Ms Christine Porter, our Course Leader, and Ms Sangeetha Srinivasan my supervisor for this research. Their continuous support has helped me to bring this research to the current form and shape that it is today.
I would also like to thank Dr Francesca Andreescu, our Module Leader. Credits are also due to Dr Elisabeth Michielsens for her valuable guidance at various points during this research.
I would also like to express my gratitude to all the respondents for the efforts they took to patiently reflect on their experiences in the implementation and application of SAP SuccessFactors Employee Central and other e-HRM tools in their organisations.
2 Abstract
This research aims to answers the main questions that the HRM functions of the organisations that make use of the SAP SuccessFactors Employee Central want to be answered. This research starts by exploring how the use of this technology increases the efficiency in the HRM working and at the same time standardises their processes. It also critically evaluates how successfully this technology has been able to meet the objectives of its use. A survey was conducted using a self-designed questionnaire to explore how the use of this application in the HRM evaluates it factoring in the organisational setup in which they operate.
A logical and methodical analysis of the survey results highlighted the pervasive and ominous use of these applications. However, the benefits which these applications offer now are in the area of administrative functions of HRM. The use of SAP SuccessFactors and other HRM technology as a strategic tool for HRM is still evolving.
With the advancement of technology, there is a high probability that these concepts will be used by SAP SuccessFactors too. The ERP HRISs will be supporting HRM across all sizes of organisations particularly for MNCs to be a strategic partner of the organisation.
3
4 Table of Contents
6.3 Challenges and Future Path.. 9
7.1 Strategic Partner and Emergence of e-HRM.. 10
7.2 ERP HR Software’s Vital to MNCs. 11
7.3 Increase in Efficiency. 12
7.4 Efficiency in Day-to-Day Operations. 13
7.5 Efficiency while Implementation and Maintenance. 17
7.7 Challenges in the use of HR Software. 18
7.8 Further Automation Required. 19
8 Research Methodology and Methods. 20
8.2 HR Research and Methods. 21
8.3 Research Questions and Objectives. 22
9.1 Decoding of the labels assigned to different questions. 27
10.2 Population and Sampling. 38
10.3 Data Collection Process and Access to Literature. 38
13 CIPD Reflective Statement 43
15.1 Figure Proposal Gantt Chart 49
15.2 Figure Actual Gantt Chart 49
15.3 Appendix: Online Survey Information presented to all participants. 50
5 Glossary Of Terms
| Notation | Description |
| AI | Artificial Intelligence It is the ability of the computer to intelligently perform common tasks (Britannica, 2022). |
| CIPD | Chartered Institute of Personnel and Development |
| e-HRM | Electronic Human Resource Management |
| ERP | Enterprise resource planning or ERP application can be defined as an application that helps organisations to run all their core process: finance, HR, supply chain, procurement, manufacturing, and others (SAP Insights, 2022). |
| HR | Human Resource |
| HRIS | Human Resource Information Systems |
| HRM | Human Resource Management |
| IT | Information Technology |
| L&D | Learning and development |
| Machine Learning | It is a branch of artificial intelligence that use algorithms and data to Enable machines to imitate the manner in which humans learn. |
| MNC | Multiple National Companies |
6 Introduction
SAP SuccessFactors Employee Central is one of the widely used ERP based HRM tools. Organisations use these tools as a driver to bring efficiency in its HRM function. This study contributes to the evolving area of use of technology through the SAP SuccessFactors Employee Central in the field of HRM and the academic interest in it of HR professionals. Empirical pieces of evidence have been used to gain an insight into how the use of SAP SuccessFactors Employee Central technology to perform HRM functions has brought efficiency and standardisation in its operations.
6.1 ERP Tools for HRM
Different formats of technological support are available for HRM and the ERP HRM solutions are considered to the best of the breed (Boroughs and Rickard, 2016). The ERP provides a complete range of functionality to support and manage the HRM. The available functionalities of SAP SuccessFactors Employee central are evaluated in light of the efficiency it embeds in the HRM operations and how it contributes in the standardisation of these operations.
These HRIS comes with options of the standardised set of configurations which can be either mirrored or customised to suit the nature and the scale of the HR functions of the organisations implementing them (Hunter, Saunders, Boroughs and Constance, 2006). The research discusses how the use of SAP SuccessFactors brings efficiency in the HRM processes of the organisations that operates as MNCs . The HR function of an organisation can operate under different setup: entity-based functions, shared service, co-sourced or outsourced. These HRIS can be used in all the setups and for varying scale of HRM operations.
6.2 ERP and Efficiency
The efficiency derived from the SAP SuccessFactors was analysing considering the existing offerings of these HRIS and then evaluating on how they contribute to the different functions of the HRM in terms of efficiency and standardisation. To do this first the primary and critical activities of the HRM were identified and then an evaluation was made on how the functionalities within the SAP SuccessFactors Employee Central supports.
A discussion on HR’s role and the organisations expectation from them has changed dramatically since 1960 i.e. roughly the time when the HRM function were digitised. how the role that HR plays within the organisation has changed was analysed.
The contribution to each critical function was analysed. Also, responses were sought to a self-designed questionnaire to confirm on what the end-users experience has been with the use of HRIS tools. The respondents were asked to share their response by easily selecting the coded labels.
The use of HRIS enables the users to maintain error free, data in a secured manner with controlled access. This data is logically processed by the systems to generate meaningful information. This information can support various functions of HRM: recruitment, on-boarding, performance management, time, and attendance, compensations and so on. The roles which these eHRM tolls support are mainly eliminate the administrative tasks of the HRM, they don’t contribute much to the strategic goal of the organisations. This is seen as a limitation of the SAP SuccessFactors Employee Central in its present state and form. But the emerging development in the technology and their successful implementation on other functions of the organisations through an integrated ERP platform is acting as a sliver lining where they will be able to support those functions of HR that are more judgemental based.
Furthermore, the capability of SAP SuccessFactors in a cloud format and how it benefits the HR has also been explored. It has to be highlighted that beside the primary benefits which the automation of these HR activities brings in terms of the savings in cost, time, compliance with the regulations and capability to generate massive reports in a concise and succinct manner for the management use there are also secondary benefits. These secondary benefits are mainly noted in the increased morale of the employees and their enhanced productivity (Boroughs and Rickard, 2016).
6.3 Challenges and Future Path
The research acknowledges the challenges which comes with the use of the HRIS. The efficiency introduced by these systems comes at a cost. There are both tangible monetary outflow and other intangible limitations with their use. The implementation of these applications is a complex process that is often managed through external support. A rigorous compliance of the agreed project implementation plan is necessary to ensure that the SAP SuccessFactors is configured to deliver the results in line with the standard agreed practises of the organisation. However, ones the application is implemented things comes down mainly on the day-to-day operating of these applications. The manner in which the users input and analysis the data on the HRIS defines whether it will add to the efficiency. Thus, the training of the employees is critical to make the efficient use of the eHRM to support the HR. The challenges are discussed more under in detail in the named section below.
The current limitations of these applications can be seen as the areas where they can support in the future. These are mainly with regards to the HR processes that are yet not support such as change management, employee relations and son on.
6.4 Research
The research mainly tries to gauge first hand experience of the users of these applications through a series of questions. The results of the survey were then then analysed manually to draw logical inferences and check their conformity or deviation to the findings of the scholars discussed in the literature review. This was then used to draw meaningful conclusions and recommendations.
7 Literature Review
7.1 Strategic Partner and Emergence of e-HRM
In modern organisations employees play a key role in determining a firm’s performance in business settings thus Human Resource Management (HRM) plays a critical management function in managing these resources (Uysal, 2014). Organisations could use human resources as differentiator so that they give them competitive leverage over their rivals. Further, for the realisation of the organisation’s strategic goals effective management of the human resources is vital (Khashman and Al-Ryalat, 2015).
The use of technology to conduct HRM activities is referred to as e-HRM. This term was initially coined in the 1990s. Earlier this term was used in a very narrow technological aspect and covered only those HR activities performed using the internet. However, as time evolved this term encompassed wider use of technology including the use of HRIS. There are three overarching applications of these HRIS: To publish information, automate transactions, transform the use of HR functions (Wilton, 2019).
HRM function has been restructured over time to fit in different roles over the time. In the 1960s HRM was mainly concerned with maintaining personal files, while in the mid of 1960s until the mid-1980s HRM function was expected to support the organisation to be compliant with all legal frameworks. From the mid-1980s HRM roles too more of the role of personal management and managing the employee life cycle. However, there has been a shift in the role of HRM from the late 1990s where it is mainly seen as a strategic partner. The traditional roles of HRM-related to database management, recruiting, appraisal support, are either outsourced or automated. Where HRM are unable to deliver on these expectations of the organisation they usually see their positions being made redundant as part of the restructuring (Torres-Coronas and Arias-Oliva, 2009). The use of technology in HR has grown and become pervasive in most of its activities like payroll, training & development, recruitment, HR planning. The drive for automation in HR is driven by the HRIS strategy which is expected to provide a competitive advantage to organisations (Torres-Coronas and Arias-Oliva, 2009).
7.2 ERP HR Software’s Vital to MNCs
The number of MNCs operating in different sectors has risen in modern times. These MNCs are organisations whose operations are spread across different geographical territories. These MNCs derive 25% or more of their revenue from operations that they carry out outside of their home country (The Black’s Law Dictionary, 2012).
The human capital of these organisations is spread across different countries. It is highly unproductive and futile to use manual processes to manage the HR of such organisations. Such companies thus usually use ERP tools which is a comprehensive way to manage the HR functions of these companies.
The use of these software/e-HRM tools allows them to automate HR processes such as managing absenteeism, performance appraisal, payroll, and learning and development. If these processes are performed manually these will take away much of HR’s time and it will have less time to support the strategic objectives of the organisation.
Further studies suggest that in these organisations HR is an active and strategic partner. Their role is elaborative in the larger organisations as compared to the role HRM has been performing in a traditional organisation. This shift in their role requires better data analysis and automation of clerical and repetitive functions.
One of the widely used e-HRM systems in the MNCs is SAP SuccessFactors Employee Software – Employee Central Module. They have positioned themselves as a Global Leader in developing and delivering software solutions for the execution of business processes and functions. This software offers various modules that can be used to automate the HR functions such as payroll, time management, compensation, recruitment and onboarding, performance management. Through its various modules, it is positioned to support the HRM functions and manage data in a manner that allows for further integration with the wide business like sharing the payroll data with the finance department for the further processing and payments of the employee salaries and compensations (SAP, 2020).
7.3 Increase in Efficiency
HRM aims to support organisations in achieving their objectives, such as recruiting the right people, developing a cordial relationship between the employer and their employees. HR proposes the people’s policies and practices while the line manager implements them while ensuring that the organisation achieves its objectives. To achieve this primary objective there are various peripheral roles that they have to perform such as mentoring and coaching, communicating across various levels, and being technologically skilled.
E-HRM provides organisations with the tools through which HR can organise, analyse and manage the personnel in a manner that would support the management to attain their strategic objectives cost-effectively and efficiently. This is particularly helpful when managers are operating in uncertainty, turbulence.
The organisation’s strategy should be driven by big data. HR systems can be used to perform people analytics to analyse people’s engagement, discourage absenteeism, evaluate the outcomes of learning and development activities, recruitment process, performance management, and reward management.
The outcomes of these analyses help organisations drive better employee engagement and reduction of employee turnover and retention. This also drives updates and changes to the HR policies and procedures, evaluation of the diversity and inclusion performance of the organisation, and estimating the social and financial return on the human resources. However, for e-HRM to be effective in this regard the input data must be cleaned, and accurate which can be used to perform multidimensional, predictive, and descriptive analytics (Armstrong, 2009).
HRM’s decision-making improves when it’s supported by the data analysed from information systems. The HRM systems provide for an organised solution to store the data systematically. Comprehensive detail of employees’ data can be maintained in this HR software These systems have been particularly helpful in the planning and development of HR setup in contemporary organisations (Alshibly, 2014).
This data is analysed to make informed and rational decisions about the employees of organisations which are also aligned to the individual’s needs. A cordial work environment is established where individual needs and matched to the organisation’s objectives. One such example can be seen when reports on completion of the assigned L&D training to the employees is analysed. In case there are delays in the completion of these pieces of training, the line manager can push the employees to complete them. This is beneficial for the organisation and their employees to upskill themselves (Chang et al., 2013).
Though there is an outflow of monetary resources when this HR software is implemented and also in their further maintenance. This, however; lead to better and more efficient results being made that support the short-term and long-term goals of organisations (Masum, Kabir, and Chowdhury, 2015).
7.4 Efficiency in Day-to-Day Operations
The use of technology in HRM is mainly targeted to accomplish HR transactions, record keeping, and other repetitive administrative HRM tasks. It is expected that through the use of this software, the HR function within the organisation will be able to support the strategic objectives of the organisation as highlighted in the sections above along with bringing financial savings for the HR department. With the evolution of technology, these tools can serve as specialised advice to the management on compensation, career development, selection, and management of the talent pool of the organisation.
Due to the relative newness of the use of technology and ERP software, there is not much-supported information and statistics to evidence their effect on the effectiveness of the HRM function. The presently available research shows that the most useful benefit is in terms of efficiency in the areas of are cost, service, and speed to bring to HRM function. When the delivery of services of HRM improves it also improves the credibility of the HRM.
However, some of the scholars opine that the existing HRIS tools do not effectively contribute to the attainment of the organisations’ objectives and decision-making by HR. The main reason for this disappointing contribution of HRIS can be attributed to the novelty of these applications and the inexperience of the organisation in the use of these tools for strategic purposes. Refinements are still sought in the manner the data is being processed by these HRIS tools before they can prove to be as effective as the finance, supply chain, or other system managing applications. The management supports building HRIS so that it can manage its dispersed and diversified workforce. The use of the HRIS in an integrated setup like SAP SuccessFactors Employee Central enables for holistic use and analysis of data and contribute to the organisation’s objective efficiently by creating knowledge of networks, improving the manager decisions on human capital, offering a positive experience to its users, and enabling the measurement of its contribution to the organisation amongst other factors. Also, a parameter to measure the effectiveness of the HRIS is measured by the amount by which it has reduced the HR cost. This at times as having negative implications for HR personnel as it is expected to lead to their redundancy (Lawler III and Boudreau, 2015).
The global operations of the organisation require the use of a networkable and advanced solution to manage the dispersed workforce make wider use of these applications. Completely integrated applications as SAP SuccessFactors Employee Central are rated much higher in terms of efficiency they bring in:
Human Resource Planning (HRP): Organisation’s demand for labour requires analysis and forecast of the demand and supply of the labour. While making such predictions factors such as expected leavers, temporary withdrawals (due to maternity/paternity leave, secondments, or sabbaticals) are to be considered. HRIS is designed to make these analyses on HRM’s behalf (Wilton, 2019). It is one of the analytics that SAP SuccessFactors’ HR Analytics can do for HR personnel. The data derived from such tools are expected to have fewer chances of error and the results of such analysis are much quicker when we compare them to the manual processing of such information (SAP, 2022).
Its various modules introduce efficiency at different points in the HRM functions. In the onboarding stage, HR professional spends a lot of time keying in the data which is shared by the employees over form. This can, however; be managed efficiently in SAP SuccessFactors that is designed around the principle of self-service. So, once the new employees are added to this application they can update their own information on the system, and HR can just verify and check the information (Murray, Mazhavanchery, and Marson, 2015).
Integration: One of the main advantages that ERP software offers is that of integration (Lawler III and Boudreau, 2015). SAP SuccessFactors is an ERP solution which means that the organisations can add different modules to their subscribed piece of software to match their growing needs. There is a native integration between these modules which means that the data of one module can act as an input for another. Like the time management modules could be used for processing of payroll. This saves some valuable time for HR personnel who can instead use that time saved on repetitive administrative work for strategic tasks.
Also, there are certain changes which have an impact on all or a group of employees in the organisation such as when change there are changes to the tax rates, or when emails are to be sent to a particular group of employees all these processes can be automated by updating the configurations of the HR software.
Availability: When organisations use HRIS to manage the data of their data it gives them the ability to access data from anywhere at any time (Lawler III and Boudreau, 2015). Users can access SAP SuccessFactors and the HRIS tools at any time and from anywhere. Also, these tools are supported across various platforms which means mobile, computers and other platforms can be used to access this data. HRM personnel using these have mobility and they longer have to be physically present at the office to access that critical information.
Cloud-Based: The cloud-based versions of the SAP application are expected to enhance the quality of the data past, current and information analysed. Thus, making them available when required and also cutting down on the cost of these systems and their maintenance to the cross-function units such as IT and the related downtime in the HR. Due to the scalability, organisations are able to upgrade their subscribed services and support the larger data processed by HRM. The could-based versions give more independence in terms of cost and thus more organisations can use these to standardise their process and increase their revenue. The Cloud version of SAP SuccessFactors is maintained and hosted by the vendor, which means that they are responsible for their maintenance, and even when there are any deletes the vendor is expected to have a backup of that data and restore them. Thus, HR does not have to re-create those data (Bondarouk, Ruël and Parry, 2017).
An HRIS is considered to be effective when it can support more tasks (Lawler III and Boudreau, 2018). There are various modules offered by SAP in their present offering for SAP SuccessFactors. This helps to automate the various processes of HRM such as recruitment and onboarding, time and attendance, learning and development. Using the recruitment and onboarding module HRM personnel can manage the recruitment requisitions, interviews, matching, compliance, offer, and also rating the candidates. Workflows can be designed and configured within the system to ensure that there are different employees involved with the requisitions, review, and approval. Thus, minimizing the chances of error and managing the process seamlessly. It also allows HR to enhance its banding and reach a larger talent pool through various channels such as LinkedIn, Facebook, job portal, corporate website, helping the management to make an informed decision (Grubb and Lessley, 2017)
The information generated and maintained by the SAP SuccessFactors depends upon the quality of data that is entered and the validation and the logic through which the data is processed by this application. With the growing relevance of the data governance the use of these HRM systems there are checks to confirm the completeness, accuracy, consistency and relevance of the data. Poor data maintained by the HRM has a cross-functional impact and can affect the over finance, compliance, productivity, and confidence of the staff in a negative way (Bondarouk, Ruël and Parry, 2017).
7.5 Efficiency while Implementation and Maintenance
Strategic and operational functionalities of HR processes can be covered through the use of SAP SuccessFactors. As the organisations grow one of the main questions that they face is whether the applications which they are using will be able to process the larger data? Thus, scalability becomes important. Here the offering of the cloud or hybrid versions SAP SuccessFactors come in handy. If the organisation chooses to go with the cloud or hybrid version of this HR software they get immediate access to scalability. This means that they have more storage and processing capability at their disposal. Thus, HR is doesn’t have to each time go back to the software provider, and there It for making a major change to the organisation’s IT infrastructure and disruption to the HR technology saving some valuable HR personals work hours (Murray, Mazhavanchery and Marson, 2015).
Further SAP offers to provide regular updates to this software to patch any vulnerability in the security of this software which means that the personal and sensitive information which is stored by HR in it is secure and HR can save a lot of time that it would otherwise spend on the management of the files and hard copies. Also, when software is used to manage data then a backup of these data is kept by the companies hosting them. Thus, there is also a facility to restore the data if the data is deleted by error or even sometimes intentionally by a distraught employee (SAP, 2022).
7.6 Shared Services
The use of HRIS has also boosted the concept of shared services. Through the use of technology, there has been a rise in the organisations that manage the HR functions of different organisations. Also, there are centralised units of HR within the organisations that manage the functions of its multiple entities. Using these outsourced and co-sourced services the organisations are able to reduce the cost, increase human motivations and focus on what is more important strategically (Boroughs and Rickard, 2016).
7.7 Challenges in the use of HR Software
There has been a spike in the demand for HR software in the UK. Between 2016-2021 a compounded growth of 7.7% was expected in the revenue of the organisations that develop such HR software. The total market revenue was expected to reach £1.2 billion (IBISWorld – Industry Market Research, Reports, and Statistics, 2022). Many companies have a share in this market such as Workday, SAP SuccessFactors, BambooHR, ADP, Oracle PeopleSoft. The selection of which application is will suit the requirements of an organisation is vital.
This has resulted in a spike in the investments which organisations make in the acquisition and maintenance of HRM tools and software with the aim to support better HR planning, employee training, and development, along with succession planning Nagendra and Deshpande, 2014). This implementation is however not always straightforward and has its own challenges. In June 2021 CIPD did a study on the larger organisations who as per them have employed between 10,000 to 60,000 employees to identify the challenges which they faced while implementing HRIS system to automate the HR functions and their learning from this change management process. This article shared the experiences of HR professionals of three such large organisations. Implementing a new HRIS involves identifying the outcomes from those systems, engaging with internal and external experts to support the implementation process, ensuring that the employees can access the data from different platforms such as laptops, mobiles, and desktops (CIPD 2021 Operating efficiently: implementing HR information systems in large organisations).
It is also vital that there are controls to ensure that the data can be accessed by only relevant individuals. It is important that any regional law and regulations related to the implementation of the new system that process any personal and sensitive personal information are complied with like in the UK the GDPR regulations published by the ICO for the implementation of such systems are to be completed with by completing the Data Protection Impact Assessment (DPIA) before implementation of these systems (Data protection impact assessments, 2022).
Adequate training is an important factor for the appropriate use of the SAP SuccessFactors and other technology in HRM. Depending upon the quality of the system the training plans are to be adjusted such as SAP is a highly technical application thus when this application is implemented then staff using these applications are imparted training for it to be effectively used. Thus, training has an impact on the efficiency of this application (Bondarouk, Ruël and Parry, 2017).
7.8 Further Automation Required
Innovation is required for HRIS to be effective. HRIS can be seen as a computer of the HRM that is expected to automate its processes. However, there are certain limitations to the state and form up to which the SAP SuccessFactors Employee Central and the other HRIS have managed to be developed. The role of HRM might be restricted to being a mere spectator of data. Mostly it is the traditional HRM functions that are at play by the EHRM tools (Bondarouk, Ruël, and Parry, 2017). There are still areas in HRM for which no electronic solution is available like employee relationship management (grievances and disciplinary). Yet these are mostly manually managed areas with the augment of AI and machine learning it might not be a surprise if we see the software providers launch software to develop these areas which are not yet captured by SAP SuccessFactors.
Further, a report shared by KPMG based on their analysis of the major 21 tasks of HRM noted that there is high potential to automate the different functions of HRM either fully or partly. The automation of the five major areas of the HRM is less susceptible: managing employee relations, change management, managing organisational effectiveness, management of the architect of people performance, and supporting the HR and business strategy. Also, there are challenges in keeping the workplace human as it is expected that the use of automation and robotics will replace the human side of human resources (Tobenkin, 2022). SAP SuccessFactors is expected to leap forward in terms of the additional functionality offered by it through the use of artificial intelligence and machine learning where it will make use of conversational interfaces and bots[1] to manage the areas unexplored by HRIS and to manage better some of already supported task more effectively (Burlacu, 2022).
8 Research Methodology and Methods
8.1 Methodology
The research analysis the results of the self-designed questionnaire though comments were sought to improve it before being circulated to the potential participants. There are chances that its purpose the understanding of the researcher may have limited its aptness for the research. Also, the information shared by the respondents has been assumed to be correct and accurate no investigative work was done to establish its correctness and completeness. This might have an impact on the quality of data used for analysis. Further, there may be many more benefits, challenges, and limitations with the SAP SuccessFactors Employee Central and other HRM software used by the respondents. But due to the constraint in the time, only those points which are assumed to be most critical by the researcher have been set as an option in the answer for the survey.
A further pragmatic approach was taken to ensure that only related empirical observations, hypotheses, and induction carried out during the research were considered to deduct any irrelevant information while proposing the recommendations (Saunders, Lewis and Thornhill, 2019, Pg.148-155).
8.2 HR Research and Methods
In simple terms, research means a systematic way to findings out things with the objective to increase one’s knowledge. HRM as a discipline involves making sound informed decisions that have an impact on the employees. Thus, HR research can be explained as a systematic and organised inquiry undertaken with an objective to increase one’s knowledge in HR that supports the action taken by HRM (Anderson, Fontinha and Robson, 2019 Pg.10-11).
Applied research is carried out with the purpose of gaining an understanding of a specified topic (Anderson, Fontinha, and Robson, 2019 Pg.11-12). As highlighted in the discussion of various literature reviews, there is a lack of research material on the impact of the implementation of SAP SuccessFactors – Employee Central in organisations. This research attempts to narrow this gap especially focusing on the impact it has had on the effectiveness of the HRM functions of the MNCs that have implemented it. The aspect of the introduction of standardisation in the processes of the HRM through the use of this software has also been explored.
Research in HR is characterised by diversity. Thus, the assumption after consideration of the various models for research processes and diagrams that there is one right way to conduct research may be incorrect (Anderson, Fontinha, and Robson, 2019 Pg.13).
An explanatory and exploratory research approach was undertaken to explain how SAP SuccessFactors have an impact on the efficiency of HRM functions and their standardisation. The research further explores finding new insight and asking questions on how this software could be used to support the HRM function better.
Explanatory and exploratory research requires the use of both quantitative and qualitative methods to answer the ‘why’ and ‘how’ and at the same time gain new insights.
Mixed methods of research see value in the use of both qualitative and quantitative data are particularly useful where are resource constraints: time and cost. These methods help to gain valuable insight into the variables cross-check the confirmations and provide a better understanding of the ‘why’ relationship between the different variables.
Mixed methods were used to design the survey. At first, participants were asked to share their responses to the standardised questions sent to all the participants by filling out the questionnaire. Follow-up clarifications were asked from them as and when necessary to gain insight into their responses.
8.3 Research Questions and Objectives
The online survey questionnaire was designed to gain insight into the research problem. The use of SAP SuccessFactors Employee Central as a preferred HR software tool was explored, along with the benefits of its uses, challenges in its use, and areas of further improvement were also gauged through this questionnaire that had these questions:
There is no publicly available document that confirms which organisations use SAP SuccessFactors Employee Central Various tools. To gain confirmation, it was ensured that the respondents know which HR software is in consideration, this question was asked first.
It is vital for the research to understand if there are organisations that prefer other eHRM tools over SAP SuccessFactors Employee Central. An analysis of this question is expected to be indicative of the limitations of this software in terms of its reach (cost limitations) and or functionalities, among others.
The number of employees impacts the volume of the data which is processed by the HRM. This study also identifies if there is a correlation between the sheer number of employees to the selection of the HRM software.
A way to attain standardisation is when similar processes are followed both at the Head Quarter’s and at the regional offices. One of the key aspects of MNCs is that they are spread across countries and many times across the continents too (James and Baruti, 2021). It was identified if there are respondents who work for organisations that operate across the borders and are required to meet the objectives of efficiency and standardisation.
This research is primarily focused on the use of SAP SuccessFactors Employee Central in the MNCs, and the respondents were asked to confirm if they work for an MNC so that correct inference can be drawn from the analysis of the data.
SAP SuccessFactors Employee Central offers various modules such as employee benefits management, time and attendance, succession and development, and others to facilitate digitisation and automation of HRM processes. Organisations have an option to subscribe to all or any of these modules (SAP, 2022).
The main aim of this study is to identify the areas within HRM that benefit from the implementation and use of SAP SuccessFactors particularly in the areas of efficiency and standardisation. Respondents were asked to choose from the main benefits advertised by SAP SuccessFactors from the use of their application (SAP, 2022). They were also given the option to choose others if they experience benefits that are different from those bulleted in the questions. They also had the option to skip this question in case they felt that there are no tangible and intangible benefits from the use of this software. An analysis of this response gives insight into what users feel are the most beneficial features of this technology. It was also analysed if users of the other software have experienced similar benefits.
HRM is the management of human resources that requires an emotional and contextual analysis. SAP is working to introduce artificial intelligence to help digitise more processes of HRM. An inquiry was made to track which are the areas of HRM are not supported by SAP SuccessFactors and is of interest to the respondents.
This inquiry was made with the target to find major challenges which the users of this application have had with its use. Being a heavy on technology application there are various implementations and day-to-day issues may face. The respondents were given the general issues that are faced by the users in such a scenario based on the reading at CIPD’s website and they were asked to choose any or all the challenges that they encounter (CIPD, 2022).
8.4 Procedure
This research was performed in an organised and structured manner following the underlying principles of the Research Onion. Attempts were made to ensure the analysis of data is performed with a neutral and unbiased view (Saunders, Lewis, and Thornhill, 2019).
The current sociological and regulatory factors were considered while deciding on the methodology. The normal work hours of employees have increased by 56% ((Impact of COVID-19 on working lives | Survey reports | CIPD, 2022). Technology has enabled more employees to know work from home. There is an increase in social isolation and increased adoption of technology-enabled methods (The impact of new tech during COVID-19 | CIPD, 2022).
To adapt to the change in the preferred ways of interactions and working online surveys were carried out with an expectation of wider and quick response. Survey Legend website was used to design the survey and later collect the results. Primary data was collected from the users through a structured interview that had pre-coded answers. Such an interview style is expected to lead to an unbiased interview but might have elements of subjective opinion from the interviewee (Saunders, Lewis, and Thornhill, 2019, Pg. 435-436).
The information on the total number of organisations that use SAP SuccessFactors Employee Central is not publicly available. A sample-based approach was used to collect responses to the survey. Sampling can be used as an alternative from obtaining a census from the entire population when there are budget constraints, and time and where it is impractical to survey the total population (Saunders, Lewis, and Thornhill, 2019, Pg. 492-494).
An outline of the survey questions to be sent out to the participants was discussed with the supervisor at the time of review of the project proposal and feedback received at that time was used to update the final questionnaire used for this project. Eleven responses were received to the online survey over 10 days. Each respondent could only fill out the survey once. The responses were coded and quantitative analysis of the descriptive data was carried out this allowed me to carry our comparisons between the data collected. Additionally, this approach also saved time (Saunders, Lewis, and Thornhill, 2019, Pg. 569 – 571).
8.5 Respondents
The online questionnaire was sent to 25 HRM professionals who have had experience in the use of SAP SuccessFactors Employee Central and other eHRM tools. The link to the survey was shared with them through email and/or mobile messages. Ethical issues such as privacy, informed consent, anonymity, and confidentiality of the respondents were considered while processing their responses and reporting them for this research (National Centre for Research Methods, 2022.
The research survey was open from 8 January 2022 to 17 January 2022, giving the professionals a window of 10 Days to respond to the survey. The users were requested to respond to all the survey questions. However, this was not made mandatory. This is analysed further in the reflective statement.
The respondents to the survey were independent of this review and anonymity was maintained throughout the survey. Also, assurance was provided on the confidentiality of the data shared by them to ensure that their opinion is free of any influence. However, as this survey is based on the experiences of the SAP SuccessFactors Employee Central users, the objectivity of their answers might be a debatable point (Saunders, Lewis, and Thornhill, 2019).
9 Results and Analysis
9.1 Decoding of the labels assigned to different questions
The response to questions 1,2, 4, and 5 of the questionnaires fall under the dichotomous category as only two categories of response are possible to them. Value labels were assigned to different categories of responses within each of the questions. The responses were coded. The coding assigned to the two labels in the dichotomous questions 1,2,4 and 5 are represented in the table below:
| Label Question No# | 1 | 2 |
| 1 | Yes | No |
| 2 | Yes | No |
| 4 | Yes | No |
| 5 | Yes | No |
The first question was to confirm if the respondents are using SAP SuccessFactors Employee Central. Code 1 was used to capture the positive responses while code 2 was used to capture a negative response. The second question tests if there are other eHRM in the market. When the respondent selected code 1 as a response to this question it confirmed that they do use an alternative HRM software while a response as 2 means that they don’t use any HRM software. Response to question 3 of the questionnaire that finds the size of the organisation has been measured using a quantitative variable. The response to it is scalable from 0 to more than 10,000 with regards to the number of staff employed by it and there are fixed intervals to it.
Question 4 gathered responses on whether the operations of the organisation in which the respondents work operate in more than one country. When the participants confirmed that their organisation operates from more than one country it coded as 1 while any negative response to this question is recorded as 2.
While question 3 was targeted to find the number of staff supported by the organisation on whose practices the participant is responding to. However, this data is not distributed in equal intervals and thus it has been analysed using a nominal basis rather than as scaled data. The following coding was used:
| Code | Label | Code | Label |
| 1 | Less than 1000 | 3 | 2000 – 5000 |
| 2 | 1000 – 2000 | 4 | 5000 – 10000 |
The next three questions were aimed to find respectively the various modules of the SAP SuccessFactors Employee Central or other eHRM tools that they are using. While question 8 seeks to know what benefits did the participants noted from the use of these tools. While in the last question inquiry was made to the challenges they faced with the use of the application. All these three questions were set as multiple choice and more than one response was possible.
In response to question 7 of the questionnaire, participants were able to select the following codes to reflect which of the modules of SAP SuccessFactors or other eHRM do they use. The following codes were used to capture their response:
| Code | Label | Code | Label |
| 1 | Saving of cost | 4 | Motivated employees |
| 2 | Time to value/efficiency | 5 | Data security |
| 3 | Time and attendance | 6 | Accuracy |
In question 8 the codes were attached to the main benefits that the use of SAP SuccessFactors as discussed in the literature review section above that the participants experience with the use of these tools.
| Code | Label | Code | Label |
| 1 | Employee relations | 3 | Motivated employees |
| 2 | HR Strategy | 4 | Data security |
In the last question of this questionnaire, the challenges experienced with the use of these applications were captured using the following codes:
| Code | Label | Code | Label |
| 1 | Initial installation | 3 | Motivated employees |
| 2 | Training employees | 4 | Data security |
SPSS software was used to analyse the data this tool doesn’t have the capability to interpret the data. The results of the analysis were interpreted to draw an objective conclusion.
The valid data is where we have a score where the participants have decided to abstain from responding those fields are taken as invalid data and have not been used for analysis and further interpretation.
The percentage is calculated based on the total sample size while the valid percentage is computed based on the number of responses from that set of samples. This research interprets data based on the valid percentage unless indicated otherwise.
9.2 Quantitative Analysis
To start with a first-level analysis was performed using frequencies. This helps users to get an understanding of the data and make primary comparisons (Anderson, Fontinha, and Robson, 2019).
Also, deviations of most observations were captured in the form of standard deviations and the behaviour of different variables was analysed.
SAP SuccessFactors is a widely used HRM software with 54.5% of the respondents confirming the use of this application to manage their HRM activities.
| Do you use SAP SuccessFactors Employee Central to manage your HRM function? | |||||
| Label | Frequency | Percent | Valid Percent | Cumulative Percent | |
| Yes | 6 | 54.5 | 54.5 | 54.5 | |
| No | 5 | 45.5 | 45.5 | 100.0 | |
| Total | 11 | 100.0 | 100.0 |
The remaining 45.5% of the users confirmed the use of other eHRM tools. This substantiates the pervasiveness of the use of technology for HRM discussed above in the literature review. Interestingly the organisation where all the respondents worked had its operations spread in more than one country. One of the main reasons for the use of this software is their capacity to bring standardisation in the processes of the MNCs that are spread across the borders and thus have different regulatory and cultural practices.
| Is your organisation considered to be a Multinational Company (MNC)? | ||||||
| Label | Frequency | Percent | Valid Percent | Cumulative Percent | ||
| Yes | 8 | 72.7 | 72.7 | 72.7 | ||
| No | 3 | 27.3 | 27.3 | 100.0 | ||
| Total | 11 | 100.0 | 100.0 | |||
72.7 of the participants confirmed they use these tools while working in an MNC. 45.45% of the respondents were those who used SAP SuccessFactors in an MNC setup.
The size of the organisation where the respondents used these tools mostly employed less than 1000 employees with 72.72% of the respondents claiming that their organisation employed less than 100 staff. 85% of these organisations use SAP SuccessFactors. The results are indicative that eHRM tools are used in all the sizes of organisations whether such size is determined based on their size, geographical spread, or the revenue generated from overseas.
| How large is your organisation (considering the total number of employees)? | ||
| Size of Employees | N | Frequency |
| Less_than_1000 | 11 | 8 |
| Between_1000 to 2000 | 11 | 1 |
| Between_2000 to 5000 | 11 | 0 |
| Between_5000 to 10000 | 11 | 1 |
| More_than_10000 | 11 | 1 |
| Valid N (listwise) | 11 |
The relationship between the use of eHRM tools, size of the organisations, the spread of operations of the organisations, and the number of staffs in that organisation. A maximum positive frequency of 8 was noted when the organisation operates in more than one country and they use eHRM tool including SAP SuccessFactors to manage, automate and standardise their large scale HRM operations.
Fig1: Relationship Map
9.3 Qualitative Analysis
The results of the survey suggest that time and attendance is the module used by most of the organisations in which the respondent works. This is closely followed by recruitment, compensation, onboarding. This further emphasises the use of SAP SuccessFactors and eHRM on the automation of the tasks that are clerical and repetitive HRM tasks introduce efficiency highlighted in the literature review. The results of the descriptive analysis are highlighted below:
| Which areas of HRM in your organisation are managed through SAP SuccessFactors or any other HR software that you use? | ||
| Module | N | Frequency |
| Time and Attendance | 11 | 10 |
| Recruitment | 11 | 9 |
| Compensation | 11 | 7 |
| Onboarding | 11 | 7 |
| Learning and Development | 11 | 6 |
| Performance and goal management | 11 | 5 |
| Succession and development | 11 | 3 |
| Valid N (listwise) | 11 |
The modules to manage the learning and development, and performance and goal management, are also used widely. However, the survey suggests that organisations make the least use of the module designed to manage the succession and development module.
Fig 2 : Analysis Graph
There are various tangible and intangible benefits from the use of this software. When users were given multiple options to select which are the most beneficial features of the survey. 72.72% of the respondents agreed that the automation of the HRM tasks mainly helps to perform more tasks and thus channel that time to manage the more strategical task as they said that its use adds value to time. The other most common benefit to which 63.64% of the participants agreed was around the cost which is saved by using the SAP SuccessFactors and other software. This may also be indicative of the fact that at places this software tends to replace the HR professional. This might also be a probable reason for the users, not 36.36% of the remaining participants not looking at this as a real benefit for the HR professional. When technology is used to manage HRM data there are in-built checks within the software. For instance, SAP SuccessFactors has the capability to stop a user to input a text value in the date field. One of the main drivers beyond this is the standardisation that the use of SAP SuccessFactors embeds into the process and various task performed by HRM. The users also, felt that this not only increase the accuracy of the data that is used to make daily and strategic HR decision but also increase the efficiency of the users as they save time to correct those errors. 54.55% of the participants also agreed that the use of these software has increased to manage the confidentiality of data as there are access controls within the systems that can be used to define who has access to what. Thus, helping them to maintain better security of the personal data that was maintained using manual processes. This also led to the fulfilment of the regulatory requirements under GDPR in the UK and other equivalent regulations outside it. These benefits and other secondary benefits keep the employees motivated as agreed by 54.44% of the participants in the survey.
| What are the main benefits of using SAP SuccessFactors or HR software? | |||
| Benefits | N | Frequency | Absolute % |
| Time Value | 11 | 8 | 72.73% |
| Cost Saving | 11 | 7 | 63.64% |
| Accuracy | 11 | 6 | 54.55% |
| Data Security | 11 | 6 | 54.55% |
| Employee motivation | 11 | 6 | 54.55% |
| Valid N (listwise) | 11 |
Technological development in the recent past has led to making the machine more intelligent and learning based on the pattern of the records processed by them. There are areas within the HRM functions that take a substantial part of the HR but there is no technology to support their automation. Respondents shared their views to confirm which areas of HRM they would like to be supported by the software. 63.64% of respondents see that it will be most beneficial for them if employee relations could be managed and supported by SAP SuccessFactors or other HR tools. The judgemental nature of this function has not been much supported by SAP SuccessFactors at the moment. Functions like change management, HR strategy and managing organisational effectiveness are other areas that respondents felt should be better supported by the software.
| Which functions of HRM are not supported by SAP SuccessFactors or the available HRM software solutions? | |||
| Areas | N | Frequency | % |
| Employee Relations | 11 | 7 | 63.64% |
| Change Management | 11 | 5 | 45.45% |
| HR Strategy | 11 | 4 | 36.36% |
| Organisational Effectiveness | 11 | 2 | 18.18% |
| Valid N (listwise) | 11 |
Lastly, an investigation was made to explore the challenges that the HRM personnel and the organisations that implement this software have to face. Users shared to have faced multiple challenges with the implementation and use of SAP SuccessFactors or HRM software. HRM generally doesn’t have the technical expertise in managing the software. They thus have to liaise with IT and finance for maintenance, support, and managing the cost of this software. This cross-functional liaising has been found most challenging by the respondents with 54.5% of them listing it to be a major challenge. Also, training the employees to use the application was found to be challenging by 45.45% of the respondents.
| What are the major challenges in the use of SAP SuccessFactors or the available HRM software solutions? | |||
| Challenges | N | Frequency | % |
| Initial Installation | 11 | 4 | 36.36% |
| Employee Training | 11 | 5 | 45.45% |
| Cross-Functional | 11 | 6 | 54.55% |
| Valid N (listwise) | 11 |
10 Limitations
10.1 Data Source
Though an axiology approach has been followed while analysing the responses these may be affected by the oncologic assumptions of the respondents. These responses were from the HRM professional, and many do not factor in the effectiveness that the organisation sees by the implementation of SAP SuccessFactors and/or other HRM software. Additionally, there was a change to the targeted source of data. At the stage of proposal, the aim was to collect data from the then place of employment. However, after the submission of the proposal the access to that organisation was eliminated due to researcher’s redundancy. Hence, judgment was made to share the questionnaire to the next best available source. These were the HR professionals who had first hand experience in the use of SAP SuccessFactors Employee Central.
10.2 Population and Sampling
The total population who uses SAP SuccessFactors is not publicly published. It is suspected that the figure could run to thousands given the limited information available on the internet. Thus, the sample size selected, and the actual response maybe not be truly indicative of the response of the substantive population and there may be many variances from the conclusion drawn in actual practice.
10.3 Data Collection Process and Access to Literature
The data considered for this research is mainly from the reading of research, books, articles, and journals of various academicians, interactions with the HRM professionals, and their responses to the survey. A read of various journals was also done. However, there is not widely available published data on SAP SuccessFactors. Thus, inferences are drawn for other HRIS applications that are developed and operated on similar philosophies and technology. Thus, there may be a generalisation of the impact of technology on HRM’s efficiency and its ability to standardise the HRM processes.
11 Conclusions
The discussion around the various available material and evaluation of the above participants’ responses highlights the various areas within HRM that could benefit from the use of SAP SuccessFactors technology. As can be seen, it is hard to find an organisation that doesn’t use technology to automate to support any of its HRM functions with the probability being nil in the survey conducted.
Although the software has various modules to cater to a range of needs in the HR function these are more standardised and the capability to be in customisation is either very restricted or heavy on the pocket (SAP, 2022).
There has been a shift in the role that HRM is expected to play in the success of the organisation. They are expected to be a strategic partner who is able to analyse further trends, design the process and procedures that supports the organisation’s strategy, and lead to developing a culture where employees are motivated to contribute to the attainment of the organisation’s objective and success. These expectations from HRM requires the automation of their traditional task. Depending upon the financial constraint’s organisations can implement various modules of SAP Success Factors and or HRM tools to automate the HRM processes. This is where the use of these software has gained appreciation. There is an obtain of scalability that SAP SuccessFactors brings in. Where the organisations have an option on which modules on the ERP they want to implement and to which entities where their operations are spread across the border.
Due to the limited development in this area and because of the involvement of the human element at the moment, there are only limited functions of HRM that can be automated such as recruitment, attendance, learning, and development to name a few. Though as a field of science the technology development in this area is still evolving. To overcome the elements of uncertainty and difficulty to predict the behaviour of human resources some critical functions of HRM have not been successfully automated so far.
These functions including employee relationship, change management, and strategic management are still not effectively supported by the available modules and tools. With the growth in artificial intelligence and machine learning, there are chances that these areas of HRM which are heavy on judgemental calls and logical processing of data will soon be supported by technology to further standardise the processes around these functions and at the same time introduce greater efficiency.
12 Recommendations
One of the recommendations which the organisations implementing these technologies should be aware of is that the technology is only as good as the users. Thus, the tech education of the users of these tools is paramount. This point was also highlighted by the respondents who agreed that training the employees to use these tools is one of the major challenges in the use of these tools. This contract which comes along with the benefit of the SAP SuccessFactors and other HRM tools should be factored into by the organisation when they evaluate the efficiency and standardisation introduced by them.
Another recommendation would be around the use of project management tools and practices when organisations implement SAP SuccessFactors. The implementation would be successful only if the settings on the SAP SuccessFactors is correctly configured to reflect the practices and procedures of the organisations. Also, an organisation invests their man-hour, finance while implementing these. This is vital that the test results are correctly checked by the knowledgeable users of these tools before these are put to actual use. Also, it is important that there is the supervision of this implementation process to ensure that it is complemented within the timeframe and is set to deliver the efficiency excepted from its use.
Finally, it is to be considered what impact the inability to access the SAP SuccessFactors applications will have on the HRM operations of the organisations. Mainly these impacts can be divided into three broad categories: operations issues, issues that are tactical, and lastly issues that have a strategic impact. Operational issues include issues that put the administrative working of the HRM function of the organisation in halt such as lots of manual intervention to the applications so that they can process the data being inaccurate and incomplete.
Tactical issues such as the inability to process the data generated through processing by the HRIS, accessibility of these systems, and coverage of the functions lead to a tactical inability by HRM to manage by relying on these applications. Then there are issues that have an impact on the strategic goals of the organisations like inability to manage the complete end-to-end process, inability to change, inability to manage change, or even to adjust based on the forecast (Boroughs and Rickard, 2016).
SAP SuccessFactors Employee Central is a comprehensive HRM management tool. However, given the present support offered by the technological advancement, it is to be considered that the above benefits induced by it or other HRIS that work on similar concepts in terms of efficiency and standardisation is to be seen in the light of the limitations of these applications.
13 CIPD Reflective Statement
Reflexivity is an important skill for a researcher. In order to have a dependable research philosophy researchers should be able to question their own assumptions and scrutinize them at the same time. This helps them to make better-informed choices (Anderson, Fontinha, and Robson, 2019).
There are some important takeaways from the research that I did for this project. Firstly, I became more aware of the use of analytics tools for HRM. My previous understanding of HR analytics has mainly been around its use for frequency analysis. While conducting this research I was introduced to various tools and their application to analyse data that use it to support HRM decision making. In particular, I made use of IBM SPSS Statistics for the first time. And while using it I learned how variable fields can be used to define the fields of the data collected. I sit work closely with my organisations Corporate Management Team and I will apply this tool to crunch data for them. This will help me to present large data in a concise manner.
Moreover, I learned that this tool has a native configuration to enable the creation of charts. I found this tool to create visuals very helpful. Especially, I received positive feedback when I have presented data to the senior management in the visual format as it helped them to digest more information in less time. I consider myself a beginner in HRM data analytics and my knowledge is limited to want I gather while attending MA HRM’s classes on projects and a few YouTube videos. This has; however, encouraged me to build further on my existing knowledge. To do this I will watch more YouTube videos on IBM SPSS Statistics 28. I will also read the IBM SPSS Statistics 28 Brief Guide that is available online for free at (IBM SPSS Statistics 28 Brief Guide IBM, 2021)
At the sage of interpretation, I also found that I could have also used ordinal and scale data measurement to identify the most beneficial function of SAP SuccessFactors Employee Central.
Though, completing this project was a rewarding experience I also had a few challenges while performing it such as designing the survey, the channel for transmission of this survey, and identifying the participants for the survey. There is limited information available on this topic which limited my access to the literature review on this topic but at the same time pushed me to make use of critical thinking and evaluate the response shared by the users of these applications through the survey results. Also, the broader use of preparing the research document is that it has made me more confident to present information to others that are backed by logically interpreted data.
14 References
Alshibly, H.H., 2014. Evaluating E-HRM success: A validation of the information systems success model. International Journal of Human Resource Studies, 4(3), p.107.
Anderson, V., Fontinha, R. and Robson, F., 2019. Research methods in human resource management. 4th ed. Kogan Page.
Armstrong, M., 2009. Armstrong’s handbook of management and leadership. London: Kogan Page.
[online] Available at: https://thelawdictionary.org/multinational-corporationmnc/ [Accessed 14 Nov. 2021].
Bondarouk, T, Ruël, H, & Parry, E (eds) 2017, Electronic HRM in the Smart Era, Emerald Publishing Limited, Bingley. Available from: ProQuest Ebook Central. [23 January 2022]
Boroughs, A. and Rickard, C., 2016. Using technology to create value. London: Routledge.
Burlacu, G., 2022. [online] https://www.sap.com. Available at: <https://www.sap.com/india/insights/hr/artificial-intelligence-may-take-your-job-but-its-a-good-thing.html> [Accessed 23 January 2022].
Chang, S., Gong, Y., Way, S.A. and Jia, L., 2013. Flexibility-oriented HRM systems, absorptive capacity, and market responsiveness and firm innovativeness. Journal of Management, 39(7), pp.1924-1951.
CIPD. (2021). Operating efficiently: implementing HR information systems in large organisations. [online] Available at: https://www.cipd.co.uk/knowledge/work/technology/digital-transformation-insights/hr-systems-large-organisations.
CIPD. 2022. Impact of COVID-19 on working lives | Survey reports | CIPD. [online] Available at: <https://www.cipd.co.uk/knowledge/work/trends/goodwork/covid-impact> [Accessed 12 January 2022].
definition of MULTINATIONAL CORPORATION (MNC) (Black’s Law Dictionary).
Grubb, A. and Lessley, K. (2017). SAP SuccessFactors Recruiting and Onboarding: The Comprehensive Guide. [online] Google Books. Rheinwerk Publishing. Available at:https://www.google.co.uk/books/edition/SAP_SuccessFactors_Recruiting_and_Onboar/VkRdMQAACAAJ?hl=en [Accessed 24 Jan. 2022].
Hunter, I., Saunders, J., Boroughs, A. and Constance, S., 2006. HR Business Partners. Cornwall: Gower Publishing Limited.
Ibisworld.com. 2022. IBISWorld – Industry Market Research, Reports, and Statistics. [online] Available at: <https://www.ibisworld.com/united-kingdom/market-research-reports/hr-payroll-software-publishing-industry/> [Accessed 9 January 2022].
IBM SPSS Statistics 28 Brief Guide IBM. (2021.). [online] Available at: https://www.ibm.com/docs/en/SSLVMB_28.0.0/pdf/IBM_SPSS_Statistics_Brief_Guide.pdf [Accessed 24 Jan. 2022].
Ico.org.uk. 2022. Data protection impact assessments. [online] Available at: <https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/accountability-and-governance/data-protection-impact-assessments/> [Accessed 8 January 2022].
James, S. and Baruti, M., 2021. Determinants Of Standardization And Localization Of Human Resource Management (Hrm) Practices In Multinational Companies’ Subsidiaries: A Review And Implications. Epra International Journal of Economic and Business Review, pp.29-42.
Khashman, A.M. and Al-Ryalat, Dr.H.A. (2015). The Impact of Electronic Human Resource Management (E-HRM) Practices on Business Performance in Jordanian Telecommunications Sector: The Employees Perspective. Journal of Management Research, 7(3), p.115.
Lawler III, E. and Boudreau, J., 2015. Global Trends in Human Resource Management.
Masum, A.K.M., Kabir, M.J. and Chowdhury, M.M., 2015. Determinants that influencing the adoption of E-HRM: An empirical study on Bangladesh. Asian Social Science, 11(21), p.117
Murray, R., Mazhavanchery, M. and Marson, L., 2015. SAP SuccessFactors Employee Central: The Comprehensive Guide. 2nd ed. Bonn, Boston: Rheinwerk Publishing.
Nagendra, A. and Deshpande, M. (2014). Human Resource Information Systems (HRIS) in HR Planning and Development in Mid to Large Sized Organizations. Procedia – Social and Behavioral Sciences, 133, pp.61–67.
National Centre for Research Methods, 2022. [online] www.ncrm.ac.uk. Available at: <https://www.ncrm.ac.uk/resources/video/RMF2010/pages/60_WAOR.php> [Accessed 12 January 2022].
SAP Insights, 2022. What is ERP?. [online] SAP Insights. Available at: <https://insights.sap.com/what-is-erp/> [Accessed 15 January 2022].
SAP, 2022. [online] Available at: <https://userapps.support.sap.com/sap/support/knowledge/en/2287597> [Accessed 23 January 2022].
SAP, 2022. [online] Available at: <https://www.sap.com/products/employee-central-hris.html> [Accessed 15 January 2022].
SAP, 2022. [online] Available at: <https://www.sap.com/uk/products/human-resources-hcm/workforce-planning-hr-analytics.html> [Accessed 11 January 2022].
SAP, 2022. [online] www.sap. Available at: <https://www.sap.com/india/products/employee-central-hris/features.html> [Accessed 15 January 2022].
Saunders, M., Lewis, P. and Thornhill, A., 2019. Research Methods for Business Students. Pearson Education Limited( P435-436 ,492-494) .
The Law Dictionary. (2012). What is MULTINATIONAL CORPORATION (MNC)?
Tobenkin, D., 2022. HR Needs to Stay Ahead of Automation. [online] SHRM. Available at: <https://www.shrm.org/hr-today/news/hr-magazine/spring2019/pages/hr-needs-to-stay-ahead-of-automation.aspx> [Accessed 23 January 2022].
Torres-Coronas, T. and Arias-Oliva, M., 2009. Encyclopaedia of human resources information systems.
Uysal, G., 2014. Taylor, HRM, strategic HRM with jobs, employee performance, business performance relationship: HR governance through 100 years. International Journal of Business and Management Studies, 6(1).
Wilton, N., 2019. An Introduction to Human Resource Management. SAGE Publications. (Pg 508-510)
15 Appendix
15.1 Figure Proposal Gantt Chart
15.2 Figure Actual Gantt Chart
15.3 Appendix: Online Survey Information presented to all participants
Hi there!
I am recently completing research for a Master’s degree. In my research, I am exploring the impact technology has had on Human Resource Management (HRM) functions.
If you could please spare 3 minutes to complete this survey which has a few questions about the use of technology for performing HRM functions at your organisation.
The information collected from this survey will be used for the purpose of this research and at any time you can withdraw from this survey. If you have any questions about this survey, please feel free to contact me on 07883916007.
Just click on the start button below to get started.
Thanks, and all the best!
15.4 Questionnaire
Do you use SAP SuccessFactors Employee Central to manage your HRM function?
- Yes [ ] No [ ]
In case the answer to the above question is ‘no’ is there any other e-HRM tool that your organisation uses
- Yes [ ] No [ ]
How large is your organisation (considering the total number of employees)?
Tick your answer
- Less than 1000
- 1000 – 2000
- 2000 – 5000
- 5000 – 10000
- More than 10,000
Does your company operate in more than one country?
- Yes [ ] No [ ]
Is your organisation considered to be a Multinational Company (MNC)?
- Yes [ ] No [ ]
Which areas of HRM in your organisation are managed through SAP SuccessFactors or any other HR software that you use?
Tick your answer:
- Recruitment
- Onboarding
- Time and attendance
- Learning and development
- Performance and goal management
- Compensation
- Succession and development
What are the main benefits of using SAP SuccessFactors or HR software?
Tick your answer:
- Saving of cost
- Time to value/efficiency
- Time and attendance
- Motivated employees
- Data security
- Accuracy
Which functions of HRM are not supported by SAP SuccessFactors or the available HRM software solutions?
Tick your answer:
- Employee relations
- HR Strategy
- Change management
- Organisational effectiveness
What are the major challenges in the use of SAP SuccessFactors or the available HRM software solutions?
Tick your answer:
- Initial installation
- Training employees
- Cross-functional
[1] Bot – a piece of software that is used to perform pre-defined, automated tasks on a repetitive basis.
Residents’ Perceived Quality Of Life in Dorset Tourism Destination
W.1 Project
A Study on How to Implement SAP SuccessFactors Software – Employee Central Module, in Human Resource Function to Improve Efficiency and Standardisation
An empirical project submitted in partial fulfilment of the requirements for the degree of
Master of Arts in Human Resource Management
at the Westminster Business School of the University of
Westminster, by
SubDeclaration
I declare that the research conducted for analysis and discussion on this dissertation has been solely composed by myself. Wherever references have been made of others’ discussion adequate references and credits have been given to them in the relevant sections.
No part of this research has been submitted for grant of academic credit of any other research.
1 Acknowledgements
This research has been possible because of the valuable guidance of Ms Christine Porter, our Course Leader, and Ms Sangeetha Srinivasan my supervisor for this research. Their continuous support has helped me to bring this research to the current form and shape that it is today.
I would also like to thank Dr Francesca Andreescu, our Module Leader. Credits are also due to Dr Elisabeth Michielsens for her valuable guidance at various points during this research.
I would also like to express my gratitude to all the respondents for the efforts they took to patiently reflect on their experiences in the implementation and application of SAP SuccessFactors Employee Central and other e-HRM tools in their organisations.
2 Abstract
This research aims to answers the main questions that the HRM functions of the organisations that make use of the SAP SuccessFactors Employee Central want to be answered. This research starts by exploring how the use of this technology increases the efficiency in the HRM working and at the same time standardises their processes. It also critically evaluates how successfully this technology has been able to meet the objectives of its use. A survey was conducted using a self-designed questionnaire to explore how the use of this application in the HRM evaluates it factoring in the organisational setup in which they operate.
A logical and methodical analysis of the survey results highlighted the pervasive and ominous use of these applications. However, the benefits which these applications offer now are in the area of administrative functions of HRM. The use of SAP SuccessFactors and other HRM technology as a strategic tool for HRM is still evolving.
With the advancement of technology, there is a high probability that these concepts will be used by SAP SuccessFactors too. The ERP HRISs will be supporting HRM across all sizes of organisations particularly for MNCs to be a strategic partner of the organisation.
3
4 Table of Contents
6.3 Challenges and Future Path.. 9
7.1 Strategic Partner and Emergence of e-HRM.. 10
7.2 ERP HR Software’s Vital to MNCs. 11
7.3 Increase in Efficiency. 12
7.4 Efficiency in Day-to-Day Operations. 13
7.5 Efficiency while Implementation and Maintenance. 17
7.7 Challenges in the use of HR Software. 18
7.8 Further Automation Required. 19
8 Research Methodology and Methods. 20
8.2 HR Research and Methods. 21
8.3 Research Questions and Objectives. 22
9.1 Decoding of the labels assigned to different questions. 27
10.2 Population and Sampling. 38
10.3 Data Collection Process and Access to Literature. 38
13 CIPD Reflective Statement 43
15.1 Figure Proposal Gantt Chart 49
15.2 Figure Actual Gantt Chart 49
15.3 Appendix: Online Survey Information presented to all participants. 50
5 Glossary Of Terms
| Notation | Description |
| AI | Artificial Intelligence It is the ability of the computer to intelligently perform common tasks (Britannica, 2022). |
| CIPD | Chartered Institute of Personnel and Development |
| e-HRM | Electronic Human Resource Management |
| ERP | Enterprise resource planning or ERP application can be defined as an application that helps organisations to run all their core process: finance, HR, supply chain, procurement, manufacturing, and others (SAP Insights, 2022). |
| HR | Human Resource |
| HRIS | Human Resource Information Systems |
| HRM | Human Resource Management |
| IT | Information Technology |
| L&D | Learning and development |
| Machine Learning | It is a branch of artificial intelligence that use algorithms and data to Enable machines to imitate the manner in which humans learn. |
| MNC | Multiple National Companies |
6 Introduction
SAP SuccessFactors Employee Central is one of the widely used ERP based HRM tools. Organisations use these tools as a driver to bring efficiency in its HRM function. This study contributes to the evolving area of use of technology through the SAP SuccessFactors Employee Central in the field of HRM and the academic interest in it of HR professionals. Empirical pieces of evidence have been used to gain an insight into how the use of SAP SuccessFactors Employee Central technology to perform HRM functions has brought efficiency and standardisation in its operations.
6.1 ERP Tools for HRM
Different formats of technological support are available for HRM and the ERP HRM solutions are considered to the best of the breed (Boroughs and Rickard, 2016). The ERP provides a complete range of functionality to support and manage the HRM. The available functionalities of SAP SuccessFactors Employee central are evaluated in light of the efficiency it embeds in the HRM operations and how it contributes in the standardisation of these operations.
These HRIS comes with options of the standardised set of configurations which can be either mirrored or customised to suit the nature and the scale of the HR functions of the organisations implementing them (Hunter, Saunders, Boroughs and Constance, 2006). The research discusses how the use of SAP SuccessFactors brings efficiency in the HRM processes of the organisations that operates as MNCs . The HR function of an organisation can operate under different setup: entity-based functions, shared service, co-sourced or outsourced. These HRIS can be used in all the setups and for varying scale of HRM operations.
6.2 ERP and Efficiency
The efficiency derived from the SAP SuccessFactors was analysing considering the existing offerings of these HRIS and then evaluating on how they contribute to the different functions of the HRM in terms of efficiency and standardisation. To do this first the primary and critical activities of the HRM were identified and then an evaluation was made on how the functionalities within the SAP SuccessFactors Employee Central supports.
A discussion on HR’s role and the organisations expectation from them has changed dramatically since 1960 i.e. roughly the time when the HRM function were digitised. how the role that HR plays within the organisation has changed was analysed.
The contribution to each critical function was analysed. Also, responses were sought to a self-designed questionnaire to confirm on what the end-users experience has been with the use of HRIS tools. The respondents were asked to share their response by easily selecting the coded labels.
The use of HRIS enables the users to maintain error free, data in a secured manner with controlled access. This data is logically processed by the systems to generate meaningful information. This information can support various functions of HRM: recruitment, on-boarding, performance management, time, and attendance, compensations and so on. The roles which these eHRM tolls support are mainly eliminate the administrative tasks of the HRM, they don’t contribute much to the strategic goal of the organisations. This is seen as a limitation of the SAP SuccessFactors Employee Central in its present state and form. But the emerging development in the technology and their successful implementation on other functions of the organisations through an integrated ERP platform is acting as a sliver lining where they will be able to support those functions of HR that are more judgemental based.
Furthermore, the capability of SAP SuccessFactors in a cloud format and how it benefits the HR has also been explored. It has to be highlighted that beside the primary benefits which the automation of these HR activities brings in terms of the savings in cost, time, compliance with the regulations and capability to generate massive reports in a concise and succinct manner for the management use there are also secondary benefits. These secondary benefits are mainly noted in the increased morale of the employees and their enhanced productivity (Boroughs and Rickard, 2016).
6.3 Challenges and Future Path
The research acknowledges the challenges which comes with the use of the HRIS. The efficiency introduced by these systems comes at a cost. There are both tangible monetary outflow and other intangible limitations with their use. The implementation of these applications is a complex process that is often managed through external support. A rigorous compliance of the agreed project implementation plan is necessary to ensure that the SAP SuccessFactors is configured to deliver the results in line with the standard agreed practises of the organisation. However, ones the application is implemented things comes down mainly on the day-to-day operating of these applications. The manner in which the users input and analysis the data on the HRIS defines whether it will add to the efficiency. Thus, the training of the employees is critical to make the efficient use of the eHRM to support the HR. The challenges are discussed more under in detail in the named section below.
The current limitations of these applications can be seen as the areas where they can support in the future. These are mainly with regards to the HR processes that are yet not support such as change management, employee relations and son on.
6.4 Research
The research mainly tries to gauge first hand experience of the users of these applications through a series of questions. The results of the survey were then then analysed manually to draw logical inferences and check their conformity or deviation to the findings of the scholars discussed in the literature review. This was then used to draw meaningful conclusions and recommendations.
7 Literature Review
7.1 Strategic Partner and Emergence of e-HRM
In modern organisations employees play a key role in determining a firm’s performance in business settings thus Human Resource Management (HRM) plays a critical management function in managing these resources (Uysal, 2014). Organisations could use human resources as differentiator so that they give them competitive leverage over their rivals. Further, for the realisation of the organisation’s strategic goals effective management of the human resources is vital (Khashman and Al-Ryalat, 2015).
The use of technology to conduct HRM activities is referred to as e-HRM. This term was initially coined in the 1990s. Earlier this term was used in a very narrow technological aspect and covered only those HR activities performed using the internet. However, as time evolved this term encompassed wider use of technology including the use of HRIS. There are three overarching applications of these HRIS: To publish information, automate transactions, transform the use of HR functions (Wilton, 2019).
HRM function has been restructured over time to fit in different roles over the time. In the 1960s HRM was mainly concerned with maintaining personal files, while in the mid of 1960s until the mid-1980s HRM function was expected to support the organisation to be compliant with all legal frameworks. From the mid-1980s HRM roles too more of the role of personal management and managing the employee life cycle. However, there has been a shift in the role of HRM from the late 1990s where it is mainly seen as a strategic partner. The traditional roles of HRM-related to database management, recruiting, appraisal support, are either outsourced or automated. Where HRM are unable to deliver on these expectations of the organisation they usually see their positions being made redundant as part of the restructuring (Torres-Coronas and Arias-Oliva, 2009). The use of technology in HR has grown and become pervasive in most of its activities like payroll, training & development, recruitment, HR planning. The drive for automation in HR is driven by the HRIS strategy which is expected to provide a competitive advantage to organisations (Torres-Coronas and Arias-Oliva, 2009).
7.2 ERP HR Software’s Vital to MNCs
The number of MNCs operating in different sectors has risen in modern times. These MNCs are organisations whose operations are spread across different geographical territories. These MNCs derive 25% or more of their revenue from operations that they carry out outside of their home country (The Black’s Law Dictionary, 2012).
The human capital of these organisations is spread across different countries. It is highly unproductive and futile to use manual processes to manage the HR of such organisations. Such companies thus usually use ERP tools which is a comprehensive way to manage the HR functions of these companies.
The use of these software/e-HRM tools allows them to automate HR processes such as managing absenteeism, performance appraisal, payroll, and learning and development. If these processes are performed manually these will take away much of HR’s time and it will have less time to support the strategic objectives of the organisation.
Further studies suggest that in these organisations HR is an active and strategic partner. Their role is elaborative in the larger organisations as compared to the role HRM has been performing in a traditional organisation. This shift in their role requires better data analysis and automation of clerical and repetitive functions.
One of the widely used e-HRM systems in the MNCs is SAP SuccessFactors Employee Software – Employee Central Module. They have positioned themselves as a Global Leader in developing and delivering software solutions for the execution of business processes and functions. This software offers various modules that can be used to automate the HR functions such as payroll, time management, compensation, recruitment and onboarding, performance management. Through its various modules, it is positioned to support the HRM functions and manage data in a manner that allows for further integration with the wide business like sharing the payroll data with the finance department for the further processing and payments of the employee salaries and compensations (SAP, 2020).
7.3 Increase in Efficiency
HRM aims to support organisations in achieving their objectives, such as recruiting the right people, developing a cordial relationship between the employer and their employees. HR proposes the people’s policies and practices while the line manager implements them while ensuring that the organisation achieves its objectives. To achieve this primary objective there are various peripheral roles that they have to perform such as mentoring and coaching, communicating across various levels, and being technologically skilled.
E-HRM provides organisations with the tools through which HR can organise, analyse and manage the personnel in a manner that would support the management to attain their strategic objectives cost-effectively and efficiently. This is particularly helpful when managers are operating in uncertainty, turbulence.
The organisation’s strategy should be driven by big data. HR systems can be used to perform people analytics to analyse people’s engagement, discourage absenteeism, evaluate the outcomes of learning and development activities, recruitment process, performance management, and reward management.
The outcomes of these analyses help organisations drive better employee engagement and reduction of employee turnover and retention. This also drives updates and changes to the HR policies and procedures, evaluation of the diversity and inclusion performance of the organisation, and estimating the social and financial return on the human resources. However, for e-HRM to be effective in this regard the input data must be cleaned, and accurate which can be used to perform multidimensional, predictive, and descriptive analytics (Armstrong, 2009).
HRM’s decision-making improves when it’s supported by the data analysed from information systems. The HRM systems provide for an organised solution to store the data systematically. Comprehensive detail of employees’ data can be maintained in this HR software These systems have been particularly helpful in the planning and development of HR setup in contemporary organisations (Alshibly, 2014).
This data is analysed to make informed and rational decisions about the employees of organisations which are also aligned to the individual’s needs. A cordial work environment is established where individual needs and matched to the organisation’s objectives. One such example can be seen when reports on completion of the assigned L&D training to the employees is analysed. In case there are delays in the completion of these pieces of training, the line manager can push the employees to complete them. This is beneficial for the organisation and their employees to upskill themselves (Chang et al., 2013).
Though there is an outflow of monetary resources when this HR software is implemented and also in their further maintenance. This, however; lead to better and more efficient results being made that support the short-term and long-term goals of organisations (Masum, Kabir, and Chowdhury, 2015).
7.4 Efficiency in Day-to-Day Operations
The use of technology in HRM is mainly targeted to accomplish HR transactions, record keeping, and other repetitive administrative HRM tasks. It is expected that through the use of this software, the HR function within the organisation will be able to support the strategic objectives of the organisation as highlighted in the sections above along with bringing financial savings for the HR department. With the evolution of technology, these tools can serve as specialised advice to the management on compensation, career development, selection, and management of the talent pool of the organisation.
Due to the relative newness of the use of technology and ERP software, there is not much-supported information and statistics to evidence their effect on the effectiveness of the HRM function. The presently available research shows that the most useful benefit is in terms of efficiency in the areas of are cost, service, and speed to bring to HRM function. When the delivery of services of HRM improves it also improves the credibility of the HRM.
However, some of the scholars opine that the existing HRIS tools do not effectively contribute to the attainment of the organisations’ objectives and decision-making by HR. The main reason for this disappointing contribution of HRIS can be attributed to the novelty of these applications and the inexperience of the organisation in the use of these tools for strategic purposes. Refinements are still sought in the manner the data is being processed by these HRIS tools before they can prove to be as effective as the finance, supply chain, or other system managing applications. The management supports building HRIS so that it can manage its dispersed and diversified workforce. The use of the HRIS in an integrated setup like SAP SuccessFactors Employee Central enables for holistic use and analysis of data and contribute to the organisation’s objective efficiently by creating knowledge of networks, improving the manager decisions on human capital, offering a positive experience to its users, and enabling the measurement of its contribution to the organisation amongst other factors. Also, a parameter to measure the effectiveness of the HRIS is measured by the amount by which it has reduced the HR cost. This at times as having negative implications for HR personnel as it is expected to lead to their redundancy (Lawler III and Boudreau, 2015).
The global operations of the organisation require the use of a networkable and advanced solution to manage the dispersed workforce make wider use of these applications. Completely integrated applications as SAP SuccessFactors Employee Central are rated much higher in terms of efficiency they bring in:
Human Resource Planning (HRP): Organisation’s demand for labour requires analysis and forecast of the demand and supply of the labour. While making such predictions factors such as expected leavers, temporary withdrawals (due to maternity/paternity leave, secondments, or sabbaticals) are to be considered. HRIS is designed to make these analyses on HRM’s behalf (Wilton, 2019). It is one of the analytics that SAP SuccessFactors’ HR Analytics can do for HR personnel. The data derived from such tools are expected to have fewer chances of error and the results of such analysis are much quicker when we compare them to the manual processing of such information (SAP, 2022).
Its various modules introduce efficiency at different points in the HRM functions. In the onboarding stage, HR professional spends a lot of time keying in the data which is shared by the employees over form. This can, however; be managed efficiently in SAP SuccessFactors that is designed around the principle of self-service. So, once the new employees are added to this application they can update their own information on the system, and HR can just verify and check the information (Murray, Mazhavanchery, and Marson, 2015).
Integration: One of the main advantages that ERP software offers is that of integration (Lawler III and Boudreau, 2015). SAP SuccessFactors is an ERP solution which means that the organisations can add different modules to their subscribed piece of software to match their growing needs. There is a native integration between these modules which means that the data of one module can act as an input for another. Like the time management modules could be used for processing of payroll. This saves some valuable time for HR personnel who can instead use that time saved on repetitive administrative work for strategic tasks.
Also, there are certain changes which have an impact on all or a group of employees in the organisation such as when change there are changes to the tax rates, or when emails are to be sent to a particular group of employees all these processes can be automated by updating the configurations of the HR software.
Availability: When organisations use HRIS to manage the data of their data it gives them the ability to access data from anywhere at any time (Lawler III and Boudreau, 2015). Users can access SAP SuccessFactors and the HRIS tools at any time and from anywhere. Also, these tools are supported across various platforms which means mobile, computers and other platforms can be used to access this data. HRM personnel using these have mobility and they longer have to be physically present at the office to access that critical information.
Cloud-Based: The cloud-based versions of the SAP application are expected to enhance the quality of the data past, current and information analysed. Thus, making them available when required and also cutting down on the cost of these systems and their maintenance to the cross-function units such as IT and the related downtime in the HR. Due to the scalability, organisations are able to upgrade their subscribed services and support the larger data processed by HRM. The could-based versions give more independence in terms of cost and thus more organisations can use these to standardise their process and increase their revenue. The Cloud version of SAP SuccessFactors is maintained and hosted by the vendor, which means that they are responsible for their maintenance, and even when there are any deletes the vendor is expected to have a backup of that data and restore them. Thus, HR does not have to re-create those data (Bondarouk, Ruël and Parry, 2017).
An HRIS is considered to be effective when it can support more tasks (Lawler III and Boudreau, 2018). There are various modules offered by SAP in their present offering for SAP SuccessFactors. This helps to automate the various processes of HRM such as recruitment and onboarding, time and attendance, learning and development. Using the recruitment and onboarding module HRM personnel can manage the recruitment requisitions, interviews, matching, compliance, offer, and also rating the candidates. Workflows can be designed and configured within the system to ensure that there are different employees involved with the requisitions, review, and approval. Thus, minimizing the chances of error and managing the process seamlessly. It also allows HR to enhance its banding and reach a larger talent pool through various channels such as LinkedIn, Facebook, job portal, corporate website, helping the management to make an informed decision (Grubb and Lessley, 2017)
The information generated and maintained by the SAP SuccessFactors depends upon the quality of data that is entered and the validation and the logic through which the data is processed by this application. With the growing relevance of the data governance the use of these HRM systems there are checks to confirm the completeness, accuracy, consistency and relevance of the data. Poor data maintained by the HRM has a cross-functional impact and can affect the over finance, compliance, productivity, and confidence of the staff in a negative way (Bondarouk, Ruël and Parry, 2017).
7.5 Efficiency while Implementation and Maintenance
Strategic and operational functionalities of HR processes can be covered through the use of SAP SuccessFactors. As the organisations grow one of the main questions that they face is whether the applications which they are using will be able to process the larger data? Thus, scalability becomes important. Here the offering of the cloud or hybrid versions SAP SuccessFactors come in handy. If the organisation chooses to go with the cloud or hybrid version of this HR software they get immediate access to scalability. This means that they have more storage and processing capability at their disposal. Thus, HR is doesn’t have to each time go back to the software provider, and there It for making a major change to the organisation’s IT infrastructure and disruption to the HR technology saving some valuable HR personals work hours (Murray, Mazhavanchery and Marson, 2015).
Further SAP offers to provide regular updates to this software to patch any vulnerability in the security of this software which means that the personal and sensitive information which is stored by HR in it is secure and HR can save a lot of time that it would otherwise spend on the management of the files and hard copies. Also, when software is used to manage data then a backup of these data is kept by the companies hosting them. Thus, there is also a facility to restore the data if the data is deleted by error or even sometimes intentionally by a distraught employee (SAP, 2022).
7.6 Shared Services
The use of HRIS has also boosted the concept of shared services. Through the use of technology, there has been a rise in the organisations that manage the HR functions of different organisations. Also, there are centralised units of HR within the organisations that manage the functions of its multiple entities. Using these outsourced and co-sourced services the organisations are able to reduce the cost, increase human motivations and focus on what is more important strategically (Boroughs and Rickard, 2016).
7.7 Challenges in the use of HR Software
There has been a spike in the demand for HR software in the UK. Between 2016-2021 a compounded growth of 7.7% was expected in the revenue of the organisations that develop such HR software. The total market revenue was expected to reach £1.2 billion (IBISWorld – Industry Market Research, Reports, and Statistics, 2022). Many companies have a share in this market such as Workday, SAP SuccessFactors, BambooHR, ADP, Oracle PeopleSoft. The selection of which application is will suit the requirements of an organisation is vital.
This has resulted in a spike in the investments which organisations make in the acquisition and maintenance of HRM tools and software with the aim to support better HR planning, employee training, and development, along with succession planning Nagendra and Deshpande, 2014). This implementation is however not always straightforward and has its own challenges. In June 2021 CIPD did a study on the larger organisations who as per them have employed between 10,000 to 60,000 employees to identify the challenges which they faced while implementing HRIS system to automate the HR functions and their learning from this change management process. This article shared the experiences of HR professionals of three such large organisations. Implementing a new HRIS involves identifying the outcomes from those systems, engaging with internal and external experts to support the implementation process, ensuring that the employees can access the data from different platforms such as laptops, mobiles, and desktops (CIPD 2021 Operating efficiently: implementing HR information systems in large organisations).
It is also vital that there are controls to ensure that the data can be accessed by only relevant individuals. It is important that any regional law and regulations related to the implementation of the new system that process any personal and sensitive personal information are complied with like in the UK the GDPR regulations published by the ICO for the implementation of such systems are to be completed with by completing the Data Protection Impact Assessment (DPIA) before implementation of these systems (Data protection impact assessments, 2022).
Adequate training is an important factor for the appropriate use of the SAP SuccessFactors and other technology in HRM. Depending upon the quality of the system the training plans are to be adjusted such as SAP is a highly technical application thus when this application is implemented then staff using these applications are imparted training for it to be effectively used. Thus, training has an impact on the efficiency of this application (Bondarouk, Ruël and Parry, 2017).
7.8 Further Automation Required
Innovation is required for HRIS to be effective. HRIS can be seen as a computer of the HRM that is expected to automate its processes. However, there are certain limitations to the state and form up to which the SAP SuccessFactors Employee Central and the other HRIS have managed to be developed. The role of HRM might be restricted to being a mere spectator of data. Mostly it is the traditional HRM functions that are at play by the EHRM tools (Bondarouk, Ruël, and Parry, 2017). There are still areas in HRM for which no electronic solution is available like employee relationship management (grievances and disciplinary). Yet these are mostly manually managed areas with the augment of AI and machine learning it might not be a surprise if we see the software providers launch software to develop these areas which are not yet captured by SAP SuccessFactors.
Further, a report shared by KPMG based on their analysis of the major 21 tasks of HRM noted that there is high potential to automate the different functions of HRM either fully or partly. The automation of the five major areas of the HRM is less susceptible: managing employee relations, change management, managing organisational effectiveness, management of the architect of people performance, and supporting the HR and business strategy. Also, there are challenges in keeping the workplace human as it is expected that the use of automation and robotics will replace the human side of human resources (Tobenkin, 2022). SAP SuccessFactors is expected to leap forward in terms of the additional functionality offered by it through the use of artificial intelligence and machine learning where it will make use of conversational interfaces and bots[1] to manage the areas unexplored by HRIS and to manage better some of already supported task more effectively (Burlacu, 2022).
8 Research Methodology and Methods
8.1 Methodology
The research analysis the results of the self-designed questionnaire though comments were sought to improve it before being circulated to the potential participants. There are chances that its purpose the understanding of the researcher may have limited its aptness for the research. Also, the information shared by the respondents has been assumed to be correct and accurate no investigative work was done to establish its correctness and completeness. This might have an impact on the quality of data used for analysis. Further, there may be many more benefits, challenges, and limitations with the SAP SuccessFactors Employee Central and other HRM software used by the respondents. But due to the constraint in the time, only those points which are assumed to be most critical by the researcher have been set as an option in the answer for the survey.
A further pragmatic approach was taken to ensure that only related empirical observations, hypotheses, and induction carried out during the research were considered to deduct any irrelevant information while proposing the recommendations (Saunders, Lewis and Thornhill, 2019, Pg.148-155).
8.2 HR Research and Methods
In simple terms, research means a systematic way to findings out things with the objective to increase one’s knowledge. HRM as a discipline involves making sound informed decisions that have an impact on the employees. Thus, HR research can be explained as a systematic and organised inquiry undertaken with an objective to increase one’s knowledge in HR that supports the action taken by HRM (Anderson, Fontinha and Robson, 2019 Pg.10-11).
Applied research is carried out with the purpose of gaining an understanding of a specified topic (Anderson, Fontinha, and Robson, 2019 Pg.11-12). As highlighted in the discussion of various literature reviews, there is a lack of research material on the impact of the implementation of SAP SuccessFactors – Employee Central in organisations. This research attempts to narrow this gap especially focusing on the impact it has had on the effectiveness of the HRM functions of the MNCs that have implemented it. The aspect of the introduction of standardisation in the processes of the HRM through the use of this software has also been explored.
Research in HR is characterised by diversity. Thus, the assumption after consideration of the various models for research processes and diagrams that there is one right way to conduct research may be incorrect (Anderson, Fontinha, and Robson, 2019 Pg.13).
An explanatory and exploratory research approach was undertaken to explain how SAP SuccessFactors have an impact on the efficiency of HRM functions and their standardisation. The research further explores finding new insight and asking questions on how this software could be used to support the HRM function better.
Explanatory and exploratory research requires the use of both quantitative and qualitative methods to answer the ‘why’ and ‘how’ and at the same time gain new insights.
Mixed methods of research see value in the use of both qualitative and quantitative data are particularly useful where are resource constraints: time and cost. These methods help to gain valuable insight into the variables cross-check the confirmations and provide a better understanding of the ‘why’ relationship between the different variables.
Mixed methods were used to design the survey. At first, participants were asked to share their responses to the standardised questions sent to all the participants by filling out the questionnaire. Follow-up clarifications were asked from them as and when necessary to gain insight into their responses.
8.3 Research Questions and Objectives
The online survey questionnaire was designed to gain insight into the research problem. The use of SAP SuccessFactors Employee Central as a preferred HR software tool was explored, along with the benefits of its uses, challenges in its use, and areas of further improvement were also gauged through this questionnaire that had these questions:
There is no publicly available document that confirms which organisations use SAP SuccessFactors Employee Central Various tools. To gain confirmation, it was ensured that the respondents know which HR software is in consideration, this question was asked first.
It is vital for the research to understand if there are organisations that prefer other eHRM tools over SAP SuccessFactors Employee Central. An analysis of this question is expected to be indicative of the limitations of this software in terms of its reach (cost limitations) and or functionalities, among others.
The number of employees impacts the volume of the data which is processed by the HRM. This study also identifies if there is a correlation between the sheer number of employees to the selection of the HRM software.
A way to attain standardisation is when similar processes are followed both at the Head Quarter’s and at the regional offices. One of the key aspects of MNCs is that they are spread across countries and many times across the continents too (James and Baruti, 2021). It was identified if there are respondents who work for organisations that operate across the borders and are required to meet the objectives of efficiency and standardisation.
This research is primarily focused on the use of SAP SuccessFactors Employee Central in the MNCs, and the respondents were asked to confirm if they work for an MNC so that correct inference can be drawn from the analysis of the data.
SAP SuccessFactors Employee Central offers various modules such as employee benefits management, time and attendance, succession and development, and others to facilitate digitisation and automation of HRM processes. Organisations have an option to subscribe to all or any of these modules (SAP, 2022).
The main aim of this study is to identify the areas within HRM that benefit from the implementation and use of SAP SuccessFactors particularly in the areas of efficiency and standardisation. Respondents were asked to choose from the main benefits advertised by SAP SuccessFactors from the use of their application (SAP, 2022). They were also given the option to choose others if they experience benefits that are different from those bulleted in the questions. They also had the option to skip this question in case they felt that there are no tangible and intangible benefits from the use of this software. An analysis of this response gives insight into what users feel are the most beneficial features of this technology. It was also analysed if users of the other software have experienced similar benefits.
HRM is the management of human resources that requires an emotional and contextual analysis. SAP is working to introduce artificial intelligence to help digitise more processes of HRM. An inquiry was made to track which are the areas of HRM are not supported by SAP SuccessFactors and is of interest to the respondents.
This inquiry was made with the target to find major challenges which the users of this application have had with its use. Being a heavy on technology application there are various implementations and day-to-day issues may face. The respondents were given the general issues that are faced by the users in such a scenario based on the reading at CIPD’s website and they were asked to choose any or all the challenges that they encounter (CIPD, 2022).
8.4 Procedure
This research was performed in an organised and structured manner following the underlying principles of the Research Onion. Attempts were made to ensure the analysis of data is performed with a neutral and unbiased view (Saunders, Lewis, and Thornhill, 2019).
The current sociological and regulatory factors were considered while deciding on the methodology. The normal work hours of employees have increased by 56% ((Impact of COVID-19 on working lives | Survey reports | CIPD, 2022). Technology has enabled more employees to know work from home. There is an increase in social isolation and increased adoption of technology-enabled methods (The impact of new tech during COVID-19 | CIPD, 2022).
To adapt to the change in the preferred ways of interactions and working online surveys were carried out with an expectation of wider and quick response. Survey Legend website was used to design the survey and later collect the results. Primary data was collected from the users through a structured interview that had pre-coded answers. Such an interview style is expected to lead to an unbiased interview but might have elements of subjective opinion from the interviewee (Saunders, Lewis, and Thornhill, 2019, Pg. 435-436).
The information on the total number of organisations that use SAP SuccessFactors Employee Central is not publicly available. A sample-based approach was used to collect responses to the survey. Sampling can be used as an alternative from obtaining a census from the entire population when there are budget constraints, and time and where it is impractical to survey the total population (Saunders, Lewis, and Thornhill, 2019, Pg. 492-494).
An outline of the survey questions to be sent out to the participants was discussed with the supervisor at the time of review of the project proposal and feedback received at that time was used to update the final questionnaire used for this project. Eleven responses were received to the online survey over 10 days. Each respondent could only fill out the survey once. The responses were coded and quantitative analysis of the descriptive data was carried out this allowed me to carry our comparisons between the data collected. Additionally, this approach also saved time (Saunders, Lewis, and Thornhill, 2019, Pg. 569 – 571).
8.5 Respondents
The online questionnaire was sent to 25 HRM professionals who have had experience in the use of SAP SuccessFactors Employee Central and other eHRM tools. The link to the survey was shared with them through email and/or mobile messages. Ethical issues such as privacy, informed consent, anonymity, and confidentiality of the respondents were considered while processing their responses and reporting them for this research (National Centre for Research Methods, 2022.
The research survey was open from 8 January 2022 to 17 January 2022, giving the professionals a window of 10 Days to respond to the survey. The users were requested to respond to all the survey questions. However, this was not made mandatory. This is analysed further in the reflective statement.
The respondents to the survey were independent of this review and anonymity was maintained throughout the survey. Also, assurance was provided on the confidentiality of the data shared by them to ensure that their opinion is free of any influence. However, as this survey is based on the experiences of the SAP SuccessFactors Employee Central users, the objectivity of their answers might be a debatable point (Saunders, Lewis, and Thornhill, 2019).
9 Results and Analysis
9.1 Decoding of the labels assigned to different questions
The response to questions 1,2, 4, and 5 of the questionnaires fall under the dichotomous category as only two categories of response are possible to them. Value labels were assigned to different categories of responses within each of the questions. The responses were coded. The coding assigned to the two labels in the dichotomous questions 1,2,4 and 5 are represented in the table below:
| Label Question No# | 1 | 2 |
| 1 | Yes | No |
| 2 | Yes | No |
| 4 | Yes | No |
| 5 | Yes | No |
The first question was to confirm if the respondents are using SAP SuccessFactors Employee Central. Code 1 was used to capture the positive responses while code 2 was used to capture a negative response. The second question tests if there are other eHRM in the market. When the respondent selected code 1 as a response to this question it confirmed that they do use an alternative HRM software while a response as 2 means that they don’t use any HRM software. Response to question 3 of the questionnaire that finds the size of the organisation has been measured using a quantitative variable. The response to it is scalable from 0 to more than 10,000 with regards to the number of staff employed by it and there are fixed intervals to it.
Question 4 gathered responses on whether the operations of the organisation in which the respondents work operate in more than one country. When the participants confirmed that their organisation operates from more than one country it coded as 1 while any negative response to this question is recorded as 2.
While question 3 was targeted to find the number of staff supported by the organisation on whose practices the participant is responding to. However, this data is not distributed in equal intervals and thus it has been analysed using a nominal basis rather than as scaled data. The following coding was used:
| Code | Label | Code | Label |
| 1 | Less than 1000 | 3 | 2000 – 5000 |
| 2 | 1000 – 2000 | 4 | 5000 – 10000 |
The next three questions were aimed to find respectively the various modules of the SAP SuccessFactors Employee Central or other eHRM tools that they are using. While question 8 seeks to know what benefits did the participants noted from the use of these tools. While in the last question inquiry was made to the challenges they faced with the use of the application. All these three questions were set as multiple choice and more than one response was possible.
In response to question 7 of the questionnaire, participants were able to select the following codes to reflect which of the modules of SAP SuccessFactors or other eHRM do they use. The following codes were used to capture their response:
| Code | Label | Code | Label |
| 1 | Saving of cost | 4 | Motivated employees |
| 2 | Time to value/efficiency | 5 | Data security |
| 3 | Time and attendance | 6 | Accuracy |
In question 8 the codes were attached to the main benefits that the use of SAP SuccessFactors as discussed in the literature review section above that the participants experience with the use of these tools.
| Code | Label | Code | Label |
| 1 | Employee relations | 3 | Motivated employees |
| 2 | HR Strategy | 4 | Data security |
In the last question of this questionnaire, the challenges experienced with the use of these applications were captured using the following codes:
| Code | Label | Code | Label |
| 1 | Initial installation | 3 | Motivated employees |
| 2 | Training employees | 4 | Data security |
SPSS software was used to analyse the data this tool doesn’t have the capability to interpret the data. The results of the analysis were interpreted to draw an objective conclusion.
The valid data is where we have a score where the participants have decided to abstain from responding those fields are taken as invalid data and have not been used for analysis and further interpretation.
The percentage is calculated based on the total sample size while the valid percentage is computed based on the number of responses from that set of samples. This research interprets data based on the valid percentage unless indicated otherwise.
9.2 Quantitative Analysis
To start with a first-level analysis was performed using frequencies. This helps users to get an understanding of the data and make primary comparisons (Anderson, Fontinha, and Robson, 2019).
Also, deviations of most observations were captured in the form of standard deviations and the behaviour of different variables was analysed.
SAP SuccessFactors is a widely used HRM software with 54.5% of the respondents confirming the use of this application to manage their HRM activities.
| Do you use SAP SuccessFactors Employee Central to manage your HRM function? | |||||
| Label | Frequency | Percent | Valid Percent | Cumulative Percent | |
| Yes | 6 | 54.5 | 54.5 | 54.5 | |
| No | 5 | 45.5 | 45.5 | 100.0 | |
| Total | 11 | 100.0 | 100.0 |
The remaining 45.5% of the users confirmed the use of other eHRM tools. This substantiates the pervasiveness of the use of technology for HRM discussed above in the literature review. Interestingly the organisation where all the respondents worked had its operations spread in more than one country. One of the main reasons for the use of this software is their capacity to bring standardisation in the processes of the MNCs that are spread across the borders and thus have different regulatory and cultural practices.
| Is your organisation considered to be a Multinational Company (MNC)? | ||||||
| Label | Frequency | Percent | Valid Percent | Cumulative Percent | ||
| Yes | 8 | 72.7 | 72.7 | 72.7 | ||
| No | 3 | 27.3 | 27.3 | 100.0 | ||
| Total | 11 | 100.0 | 100.0 | |||
72.7 of the participants confirmed they use these tools while working in an MNC. 45.45% of the respondents were those who used SAP SuccessFactors in an MNC setup.
The size of the organisation where the respondents used these tools mostly employed less than 1000 employees with 72.72% of the respondents claiming that their organisation employed less than 100 staff. 85% of these organisations use SAP SuccessFactors. The results are indicative that eHRM tools are used in all the sizes of organisations whether such size is determined based on their size, geographical spread, or the revenue generated from overseas.
| How large is your organisation (considering the total number of employees)? | ||
| Size of Employees | N | Frequency |
| Less_than_1000 | 11 | 8 |
| Between_1000 to 2000 | 11 | 1 |
| Between_2000 to 5000 | 11 | 0 |
| Between_5000 to 10000 | 11 | 1 |
| More_than_10000 | 11 | 1 |
| Valid N (listwise) | 11 |
The relationship between the use of eHRM tools, size of the organisations, the spread of operations of the organisations, and the number of staffs in that organisation. A maximum positive frequency of 8 was noted when the organisation operates in more than one country and they use eHRM tool including SAP SuccessFactors to manage, automate and standardise their large scale HRM operations.
Fig1: Relationship Map
9.3 Qualitative Analysis
The results of the survey suggest that time and attendance is the module used by most of the organisations in which the respondent works. This is closely followed by recruitment, compensation, onboarding. This further emphasises the use of SAP SuccessFactors and eHRM on the automation of the tasks that are clerical and repetitive HRM tasks introduce efficiency highlighted in the literature review. The results of the descriptive analysis are highlighted below:
| Which areas of HRM in your organisation are managed through SAP SuccessFactors or any other HR software that you use? | ||
| Module | N | Frequency |
| Time and Attendance | 11 | 10 |
| Recruitment | 11 | 9 |
| Compensation | 11 | 7 |
| Onboarding | 11 | 7 |
| Learning and Development | 11 | 6 |
| Performance and goal management | 11 | 5 |
| Succession and development | 11 | 3 |
| Valid N (listwise) | 11 |
The modules to manage the learning and development, and performance and goal management, are also used widely. However, the survey suggests that organisations make the least use of the module designed to manage the succession and development module.
Fig 2 : Analysis Graph
There are various tangible and intangible benefits from the use of this software. When users were given multiple options to select which are the most beneficial features of the survey. 72.72% of the respondents agreed that the automation of the HRM tasks mainly helps to perform more tasks and thus channel that time to manage the more strategical task as they said that its use adds value to time. The other most common benefit to which 63.64% of the participants agreed was around the cost which is saved by using the SAP SuccessFactors and other software. This may also be indicative of the fact that at places this software tends to replace the HR professional. This might also be a probable reason for the users, not 36.36% of the remaining participants not looking at this as a real benefit for the HR professional. When technology is used to manage HRM data there are in-built checks within the software. For instance, SAP SuccessFactors has the capability to stop a user to input a text value in the date field. One of the main drivers beyond this is the standardisation that the use of SAP SuccessFactors embeds into the process and various task performed by HRM. The users also, felt that this not only increase the accuracy of the data that is used to make daily and strategic HR decision but also increase the efficiency of the users as they save time to correct those errors. 54.55% of the participants also agreed that the use of these software has increased to manage the confidentiality of data as there are access controls within the systems that can be used to define who has access to what. Thus, helping them to maintain better security of the personal data that was maintained using manual processes. This also led to the fulfilment of the regulatory requirements under GDPR in the UK and other equivalent regulations outside it. These benefits and other secondary benefits keep the employees motivated as agreed by 54.44% of the participants in the survey.
| What are the main benefits of using SAP SuccessFactors or HR software? | |||
| Benefits | N | Frequency | Absolute % |
| Time Value | 11 | 8 | 72.73% |
| Cost Saving | 11 | 7 | 63.64% |
| Accuracy | 11 | 6 | 54.55% |
| Data Security | 11 | 6 | 54.55% |
| Employee motivation | 11 | 6 | 54.55% |
| Valid N (listwise) | 11 |
Technological development in the recent past has led to making the machine more intelligent and learning based on the pattern of the records processed by them. There are areas within the HRM functions that take a substantial part of the HR but there is no technology to support their automation. Respondents shared their views to confirm which areas of HRM they would like to be supported by the software. 63.64% of respondents see that it will be most beneficial for them if employee relations could be managed and supported by SAP SuccessFactors or other HR tools. The judgemental nature of this function has not been much supported by SAP SuccessFactors at the moment. Functions like change management, HR strategy and managing organisational effectiveness are other areas that respondents felt should be better supported by the software.
| Which functions of HRM are not supported by SAP SuccessFactors or the available HRM software solutions? | |||
| Areas | N | Frequency | % |
| Employee Relations | 11 | 7 | 63.64% |
| Change Management | 11 | 5 | 45.45% |
| HR Strategy | 11 | 4 | 36.36% |
| Organisational Effectiveness | 11 | 2 | 18.18% |
| Valid N (listwise) | 11 |
Lastly, an investigation was made to explore the challenges that the HRM personnel and the organisations that implement this software have to face. Users shared to have faced multiple challenges with the implementation and use of SAP SuccessFactors or HRM software. HRM generally doesn’t have the technical expertise in managing the software. They thus have to liaise with IT and finance for maintenance, support, and managing the cost of this software. This cross-functional liaising has been found most challenging by the respondents with 54.5% of them listing it to be a major challenge. Also, training the employees to use the application was found to be challenging by 45.45% of the respondents.
| What are the major challenges in the use of SAP SuccessFactors or the available HRM software solutions? | |||
| Challenges | N | Frequency | % |
| Initial Installation | 11 | 4 | 36.36% |
| Employee Training | 11 | 5 | 45.45% |
| Cross-Functional | 11 | 6 | 54.55% |
| Valid N (listwise) | 11 |
10 Limitations
10.1 Data Source
Though an axiology approach has been followed while analysing the responses these may be affected by the oncologic assumptions of the respondents. These responses were from the HRM professional, and many do not factor in the effectiveness that the organisation sees by the implementation of SAP SuccessFactors and/or other HRM software. Additionally, there was a change to the targeted source of data. At the stage of proposal, the aim was to collect data from the then place of employment. However, after the submission of the proposal the access to that organisation was eliminated due to researcher’s redundancy. Hence, judgment was made to share the questionnaire to the next best available source. These were the HR professionals who had first hand experience in the use of SAP SuccessFactors Employee Central.
10.2 Population and Sampling
The total population who uses SAP SuccessFactors is not publicly published. It is suspected that the figure could run to thousands given the limited information available on the internet. Thus, the sample size selected, and the actual response maybe not be truly indicative of the response of the substantive population and there may be many variances from the conclusion drawn in actual practice.
10.3 Data Collection Process and Access to Literature
The data considered for this research is mainly from the reading of research, books, articles, and journals of various academicians, interactions with the HRM professionals, and their responses to the survey. A read of various journals was also done. However, there is not widely available published data on SAP SuccessFactors. Thus, inferences are drawn for other HRIS applications that are developed and operated on similar philosophies and technology. Thus, there may be a generalisation of the impact of technology on HRM’s efficiency and its ability to standardise the HRM processes.
11 Conclusions
The discussion around the various available material and evaluation of the above participants’ responses highlights the various areas within HRM that could benefit from the use of SAP SuccessFactors technology. As can be seen, it is hard to find an organisation that doesn’t use technology to automate to support any of its HRM functions with the probability being nil in the survey conducted.
Although the software has various modules to cater to a range of needs in the HR function these are more standardised and the capability to be in customisation is either very restricted or heavy on the pocket (SAP, 2022).
There has been a shift in the role that HRM is expected to play in the success of the organisation. They are expected to be a strategic partner who is able to analyse further trends, design the process and procedures that supports the organisation’s strategy, and lead to developing a culture where employees are motivated to contribute to the attainment of the organisation’s objective and success. These expectations from HRM requires the automation of their traditional task. Depending upon the financial constraint’s organisations can implement various modules of SAP Success Factors and or HRM tools to automate the HRM processes. This is where the use of these software has gained appreciation. There is an obtain of scalability that SAP SuccessFactors brings in. Where the organisations have an option on which modules on the ERP they want to implement and to which entities where their operations are spread across the border.
Due to the limited development in this area and because of the involvement of the human element at the moment, there are only limited functions of HRM that can be automated such as recruitment, attendance, learning, and development to name a few. Though as a field of science the technology development in this area is still evolving. To overcome the elements of uncertainty and difficulty to predict the behaviour of human resources some critical functions of HRM have not been successfully automated so far.
These functions including employee relationship, change management, and strategic management are still not effectively supported by the available modules and tools. With the growth in artificial intelligence and machine learning, there are chances that these areas of HRM which are heavy on judgemental calls and logical processing of data will soon be supported by technology to further standardise the processes around these functions and at the same time introduce greater efficiency.
12 Recommendations
One of the recommendations which the organisations implementing these technologies should be aware of is that the technology is only as good as the users. Thus, the tech education of the users of these tools is paramount. This point was also highlighted by the respondents who agreed that training the employees to use these tools is one of the major challenges in the use of these tools. This contract which comes along with the benefit of the SAP SuccessFactors and other HRM tools should be factored into by the organisation when they evaluate the efficiency and standardisation introduced by them.
Another recommendation would be around the use of project management tools and practices when organisations implement SAP SuccessFactors. The implementation would be successful only if the settings on the SAP SuccessFactors is correctly configured to reflect the practices and procedures of the organisations. Also, an organisation invests their man-hour, finance while implementing these. This is vital that the test results are correctly checked by the knowledgeable users of these tools before these are put to actual use. Also, it is important that there is the supervision of this implementation process to ensure that it is complemented within the timeframe and is set to deliver the efficiency excepted from its use.
Finally, it is to be considered what impact the inability to access the SAP SuccessFactors applications will have on the HRM operations of the organisations. Mainly these impacts can be divided into three broad categories: operations issues, issues that are tactical, and lastly issues that have a strategic impact. Operational issues include issues that put the administrative working of the HRM function of the organisation in halt such as lots of manual intervention to the applications so that they can process the data being inaccurate and incomplete.
Tactical issues such as the inability to process the data generated through processing by the HRIS, accessibility of these systems, and coverage of the functions lead to a tactical inability by HRM to manage by relying on these applications. Then there are issues that have an impact on the strategic goals of the organisations like inability to manage the complete end-to-end process, inability to change, inability to manage change, or even to adjust based on the forecast (Boroughs and Rickard, 2016).
SAP SuccessFactors Employee Central is a comprehensive HRM management tool. However, given the present support offered by the technological advancement, it is to be considered that the above benefits induced by it or other HRIS that work on similar concepts in terms of efficiency and standardisation is to be seen in the light of the limitations of these applications.
13 CIPD Reflective Statement
Reflexivity is an important skill for a researcher. In order to have a dependable research philosophy researchers should be able to question their own assumptions and scrutinize them at the same time. This helps them to make better-informed choices (Anderson, Fontinha, and Robson, 2019).
There are some important takeaways from the research that I did for this project. Firstly, I became more aware of the use of analytics tools for HRM. My previous understanding of HR analytics has mainly been around its use for frequency analysis. While conducting this research I was introduced to various tools and their application to analyse data that use it to support HRM decision making. In particular, I made use of IBM SPSS Statistics for the first time. And while using it I learned how variable fields can be used to define the fields of the data collected. I sit work closely with my organisations Corporate Management Team and I will apply this tool to crunch data for them. This will help me to present large data in a concise manner.
Moreover, I learned that this tool has a native configuration to enable the creation of charts. I found this tool to create visuals very helpful. Especially, I received positive feedback when I have presented data to the senior management in the visual format as it helped them to digest more information in less time. I consider myself a beginner in HRM data analytics and my knowledge is limited to want I gather while attending MA HRM’s classes on projects and a few YouTube videos. This has; however, encouraged me to build further on my existing knowledge. To do this I will watch more YouTube videos on IBM SPSS Statistics 28. I will also read the IBM SPSS Statistics 28 Brief Guide that is available online for free at (IBM SPSS Statistics 28 Brief Guide IBM, 2021)
At the sage of interpretation, I also found that I could have also used ordinal and scale data measurement to identify the most beneficial function of SAP SuccessFactors Employee Central.
Though, completing this project was a rewarding experience I also had a few challenges while performing it such as designing the survey, the channel for transmission of this survey, and identifying the participants for the survey. There is limited information available on this topic which limited my access to the literature review on this topic but at the same time pushed me to make use of critical thinking and evaluate the response shared by the users of these applications through the survey results. Also, the broader use of preparing the research document is that it has made me more confident to present information to others that are backed by logically interpreted data.
14 References
Alshibly, H.H., 2014. Evaluating E-HRM success: A validation of the information systems success model. International Journal of Human Resource Studies, 4(3), p.107.
Anderson, V., Fontinha, R. and Robson, F., 2019. Research methods in human resource management. 4th ed. Kogan Page.
Armstrong, M., 2009. Armstrong’s handbook of management and leadership. London: Kogan Page.
[online] Available at: https://thelawdictionary.org/multinational-corporationmnc/ [Accessed 14 Nov. 2021].
Bondarouk, T, Ruël, H, & Parry, E (eds) 2017, Electronic HRM in the Smart Era, Emerald Publishing Limited, Bingley. Available from: ProQuest Ebook Central. [23 January 2022]
Boroughs, A. and Rickard, C., 2016. Using technology to create value. London: Routledge.
Burlacu, G., 2022. [online] https://www.sap.com. Available at: <https://www.sap.com/india/insights/hr/artificial-intelligence-may-take-your-job-but-its-a-good-thing.html> [Accessed 23 January 2022].
Chang, S., Gong, Y., Way, S.A. and Jia, L., 2013. Flexibility-oriented HRM systems, absorptive capacity, and market responsiveness and firm innovativeness. Journal of Management, 39(7), pp.1924-1951.
CIPD. (2021). Operating efficiently: implementing HR information systems in large organisations. [online] Available at: https://www.cipd.co.uk/knowledge/work/technology/digital-transformation-insights/hr-systems-large-organisations.
CIPD. 2022. Impact of COVID-19 on working lives | Survey reports | CIPD. [online] Available at: <https://www.cipd.co.uk/knowledge/work/trends/goodwork/covid-impact> [Accessed 12 January 2022].
definition of MULTINATIONAL CORPORATION (MNC) (Black’s Law Dictionary).
Grubb, A. and Lessley, K. (2017). SAP SuccessFactors Recruiting and Onboarding: The Comprehensive Guide. [online] Google Books. Rheinwerk Publishing. Available at:https://www.google.co.uk/books/edition/SAP_SuccessFactors_Recruiting_and_Onboar/VkRdMQAACAAJ?hl=en [Accessed 24 Jan. 2022].
Hunter, I., Saunders, J., Boroughs, A. and Constance, S., 2006. HR Business Partners. Cornwall: Gower Publishing Limited.
Ibisworld.com. 2022. IBISWorld – Industry Market Research, Reports, and Statistics. [online] Available at: <https://www.ibisworld.com/united-kingdom/market-research-reports/hr-payroll-software-publishing-industry/> [Accessed 9 January 2022].
IBM SPSS Statistics 28 Brief Guide IBM. (2021.). [online] Available at: https://www.ibm.com/docs/en/SSLVMB_28.0.0/pdf/IBM_SPSS_Statistics_Brief_Guide.pdf [Accessed 24 Jan. 2022].
Ico.org.uk. 2022. Data protection impact assessments. [online] Available at: <https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/accountability-and-governance/data-protection-impact-assessments/> [Accessed 8 January 2022].
James, S. and Baruti, M., 2021. Determinants Of Standardization And Localization Of Human Resource Management (Hrm) Practices In Multinational Companies’ Subsidiaries: A Review And Implications. Epra International Journal of Economic and Business Review, pp.29-42.
Khashman, A.M. and Al-Ryalat, Dr.H.A. (2015). The Impact of Electronic Human Resource Management (E-HRM) Practices on Business Performance in Jordanian Telecommunications Sector: The Employees Perspective. Journal of Management Research, 7(3), p.115.
Lawler III, E. and Boudreau, J., 2015. Global Trends in Human Resource Management.
Masum, A.K.M., Kabir, M.J. and Chowdhury, M.M., 2015. Determinants that influencing the adoption of E-HRM: An empirical study on Bangladesh. Asian Social Science, 11(21), p.117
Murray, R., Mazhavanchery, M. and Marson, L., 2015. SAP SuccessFactors Employee Central: The Comprehensive Guide. 2nd ed. Bonn, Boston: Rheinwerk Publishing.
Nagendra, A. and Deshpande, M. (2014). Human Resource Information Systems (HRIS) in HR Planning and Development in Mid to Large Sized Organizations. Procedia – Social and Behavioral Sciences, 133, pp.61–67.
National Centre for Research Methods, 2022. [online] www.ncrm.ac.uk. Available at: <https://www.ncrm.ac.uk/resources/video/RMF2010/pages/60_WAOR.php> [Accessed 12 January 2022].
SAP Insights, 2022. What is ERP?. [online] SAP Insights. Available at: <https://insights.sap.com/what-is-erp/> [Accessed 15 January 2022].
SAP, 2022. [online] Available at: <https://userapps.support.sap.com/sap/support/knowledge/en/2287597> [Accessed 23 January 2022].
SAP, 2022. [online] Available at: <https://www.sap.com/products/employee-central-hris.html> [Accessed 15 January 2022].
SAP, 2022. [online] Available at: <https://www.sap.com/uk/products/human-resources-hcm/workforce-planning-hr-analytics.html> [Accessed 11 January 2022].
SAP, 2022. [online] www.sap. Available at: <https://www.sap.com/india/products/employee-central-hris/features.html> [Accessed 15 January 2022].
Saunders, M., Lewis, P. and Thornhill, A., 2019. Research Methods for Business Students. Pearson Education Limited( P435-436 ,492-494) .
The Law Dictionary. (2012). What is MULTINATIONAL CORPORATION (MNC)?
Tobenkin, D., 2022. HR Needs to Stay Ahead of Automation. [online] SHRM. Available at: <https://www.shrm.org/hr-today/news/hr-magazine/spring2019/pages/hr-needs-to-stay-ahead-of-automation.aspx> [Accessed 23 January 2022].
Torres-Coronas, T. and Arias-Oliva, M., 2009. Encyclopaedia of human resources information systems.
Uysal, G., 2014. Taylor, HRM, strategic HRM with jobs, employee performance, business performance relationship: HR governance through 100 years. International Journal of Business and Management Studies, 6(1).
Wilton, N., 2019. An Introduction to Human Resource Management. SAGE Publications. (Pg 508-510)
15 Appendix
15.1 Figure Proposal Gantt Chart
15.2 Figure Actual Gantt Chart
15.3 Appendix: Online Survey Information presented to all participants
Hi there!
I am recently completing research for a Master’s degree. In my research, I am exploring the impact technology has had on Human Resource Management (HRM) functions.
If you could please spare 3 minutes to complete this survey which has a few questions about the use of technology for performing HRM functions at your organisation.
The information collected from this survey will be used for the purpose of this research and at any time you can withdraw from this survey. If you have any questions about this survey, please feel free to contact me on 07883916007.
Just click on the start button below to get started.
Thanks, and all the best!
15.4 Questionnaire
Do you use SAP SuccessFactors Employee Central to manage your HRM function?
- Yes [ ] No [ ]
In case the answer to the above question is ‘no’ is there any other e-HRM tool that your organisation uses
- Yes [ ] No [ ]
How large is your organisation (considering the total number of employees)?
Tick your answer
- Less than 1000
- 1000 – 2000
- 2000 – 5000
- 5000 – 10000
- More than 10,000
Does your company operate in more than one country?
- Yes [ ] No [ ]
Is your organisation considered to be a Multinational Company (MNC)?
- Yes [ ] No [ ]
Which areas of HRM in your organisation are managed through SAP SuccessFactors or any other HR software that you use?
Tick your answer:
- Recruitment
- Onboarding
- Time and attendance
- Learning and development
- Performance and goal management
- Compensation
- Succession and development
What are the main benefits of using SAP SuccessFactors or HR software?
Tick your answer:
- Saving of cost
- Time to value/efficiency
- Time and attendance
- Motivated employees
- Data security
- Accuracy
Which functions of HRM are not supported by SAP SuccessFactors or the available HRM software solutions?
Tick your answer:
- Employee relations
- HR Strategy
- Change management
- Organisational effectiveness
What are the major challenges in the use of SAP SuccessFactors or the available HRM software solutions?
Tick your answer:
- Initial installation
- Training employees
- Cross-functional
[1] Bot – a piece of software that is used to perform pre-defined, automated tasks on a repetitive basis.
Thesis – On the job and beyond: Whose anxiety is it anyway? Experiences of CQC inspections for registered managers. An exploratory study on the impact of Care Quality Commission (CQC) inspections on Registered Manager’s working in adult Mental Health Care Homes.
12 pages + well-structured + cited references
Description
What is the impact of Care Quality Commission (CQC) inspections on the lived experience of registered
managers working in care homes for people with mental health illness?
Improvements required in relation to order reference 713337 due to changes in the research questions. Therefore
modifications are needed for the Findings/Analysis, Discussion and Conclusion reflect the questions below
Question
- What is the nature of RM’s relationships with CQC and the intensity of anxieties experienced in the face of
inspections? - What are the range of factors, forces, and variables that make up the uniqueness of the RM role?
- What is the impact of COVID-19 pandemic on CQC inspections and registered managers?
Advice is that presentation of data finding can be presented as it was to purify to give voice to the participants –
could start with participants’ profiles to take us through the data
generation and the data analysis processes. Preferred Font is Ariel and size no less than 12 and no greater than
14 – attached information / excerpts and others documents previously submitted for 713337 may be helpful.
THE IMPACT OF COVID-19 ON THE PRACTICE OF PASTORAL CARE PRACTITIONERS
Revise and update the attached Literature Review to create a substantial chapter for a doctoral-level thesis. This
should include reflections and insights from the attached Research Proposal and Data Analysis. It should also
include conceptual or methodological insights gained from an expanded engagement with the literature in the
chosen field of inquiry
Are the social determinants of health effecting poor children’s oral health in London
Draft required
12 pages + well-structured + cited references
Description
Good day, this is a 10,000 word dissertation which requires at least 100 references but more is welcome, the
design method is a quantitative systematic review. My research question is “Are the social determinants of
health effecting poor children’s oral health in London”. We are required to have 15 – 20 research papers, mine all
need to please be UK based, quantitative and from within this decade.
Nurse -led Biliary Pathway- a service improvement implementation project
IMPLEMENTATION OF AN INTEGRATED MULTIDISCIPLINARY DAY HOSPITAL
FOLLOW-UP SERVICE TO IMPROVE THE MANAGEMENTOF PEOPLE DIAGNOSED WITH ATYPICAL PARKINSON’S SYNDROMES
Student name
Student number
Cardiff University
School of Healthcare Sciences
MSc (18/19 NRT079 DISSERTATION JULY 2020)
Presented to Cardiff University in partial fulfillment of the requirements for the degree of Masters of
[ADVANCED PRACTICE]
Word Count: 19990
Date of Submission: 07/07/20
Implementation of an integrated multidisciplinary
day hospital follow-up service to improve the management
of people diagnosed with atypical Parkinson’s
syndromes
Acknowledgments
I would like to extend my gratitude and thanks to my family, friends and work colleagues for their support. This workbased project has presented many challenges both physical and mental and without their understanding I feel I could not have got through it. A particular mention to my husband for his knowledge and skill with all things I.T. related. He came up with solutions to all my technology issues and managed to resolve some very tricky situations. He also provided regular refreshments and ensured that I kept going even when I felt like giving up.
A special mention must also go to my tutor. She managed to calm my anxieties with practical feedback and supportive words and was always available for advice. There were times when I felt I couldn’t continue but she gave me the courage to carry on.
Thank you all.
Abstract
Atypical Parkinson’s syndromes are rare degenerative disorders that are rapidly progressive, have decreased life expectancy and little or no response to symptomatic treatment in comparison to Idiopathic Parkinson’s disease (IPD). Relatively unknown they present with a plethora of complex symptoms which require immediate and consistent intervention. They include; Progressive Supranuclear Palsy (PSP), Corticobasal Syndrome (CBS), Multiple System Atrophy (MSA) and Dementia with Lewy Bodies (DLB). The National Institute for Health and Care Excellence (NICE) Parkinson’s guidelines (2017) stresses the importance of early multidisciplinary team (MDT) involvement at the point of diagnosis as an optimum standard of practice. The paucity of literature pertaining to this group of patients is reflective of services which treat all Parkinson’s conditions collectively regardless of trajectory or treatment (Hohler et al. 2012).
The aim of this local workbased project involved developing an integrated multidisciplinary follow up service for people with atypical Parkinsonism within a day hospital setting to address and potentially resolve variability and delays to care. ‘The Model for Improvement (NHS Wales “1000 lives” improvement 2014) incorporating three questions and a series of PDSA cycles, was used as a framework to guide the process and maintain focus and structure. A retrospective baseline audit (October 2017-October2018) of 22 patients was performed to compare with data gathered following the service improvement. A designated 6 month post implementation audit (November 2018 –April 2019) identified 12 people had been diagnosed with an atypical Parkinsonism. Information pre and post implementation of the service improvement was gathered and analysed. The baseline audit identified out of 22 patients only 33% received MDT therapy input with an average (mean) wait to access therapy of 78 days. There was significant variability in wait times and noted impact to perceived effects on QoL (PDQ-39 over 200 responses to ‘always). In comparison, following the service improvement results identified that there was an 89% reduction in waiting time to access therapy, the variation in referral to access MDT went from 156 days to 11 days and of the 12 patients included in the audit 100% received MDT input. PDQ-39 responses for ‘always` fell below 60 indicating less perceived impact to QoL. The changes introduced as part of this workbased project demonstrate the benefits of collaborative working and putting the patient at the centre of everything that we do (WG 2015).
CONTENTS
Acknowledgements 3
Abstract 4
Chapter 1 8
Introduction 8
Background 13 • Multiple System Atrophy (MSA) 14
• Progressive Supranuclear Palsy (PSP) 15
• Corticobasal Syndrome (CBS) 16
• Dementia with Lewy Bodies (DLB) 17
Project Aim 20
Objectives 20
Chapter 2 21
Literature review 21
• Integrated MDT input benefits functional ability 29
• Accessing cohesive MDT services improves quality 36
of life (QoL)
Concluding remarks of the Literature review 39
Chapter 3 40
Methodology 40
• Project Trigger 51
• What are we trying o accomplish? AIMS 53
• Driver 1 53
• How will we know if a change is an improvement? 56
MEASUREMENT
• Driver 2 58
• Consideration of the four key parameters 63
• Length of time from first diagnostic outpatient 63
appointment to follow up review
• Was a referral for MDT completed? 64
• Length of time from MDT referral to contact 64
• Quality of life- Review o Parkinson’s disease 64
questionnaire -39 scores (PDQ-39)
• What changes can we make that will result in an 65
improvement? IDEAS
• Driver 3 66
• Consideration of the referral process 66
• Driver 4 67
Chapter 4 72
Results 72 • Driver 5 – continuation of PDSA cycle 2 72
• PDQ-39 78
Chapter 5 81
Discussion 81
• Driver 6 81
• Analysis 81
• Evaluation of the service improvement 85
Chapter 6 89
Conclusion 89
Recommendations for practice 91
Appendix
Appendix 1- Epidemiology chart 93
Appendix 2 – The four principles of person-centred care 94
Appendix 3 – PRISMA Flow Diagram 95
Appendix 4 – Evaluation of studies in literature review 96
Appendix 5 – Hoehn and Yahr scale 112
Appendix 6 – Unified Parkinson’s Disease Rating Scale 113
Appendix 7 – Scoping exercise 115
Appendix 8 – R&D approval 117
Appendix 9 – Mind Map 120
Appendix 10 – Letter 121
Appendix 11 – PDQ-39 Questionnaire 122
Appendix 12 – Adapted PUKAT (2017) Tracking/audit sheet 124
Glossary 127
References 129
CHAPTER 1
Introduction
Delivering integrated services which are responsive to the individual needs of people with complex neurological conditions is challenging (Welsh Government (WG) 2017). In Wales there are approximately 7,692 people with a diagnosis of a Parkinson’s condition which is set to rise by 18% in the next 6 years (Parkinson’s UK 2018). This increase reflects the escalating aging population where diagnoses of Parkinson’s syndromes are more common. In the context of service delivery growing demand is set to place enormous pressure on current resources (WG 2017). Compounding this is the differing complexity of syndromes under the umbrella of Parkinson’s, with atypical conditions being amongst the most challenging to manage. It has been considered that facilitating affordable integrated services is the way forward (WG 2017). However, there are challenges with ensuring standards of care and prioritising people remain at the forefront (Nursing and Midwifery
Council (NMC) 2018)
Atypical Parkinson’s syndromes are rare degenerative disorders that are rapidly progressive, have little or no response to symptomatic treatment and decreased life expectancy in comparison to Idiopathic Parkinson’s Disease (IPD) (Appendix 1). These relatively unknown conditions which include Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP), Corticobasal Syndrome (CBS) and Dementia with Lewy Bodies (DLB) present with a plethora of complex symptoms which require immediate and consistent intervention. In the updated version of the National Institute for Health and Care Excellence (NICE) Parkinson’s guidelines (2017) particular attention is paid to the importance of early multidisciplinary team (MDT) involvement at the point of diagnosis. This requires an integrated cohesive service which according to the All Party Parliamentary Group for Parkinson’s disease (APPG) (2009) in their inquiry into accessing health and social care optimises outcomes and improves standards of practice. People with atypical Parkinson’s syndromes do not fit the traditional outpatient model of care which relies on individualised referral for MDT input rather than structured processes. Inconsistencies and delays in treatment increase the risk of hospital admission, prolonged length of stay and death (Low et al. 2015). There are no guarantees that hospital admission can be avoided but there is evidence that functional ability and quality of life can be enhanced with utilisation of MDT support (Hohler et al. 2012). With one in seven consultations and one in five emergency admissions related to a neurological condition rationalisation of service delivery has become a priority (WG 2017).
Progress is being made in Wales to improve neurological service delivery. Latest figures published in Welsh governments Neurological Conditions Delivery Plan (WG 2017) show a reduction in the length of an individual’s in-patient admission from 6.4 days in 2010-2011 to
4.2 days in 2015-2016. Early indications suggest that service development within neurological rehabilitation with providing high quality diagnosis, treatment, care and the introduction of quality information have attributed to this (WG 2017). Yet inconsistencies remain within outpatient services related to the method of consultation, interval for follow up review and referral for MDT support. With expenditure on neurological conditions having risen by 65% in 5 years (WG 2017) the pressure to deliver cost effective services within current resources has never been greater. However, there are challenges to this. Atypical Parkinson’s syndromes are notoriously difficult to diagnose due to their similarities with idiopathic Parkinson’s in the early stages (Lindop et al. 2014). Additionally their swift progression means there is a very limited window of opportunity to provide effective intervention. Dependent on symptom onset and development the median life expectancy is 3-8 years (Schrag et al. 2008, Ludolph et al. 2009).
Recent results from a national Parkinson’s service audit identify that only 13.5% of Parkinson’s clinics follow an integrated multidisciplinary model. This compares to 58.7% where a more traditional service is in operation inclusive of consultant specialist and Parkinson’s disease nurse specialist (PDNS) only. Disappointingly progress towards integrated MDT services has been slow with only a 1% increase in teams adopting this model over the past 2 years (Parkinson’s UK 2017). Capacity to incorporate this way of working does not appear to be an issue with latest figures from the Welsh NHS Activity and Performance Summery (March/April 2019) showing a downward trend in waiting times accessing therapies (WG 2019). However, there has been a simultaneous fall in therapy referrals for people newly diagnosed with Parkinson’s conditions, continuing variability within clinical practice and delays with accessing both new and follow up appointments possibly contributing to this (Parkinson’s UK 2017). As data was not extracted specifically related to people with atypical syndromes the degree with which these factors impact on their management is unknown. Despite this there are many studies supporting the need for integrated follow up services for people with chronic neurological conditions including the benefits of bespoke services for people with Atypical conditions (Portillo and Cowley 2010, Flabeau et al. 2010, Bukki et al. 2016, Peel et al. 2019).
The focus of this service improvement is to provide an integrated outpatient MDT follow up service for people with atypical Parkinsonism. Patients are reviewed as part of the Parkinson’s and movement disorders clinic during a standard 15 minute time slot. Referral for MDT involvement is based on clinical presentation and individual practice with complex cases discussed at the multidisciplinary meeting (MDM) post clinic. The core team consists of two consultant geriatricians and physicians with an interest in Parkinson’s syndromes and two full time PDNS. Outlying support is provided by two day hospitals with access to MDT input and associate specialist doctor support. In the context of this project MDT will refer to the associate specialist doctor, PDNS x 2, Occupational therapists (OT), Physiotherapists (PT), Speech and Language therapists (SALT), qualified nurses and support staff.
During team meetings increasing concerns have been raised that the current provision of outpatient follow up services were not meeting the needs of people with atypical syndromes. Extended consultations beyond the allocated time slot, inconsistencies in referral to therapies, delays in accessing treatment and variability with follow up appointments were highlighted. As people with these conditions experience a more rapid decline there is a potential risk that the window of opportunity to optimise management under the existing system may be lost. It is also worth considering that progression renders a person less capable of performing tasks due to increasing functional disability. Therefore, the likelihood that patients will be unable to participate in treatment increases with time. Services which lack integration delaying access to support contravene best practice recommendations (NICE 2017, WG 2017). Implementing integrated multidisciplinary follow up for people with complex atypical syndromes has the potential to improve outcomes and quality of life (Lamb et al. 2016).
The author is a Parkinson’s disease nurse specialist (PDNS) working within one university health board (UHB) serving an estimated population of 484,752. The Parkinson’s service is situated within the medical directorate and has a caseload of approximately 1,450 patients diagnosed with a Parkinson’s syndrome. This number does not include people from other specialities within the UHB who are accessing support as they do not have a Parkinson’s specialist nurse team available to them. The PDNS role is multifaceted with a considerable proportion of time being spent working and liaising with the multidisciplinary team and performing complex reviews. Over the past few years numbers within the Parkinson’s clinic have escalated. This increasing demand is placing pressure on meeting targets for new diagnostic consultations and having a direct impact on the time for follow up reviews extending them by up to 3 months. The current clinic allocation for Parkinson’s nurses is 810 patients within a 2.5 hour time slot. Due to the complexity of each review consultation times regularly overrun often by as much as 30 minutes. This tends to occur more typically when assessing patients with atypical Parkinson’s syndromes as a result of their multiple symptoms requiring more detailed analysis. This has a knock on effect to waiting times and patient morale. With outpatient services nationally under considerable pressure to meet the needs of an expanding elderly population, employing strategies that provide effective, efficient and economical use of resources is crucial (The Wales Audit Office Study Team 2018).
This service improvement will show the process by which a change in practice was implemented to manage patients with atypical Parkinson’s syndromes. A fundamental component to this will be the development of an integrated follow up service within a multidisciplinary day hospital setting designed to address and potentially resolve variability and delays to care.
Background
According to the Global Burden of Diseases (GBD), Injuries and Risk Factors study (Global Burden of Diseases (GBD) Study 2015) neurological disorders are the leading cause of disability and death worldwide. In the updated version of the Parkinson’s NICE guidelines (NICE 2017) recommendations place early MDT intervention as fundamental to improved outcomes and maintenance of function. These standards are principle in influencing and transforming practice having derived from a robust systematic review of best available evidence. This concept is even more prevalent when managing atypical Parkinson’s syndromes as drug treatments are less effective in these conditions (Hohler et al. 2012). However, this is challenging due to the individual complexity of each of the syndromes and their more rapid progression.
Atypical Parkinson’s syndromes present with key features which sets them apart from IPD in clinical presentation (Table 1.1).
Table 1. 1 Red flags for identifying Idiopathic and Atypical Parkinsonism syndromes
Idiopathic Parkinson’s Multiple system Progressive supranuclear
disease atrophy1 palsy2 Corticobasal degeneration3 Dementia with Lewy bodies 4
Unilateral onset of symptoms
Presence of slowness of repetitive finger taps with fatigueable decrement
Presence of a resting tremor Presence of unilateral reduced arm swing
Postural instability but usually no falls at diagnosis and in early disease
Good response to levodopa
treatment Symmetrical symptoms, rapid progression
Early falls, often backwards
Disproportionate antecollis
Camptocormia
Autonomic dysfunction
Stridor
Snoring
Involuntary sighing
Emotionally labile Reduced eye movements, especially downwards
Early falls, often backwards
Motor recklessness
‘Mona Lisa’ stare
Positive applause sign
Cognitive changes
Behavioural changes
Emotional lability Reduced coordination/ function in one upper limb
Cognitive dysfunction
Pout reflex
Pallilalia
Echolalia Hallucinations at diagnosis
Fluctuating cognitive changes
Impairment in attention, executive and visuoperceptual function
Parkinsonian features, e.g. tremor, rigidity bradykinesia, shuffling gait, which respond less well to levodopa treatment
Conditions also known as: 1=Shy Drager; olivopontocerebellar atrophy (MSA-C); striatonigral degeneration (MSA-P); 2=Steele-Richardson Olszewski syndrome; 3= Also known as: corticobasal ganglionic degeneration (CBGD); 4=Lewy body dementia; diffuse Lewy body disease; cortical Lewy body disease; senile dementia of Lewy type
(Lindop et al. 2014)
Diagnosis of these conditions is challenging due to the later presentation of the more distinguishing features and overlap in clinical presentation with IPD in the early stages. When red flag symptoms present in conjunction with a lack of response to Levodopa medication it is only at this point atypical Parkinsonism can be considered. Advances in neuroimaging in recent years has resulted in brain Magnetic Resonance Imaging (MRI) scan being used to assist in obtaining a more reliable and accurate diagnosis (Meijer et al. 2017). However, first and foremost MRI is used to exclude cerebrovascular damage but also other possible causes for Parkinsonism that are sometimes treatable such as normal pressure hydrocephalus.
Multiple System Atrophy (MSA)
First reported in 1960 (The Multiple System Atrophy Coalition 2019) the main characteristics of this condition are autonomic failure (orthostatic hypotension, urinary dysfunction, digestive abnormalities). There are two forms MSA-P resulting from degeneration mainly within the basal ganglia thus primary Parkinsonian signs, and MSA-C arising from predominant changes within the cerebellum eliciting cerebellar features. As they are both subject to autonomic changes they are generally catagorised as simply MSA (Lindop et al. 2014). On MRI scan atrophy within the putamen, pons and/or cerebellum can be visualised with a characteristic ‘hot cross bun’ sign supporting the diagnosis (Fig. 1.1). Microscopic presentation of damaged neurons reveals abnormal quantities of the protein alphasynuclein contained within the cell. Despite numerous hypothesis there has thus far been no definitive explanation found as to the cause (Flabeau et al. 2010). Fig.1.1
Subject diagnosed with the cerebellar form of MSA. Left image, T2-weighted transversal sequence demonstrating pontine atrophy with the ‘hot cross bun’ sign (encircled). Middle image, FLAIR hyper-intense signal intensity changes of the middle cerebellar peduncles (arrows). Right image, T1-weighted sagittal plane demonstrating pontocerebellar atrophy.
(Meijer et al. 2017, p214)
Progressive Supranuclear Palsy (PSP)
The initial identification of PSP was by Steele et al. (1964). Distinguishing features of this condition are supranuclear gaze palsy or ‘dolls eye syndrome’ referring to the slowing of vertical saccades with progression to complete vertical gaze paralysis and early falls mainly backwards. As with MSA there is no known cause but speculation exists that environmental, viral or a genetic mutation is responsible (Litvan 2005). MRI imaging reveals atrophy within the midbrain referred to as a ‘hummingbird’ or ‘morning glory’ sign (Fig. 1.2). It has been found that deteriorating brain cells contain neurofibrillary tangles of tau proteins similar to those found in Alzheimer’s disease.
Fig.1.2
T1-weighted images in transversal (left image) and sagittal (middle image) planes demonstrating atrophy of the midbrain also referred to as the ‘morning glory’ sign and ‘hummingbird’ sign. The subject was diagnosed with PSP. Right image, T1weighted sagittal plane of a healthy subject for comparison.
(Meijer et al. 2017, p214)
Corticobasal Syndrome (CBS)
This is the rarest of all the atypical disorders having first been recognised by Rebeiz et al.
(1968). It has the same characteristics as PSP but is distinguishable by the presentation of ‘alien limb syndrome’. This refers to the uncontrollable way an upper limb behaves which is perceived as foreign to the person (Tiwari and Amar 2008). As with PSP tauopathy associated with the aggregation of tau protein into neurofibrillary tangles within neurones results in atrophy. The structures affected are the cortex and basal ganglia with MRI imaging revealing atrophy within the frontoparietal cortical area (Fig. 1.3).
Fig. 1.3
Corticobasal degeneration -mild frontal atrophy with some asymmetry
(Tokumaru et al. 2009)
Dementia with Lewy Bodies (DLB)
The second most common form of dementia after Alzheimer’s it falls under the umbrella of atypical syndromes due to its similar pathology and clinical presentation with IPD. Both involve the presence of intra-cytoplasmic inclusions (Lewy bodies) in the nuclei of neurones formed from the protein alpha-synuclein (Schulz-Schaeffer 2010). In IPD these inclusions tend to be concentrated within the substantia nigra whereas in DLB they are more widely distributed involving both the substantia nigra and deep cortical layers. The distinguishing clinical features which set it apart from IPD are early cognitive impairment and repeated frank visual hallucinations (McKeith et al. 2005). Radiological imaging with dopamine transporter (DaT-scan) is only used for the differential diagnosis of Alzheimer’s (no changes) and DLB where loss of dopaminergic neurones is identified (Fig. 1.4) (Bhogal et al. 2013).
Fig. 1.4
Normal DaT scan (a) for comparison. DaT scan of a patient with DLB (b) showing lack of tracer uptake in the putamen bilaterally.
(Bhogal et al. 2013)
The complexity of diagnosis in conjunction with the array of different symptoms between the atypical syndromes presents a variety of challenges with management. Current outpatient services for Parkinson’s have been designed to cater for general rather than specific need. This is not ideal considering the trajectory and lack of effective treatment available. Improving outpatient services is an initiative gaining momentum in Wales. Transforming the current system in a direction that addresses need where appropriate is considered prudent to sustainability in the long term (NHS Wales “1000 Lives” Improvement 2014). Focus has been set on tackling six key domains to guide good practice including:
• Patient safety
• Provision of clinically effective services
• Services centred on patients
• Services provided in a timely way
• Efficient provision of services
• Equitable care
This change in direction guided by the “1000 Lives” campaign (2014) does present challenges particularly when addressing the needs of people with rare complex conditions who do not fit a standard model of care. However, onus is being placed on practitioners to develop shared decision making and build close personal relationships together and with their patients. According to The Health Foundation (2015) changing practice would not be possible unless underpinned by core principles of patient centred care (Appendix 2). This is a move away from traditional models which have generally taken a reactive approach (NHS Wales “1000 Lives” Improvement 2014).
People with atypical disorders require timely multifaceted intervention which takes into account the complexity and variability of their symptoms. Advanced care planning is crucial to this (Lamb et al. 2016). However, as these conditions are rapidly progressive this requires prompt action, patience and sensitive discussion which is often outside the scope of an outpatient interaction. Communicating preferences and care wishes is a key component to this process with time allocated to consider resuscitation status, hospital admission and feeding (Lindop et al. 2014). With time constraints in clinic valuable information and educational opportunities can be missed. Inconsistencies in clinical management pose the risk of referral to specialist hospital services such as palliative care and third sector support being omitted. As there are no clinically effective drug treatments currently available it is essential the services for these complex conditions employ alternative strategies to maintain quality of life (Lamb et al. 2016).
Project Aim
To develop an integrated multidisciplinary follow up service for people with atypical Parkinsonism within a day hospital setting to address and potentially resolve variability and delays to care.
Objectives
• To review the literature exploring the benefits and challenges of integrated multidisciplinary team working with managing patients who have complex chronic conditions.
• To collect baseline data regarding current outpatient clinic services.
• Implement the service improvement to provide an integrated MDT follow-up service for people with atypical Parkinson’s syndromes.
• Outcome measures to evaluate benefits with the service improvement in reducing waiting times for follow up review, more timely and consistent access to MDT input and impact on quality of life using:
- Parkinson’s UK Audit Tool (2017) (adapted)
- Parkinson’s disease questionnaire-39 (PDQ-39) (Jenkinson et al. 1997)
- Hoehn and Yahr (1967) Parkinson’s stages of disease
- Run charts
• Put forward recommendations to reinforce future practice in terms of sustainability of the service.
Chapter 2
Literature review
This chapter details the process of a literature review which was conducted to investigate articles pertinent to the management of people with atypical Parkinson’s conditions. Literature review serves to explore, increase understanding, contextualise what is already known and identify the most recent evidence based material available (Parahoo 2014). A systematic approach to the search strategy critically analysed background information to support practice in developing, evaluating and implementing quality service improvement (Gerrish and Lathlean 2015).
Appraisal of the literature was carried out to establish validity and reliability of the studies followed by a process of data extraction to select articles for inclusion in the analysis. In advance of this, a planned search strategy was utilised involving the development of a focused question. According to Gerrish and Lathlean (2015) this ensures the search is suitably streamlined, accuracy is maintained and volume of literature retrieved is controllable. The PICO (Patient/Problem/Population, Intervention,
Comparison/Control/Comparator and Outcome) or SPICE (setting, Perspective, Intervention, Comparison and Evaluation) models can be used to assist with this process of formulating the focused question by identify key words and phrases for the search (Table 2.1). Gerrish and Lathlean (2015) deem the PICO model a preferred format for questions surrounding healthcare interventions as opposed to SPICE which is preferred for qualitative approaches. PICO is deemed the preferred model for this service improvement as it takes a more interventional approach.
Table 2.1 PICO MODEL Identified words and phrases
Patient/Problem/Population Atypical Parkinson’s/Parkinsonism
Parkinson’s Plus Syndromes
MSA
PSP
CBD
DLB
Movement disorders
Neurodegenerative diseases
Intervention Multidisciplinary Team Intervention
Rehabilitation
Integration of healthcare
Holistic management
Treatment
Palliative care
Comparison/Control/Comparator Current Outpatient services
Outcome More timely intervention
Having generated key search words using the PICO model these were employed as a basis for a rigorous search of multiple acknowledged databases. Gerrish and Lathlean (2015) recognise that by applying this method a more thorough return of results can be achieved. The electronic databases used were the Cumulative Index to Nursing and Allied Health
(CINAHL), The British Nursing Index (BNI), MEDLINE, Web of Science, Scopus and Turning Research into Practice (TRIP). Boolean operators AND, OR and truncation * streamlined the search combining and excluding terms for increased accuracy of results retrieved. According to Parahoo (2014) this process reduces the risk of missing relevant articles and ensures literature retrived is as broad as possible.
Inclusion and exclusion criteria have been set (Table 2.2) to establish boundaries and focus the search, which according to Parahoo (2014) improves the generalisability of the findings.
Table 2.2
Inclusion Exclusion
• English language articles
• Peer reviewed
• Adult
• Systematic reviews
• Meta-analysis
• Atypical Parkinson’s
• Parkinsonism
• Parkinson’s plus
• MSA,PSP,CBD
• Parkinson’s disease
• Complex Parkinson’s
• Individual and group interventions
• Multidisciplinary team (MDT) input
• Integrated
• Similar healthcare approaches • Hospital or hub based settings
• Methods of service improvement/change
• Outpatient services
• Neurological conditions
• Chronic disease-neurological base
• Rehabilitation
• Palliative care
• Open time frame (consideration to seminal literature) • Children
• Non intervention literature (based on telephone, internet, video interaction)
• Commentary based articles
• Home based intervention
• Surgical/post operative rehabilitation
• Drug induced/vascular Parkinsonism
• Primary care based services
• Individual therapies
• Non-neurological chronic diseaseDiabetes, epilepsy, respiratory, heart disease
An initial search of the databases identified a limited number of articles specifically related to integrated/multidisciplinary input of people with atypical syndromes. As care forms part of a Parkinson’s service as a whole broadening the search to include all Parkinson’s related conditions and neurodegenerative disorders resulted in more comprehensive retrieval of literature. Many of the studies did not distinguish the syndromes as separate and thus they were included under the umbrella term of Parkinson’s or Parkinsonism. In respect of integrated/multidisciplinary/rehabilitation there was differing opinion in the literature regarding what therapies constituted the makeup of a service. In terms of this project variation in service provision and location was used to enhance the review and broaden the evidence base. Studies which involved home based intervention alone were excluded. However, literature where home based intervention formed part of an outpatient or hospital based service were included as links between intervention and outcome added context to the analysis. One study by Rooney et al. (2015) which was initially excluded as it involved people with Amyotrophic lateral Sclerosis (ALS) on further analysis was included as comparisons could be drawn in care provision which added insight into service delivery.
Additional hand searching of articles was carried out using relevant journals content pages. According to Aveyard (2012) this process can capture studies that may have been missed via the electronic search. Further literature was sourced where relevant articles were back chained using reference lists (Parahoo 2014). Following a comprehensive search the retrieved literature was scrutinised based on the inclusion criteria to identify relevant information and selected for the literature review (Table 2.3). Explanation of the explicit selection process has been captured using a PRISM (Preferred Reporting Items for Systematic Reviews flowchart (PRISMA 2015) (Appendix 3). Seminal articles were identified which were analysed within the systematic reviews (Gage and Storey 2004, Johnston and Chu, 2010, Prizer and Browner, 2012, Tan et al.2014). Despite being small studies they were included as being pivotal in identifying an interrelationship between integrated intervention and positive patient outcomes.
Table 2.3 Search results
Databases Number of Hits Articles Retrieved Relevant studies
Cumulative Index of Nursing and
Allied Health (CINAHL)
British Nursing Index (BNI)
MEDLINE
Web of Science
Scopus
Turning Research Into Practice (TRIP)
122
83
56
41
10
3
21
12
10
6
2
1
5
3
2
2
0
1
Additional searches (other sources) 23 8 2
The total number of articles that were finally retrieved amounted to fifteen and was deemed to provide evidence relevant to the project. The literature was comprised mainly of quantitative studies including randomised controlled trials (RCTs) which are considered the ‘gold standard’ of evidence (Parahoo 2014). Booth (2010) rejects the concept of applying rank or hierarchy to studies in favour of the method being appropriate to the question to be answered. This is however not the consensus of opinion. Murad et al. (2016) recognise that applying hierarchies of evidence allows for key markers to be identified in terms of quality and underpinning theory which is an integral part of appraising research evidence. Trials of this nature are deemed to employ rigorous approaches through their methods of data collection and numerical reporting (Polit and Beck 2018). RCTs can also act as a springboard to further investigation. The approach utilised within RCTs employs the use of comparative data generally looking at like groups being exposed to different stimuli (Parahoo 2014). As this project is based on current outpatient provision verses the introduction of multidisciplinary follow-up, inclusion of these trials was deemed to provide a strong evidence base.
One of the retrieved studies by Frundt et al. (2018) is based on a service improvement which employs practice observation as a means of gathering quantitative data. Previously considered as less robust (Parahoo 2014) more recently there is increased understanding that service improvement methods have impact in enhancing the efficiency of healthcare delivery (Goldstein et al. 2018). Consistent in its use of both subjective and objective data collection Frundt et al. (2018) employed recognised Parkinson’s motor and non motor tools. Utilisation of the same data collection instruments to a greater or lesser degree was seen throughout the quantitative literature retrieved. With this being the case there is a greater opportunity for generalisability of results which according to Parahoo (2014) can be an indicator of more robust methodology.
Qualitative studies were less prevalent within the search with only one being identified for inclusion in the literature review. Historically evidence retrieved through these methods has been considered less significant (Dharamsi and Charles 2011). However, this opinion is outdated with acceptance now that they add depth, context, understanding and holism by exploring thoughts, experiences and behaviour (Polit and Beck 2018). The psychological context of care is important when managing people with atypical syndromes. The study by Murdock et al. (2015) has been discussed to highlight the interrelationship between the physical benefits of MDT input and perceived benefits to quality of life. Whilst its focus is on people with advanced Parkinson’s comparisons can be drawn as these conditions overlap in complexity and impact to emotional and physical aspects of daily life.
The studies included within this review are a spread of United Kingdom, European and International literature. This highlights that there are potential issues globally with care for people with Parkinson’s and atypical syndromes and that this is not just a product of our healthcare system. Integrated multidisciplinary healthcare is open to interpretation with inconsistencies in service provision and models of care continuing to exist (Post et al. 2011).
However, studies which provide clear explanations of what represents service delivery
(Hohler et al. 2012, Monticone et al. 2015, Frundt et al. 2018) can be more easily replicated. This is an important consideration when interpreting the results, as reliability is dependent on being able to reproduce the research in order to draw comparisons (Parahoo 2014). It also allows improved transparency when reviewing the literature and analysing the results.
Review of the chosen literature has been carried out using a systematic approach analysing for reliability, validity and rigour. This process of examination is used to determine the trustworthiness, value and relevance of the study whilst questioning its applicability within a particular context (Gerrish and Lathlean 2015). Critical appraisal tools provide a means of guiding this process by way of checklists or frameworks which evaluate the quality of the research (Parahoo 2014). Numerous tools are available which according to Buccheri and
Sharifi (2017) require careful navigation in order to select the most appropriate for the job. This literature review utilises the Critical Appraisal Skills Programme (CASP 2018) checklists which provides a framework for evaluation of published studies. This comprehensive framework offers tools for use with various methodologies appointing questions to guide critical thinking for appraisal. According to Whiffin and Hasselder (2013), this procedure allows more objective and analytical evaluation of evidence and improves critical thinking.
The Specialist Unit for Review Evidence (SURE) checklist was considered but was discounted on the basis that the majority of literature retrieved was quantitative therefore suiting the format approached through CASP (2018). On completion of this process the information was entered into a table (Appendix 4) which enabled further scrutiny and to facilitate the extraction of commonalities and identify voids in practice. A comprehensive critical analysis having been directed by CASP identified key themes which were extrapolated and will be used to guide the literature review which are:
• Integrated MDT input benefits functional ability
• Accessing cohesive MDT services improves quality of life
As stated earlier the lack of studies pertinent to atypical Parkinson’s syndromes reflects that there is a discrepancy in considering that these conditions are unique. Globally there is a tendency to deliver care symbiotically under the umbrella of Parkinson’s as these atypical disorders are so rare. However, rapid progression and lack of response to treatment do set them apart (Hohler et al. 2012). Despite this there are similarities in care provision between Parkinson’s syndromes as a consequence of overlap in developing symptoms. As a result studies did not tend to distinguish between conditions but instead focused on provision of MDT input and structure of follow up as a whole. As this is an integral component of this local workbased project, articles related to this were considered relevant for inclusion and also provided further depth to the analysis.
What follows is an examination of the literature in the main pertaining to multidisciplinary input and integrated care of people across the spectrum of Parkinson’s syndromes. The paucity of studies which relate directly to atypical conditions suggests they are considered to have less gravitas. As a potential secondary outcome and unintended consequence, this project may be beneficial in exploring care provision which to a degree has been missed.
Integrated MDT input benefits functional ability
Throughout the literature it is evident that there is no clear standard of what constitutes integrated multidisciplinary care. Marck et al. (2013) in their study viewed this concept as the introduction of movement disorders specialist, PD specialist nurse and PD social worker as an alternative to stand-alone care by a neurologist. Hohler et al. (2012) however, have a broader perspective combining multiple therapists with a traditional specialist consultant and PD nurse model as their representation of multidisciplinary. On the whole inclusion of therapists was seen as an integral part of integrated care and as such was represented within the majority of studies.
Systematic reviews provide a rigorous summary of primary research studies as a means to answer a specific question (Parahoo 2014). Three articles from the review employed this method to discuss integrated MDT care in relation to Parkinson’s syndromes. Prizer and Browner (2012) despite a robust search process were limited to finding two articles which looked directly at the effectiveness of integrated MDT care in the context of Parkinson’s management. Their rationale for limiting the search by focusing directly in this area was to highlight gaps in order to determine potential next steps in research and development of best practice for PD. In earlier studies by Gage and Storey (2004) and Johnston and Chu (2010) where they opened up their search to looking at rehabilitation as a whole, there was again limited retrieval of evidence that specifically related to integrated care and Parkinson’s /Parkinsonism. All three studies noted gravitation towards improvement in all outcome measures with the implementation of MDT input. A seminal piece by Szekely et al.
(1982) was included in the earlier reviews but was notably discounted by Prizer and
Browner (2012) possibly due to it not being a truly integrated model (only included a physiotherapist and nurse psychologist) , low rate of participants (n=7) and no follow up data. An outpatient MDT model by Trend et al. (2002) was included in all three reviews being recognised as having a more reliable and valid research strategy. This is the first piece of robust work (n=118) that explored the relationship between integrated MDT care (inclusion of multiple therapies) having a positive impact on physical and psychological function in PD. All three studies recognised limitations in quality of evidence and inconsistencies in the concept of an MDT model. Interestingly Prizer and Browner (2012) in their later study continue to acknowledge the need for further research as a consequence of a continued paucity and lack of robust evidence available. As a result of the literature search it appears that certainly in the last few years increasing evidence is becoming available in this area possibly as a result of more robust guidelines being made available (NICE 2017).
There is recognition that multidisciplinary input is beneficial in managing Parkinson’s across the whole spectrum of syndromes as a part of follow up management (NICE 2017). Atypical Parkinson’s has been somewhat neglected with more robust evidence needed to support this concept. In a study by Hohler et al. (2012) this link is explored using a pretest-posttest design to investigate the effectiveness of an MDT program on improving functional status. A convenience sample of participants (n=91) was used encompassing a wide range of atypical syndromes (25 vascular PD, 19 MSA, 4 PSP, 43 combination CBD, DLB, drug/toxin induced). This form of sampling has limitations for replication and potential generalisability to other areas as a result of using an easily available sample which may not be representative within a wider context (Parahoo 2014). However, longitudinal data collection (over 4.5 years) capitalised on obtaining a representative cohort and demographic for inclusion thus improving rigour. Hoehn and Yahr (1967) classification of staging was used to identify severity of disease (Appendix 5). Updated by the Movement Disorders Task Force (Goetz et al 2004) this universally recognised system describes Parkinson’s progression in a simple format that can be used by any professional. Participants were categorised as stage 3-5 thus identifying them as moderate/complex phase disease.
Findings from the study showed improvements in outcome measures across all five motor scores (for example 2 minute walk test increased from 138.9ft to 202.5ft). The majority of participants (n=81) where measured based on a combination of medication adjustments and MDT input with the remaining cohort (n=10) assessed on MDT input alone. Consistency was maintained using the same therapists to deliver interventions, record outcome measures whilst applying the same validated tools thus aiming to improve inter-rater reliability (Waltz et al. 2010). The MDT in-patient program was intense (3 hourly sessions, 5/7 days a week for an average of 2.5 weeks) and as such it could be questioned as to whether this level of intensity and contact played a part in any improvement. Further limitations include lack of a control group and follow up data which may potentially reduce the reliability of the study. However, it is worth noting that confidence intervals were narrow (95% (28.4 to 32.5) for functional Independence Measure (FIM) disability score and 95% (-20.6 to -28.2) for Timed Up and Go (TUG) which suggests a degree of validity.
Monticone et al. (2015) utilised a similar in-patient approach in their RCT to identify a correlation between integrated MDT input and improved functional outcomes in people with complex PD (defined as Hoehn and Yahr stage 2.5-4). The programme used a combination of 30 and 90 minute MDT interventions which were spaced over an 8 week period. Improvements were noted in terms of motor function, activities of daily living (ADL) and QoL. A 51% increase in Berg Balance Scores (BBS) which is used to assess falls risk was seen in the experimental group compared to an unclear trend being noted in the control (BBS improved in 20% with 17% showing a decline). This identified an overall reduction in falls risk within the experimental group. Improvement was maintained 1 year post treatment which was attributed to higher rates of satisfaction facilitating adherence to the programme at home. Another major contributor was education and psychologist support which was delivered consistently to the intervention group. This was seen as an integral component within the programme in maintaining motivation as improvement in motor Unified Parkinson’s Disease Rating Scores (UPDRS) (Appendix 6) (range 0-132 with zero signifying a high level of function) was identified at follow up assessment (Post training UPDRS 40.8 and 1yr review 37.3). This occurred despite participants admitting that they had modified the program towards a more streamlined version, although it is worth considering that this may have skewed the results. It is also worth noting that medication compliance was more stringently monitored during the study and may well have contributed to functional improvement. There are also issues pertaining to sustainability as the cost of the programme amounted to 20,000 Euros funded by the Italian Healthcare system. It is recognised that this does limit its transferability to other systems particularly those where admission is only considered following an acute event (Monticone et al. 2015).
Similarly to previous studies, Traistaru et al. (2017) in their small RCT (n=27) utilised a complex programme of MDT input using aerobic exercise to identify if functional ability and quality of life could be improved using validated tools for assessment. This was delivered over a 6 week period but unlike the previous studies took place within an outpatient rehabilitation setting and involved people solely with a diagnosis of vascular Parkinsonism. As with Monticone et al. (2015) there were important links made regarding the role of education in training as being integral to the process. In the intervention group significant differences were seen in all studied parameters from baseline with the highest level of significance noted in BBS (P=0.0001) and TUG (P=0.0009). Having a robust multidisciplinary team set up in place that could provide visual and auditory prompts (cueing) as needed was identified as a factor for this improvement. Quality of life was noted to have enhanced but as this was based solely on ability to perform ADL its significance in respect of psychological wellbeing is unknown. Follow up progress was not reported despite an intervention programme being supplied to be continued at home therefore, long term outcomes could not be assessed.
In contrast, Marck et al. (2013) in their study had a different view of what constitutes MDT input. They utilised what is often considered to be a regular Parkinson’s service (PDNS, movement disorders specialist) plus social worker to compare with stand alone treatment by a neurologist. As there were no therapists included within the study outcome measures to assess effectiveness utilised specific Parkinson’s based tools including the UPDRS part III (motor section) and Parkinson’s disease questionnaire (PDQ-39). These are validated assessments used globally within the field of Parkinson’s. The UPDRS was originally developed by Fahn and Elton (1987) for use as a clinical assessment tool bespoke to Parkinson’s and is comprised of a 50 question assessment of both motor and non-motor function. This has undergone a sponsored revision by the Movement Disorders society (Goetz et al. 2008) and deemed valid for continued use. There are four sections to its structure; non-motor experiences of daily living, motor experiences to daily living, motor examination and motor complications. These can be used interchangeably or stand alone. The PDQ-39 is again a widely used evidence-based tool which assesses how people with Parkinson’s experience difficulties across eight dimensions of daily living including; mobility, ADL, emotional well-being, stigma, social support, cognitions, communication and bodily discomfort (Jenkinson et al. 1997). These tools can be applied to all patients with Parkinson’s or Parkinsonism regardless of disease trajectory.
Despite a lack of therapy input Marck et al. (2013) identified improvements within the intervention group with a 3.4 point improvement in PDQ-39 and 4 point improvement in
UPDRS part III. It was noted that the most significant increase in interactions was with the Parkinson’s nurses (86%) compared with the social worker (69%) and specialist (59%). The majority of interactions with the nurse were via the telephone. This seems to suggest that there is a relationship between functional improvement and increased access to professionals for advice and support. Unfortunately this was not explored further with no evidence presented regarding the nature of the calls or interactions. Also it needs to be considered that the majority of participants were in the earlier stages of disease making it unclear if this MDT structure would transpose to people with more complexity that may require increased face to face interaction. Further deliberation should also be given as to whether this can be considered an MDT or is in fact a team approach. It is generally considered that MDT refers to the integration of multiple therapies and that an important component of this is physical interaction. This is supported by Gage and Storey (2004), Johnston and Chu (2010) and Prizer and Browner (2012) in their systematic reviews where studies involving integrated MDT input all included the involvement of physiotherapy and occupational therapy as a minimum. Therefore it is difficult to view this study in the context of integrated MDT care however, it is significant in establishing the influence that increased interaction and engagement has on improving motor function and ADLs.
Within the past few years research related to atypical syndromes and the benefits of integrated MDT models for follow up management have escalated. Since 2016 three studies were found that were directly focused on or included as part of the study atypical conditions
(Bukki et al. 2016, Clerici et al. 2017, Frundt et al. 2018). However, similar to Hohler et al. (2012) both Bukki et al. (2016) and Clerici et al. (2017) utilise an in-patient programme to deliver MDT follow up which has been recognised can be costly (Monticone et al. 2015). In all three studies participant numbers were low (range 5-38) although this does reflect the rarity of these conditions in the wider context of Parkinson’s syndromes. It is interesting to note the predominant conditions studied were PSP and CBD despite MSA and DLB being more common. Bukki et al. (2016) in their palliative care MDT model noted 68% of participants stabilised or improved following intervention with 47% able to be discharged without carer support. Similar functional improvements were seen by Clerici et al. (2017) noting that direct MDT involvement positively impacts on gait and limb efficiency resulting in a reduction in falls. In the most recent study by Frundt et al. (2018) an outpatient clinic model proved to be just as beneficial as in-patient intervention but with the added bonus that it was less costly. Furthermore, as treatments were being delivered under real-life conditions with participants being exposed to their daily routine whilst having intervention, this allowed more time for fine tuning and evaluation increasing the efficiency of interventions. This approach has also been used for the management of ALS with Rooney et al. (2015) noting marked improvements in survival benefits (p <0.001) with MDT intervention clinics and clinical outcomes. This large retrospective study (n=719) using data from the ALS registers over a 6 year period, compared two healthcare systems in the Republic of Ireland (ROI) and Northern Ireland (NI) which employed different strategies for managing people with ALS. The ROI system which used a centralised MDT outpatient approach showed the most marked benefits in comparison to the NI system which used care coordinator alone. However, as this study focused on survival rates there was no exact determination as to the precise advantages of MDT input. It was also noted the ROI group were younger onset which may have skewed the results. Validity and reliability can also be questioned in terms of lack of control group and being unable to determine if extraneous factors influenced the findings. It is worth considering that in the context of complex neurological disease management clinics which boarder in-patient and out-patient MDT models seem to be gaining momentum.
Although there are methodological limitations throughout these studies especially in relation to sample size and what constitutes the makeup of an MDT model, there are features which can be pertained to this project. It seems integrated models are the way forward however further research in relation to atypical/complex Parkinson’s syndromes is required.
Accessing cohesive MDT services improves quality of life (QoL)
An integral part of this project is focused on integrated care models for follow up management having the best outcomes for people with atypical Parkinson’s syndromes in comparison to current outpatient provision. However, an addendum to this and a theme not greatly addressed in the previous studies but eluded to is improved QoL. Five of the studies within this review identified a direct relationship between MDT integrated care and perceived well-being.
Ferrazzoli et al. (2018) explored the effect of four week in-patient aerobic, motor-cognitive integrated MDT intervention on QoL using the PDQ-39 questionnaire. The most significant improvements (p<0.0001) were seen in emotional well-being and cognition. However, interestingly there was no change from enrolment or between intervention and control in regard to awareness of stigma (p=0.21). Consideration was given to this particularly as the concept of stigma encompasses feelings of shame, embarrassment and disgrace which is likely to impact on QoL (Cacioppo et al. 2015). It was felt that even though this variable had been unresponsive to treatment in itself it did not impact on feelings of well-being even at three month follow up. It is interesting to note that there was a large discrepancy in numbers between contol (n=48) and intervention (n=200) groups with a further limitation in respect of the lack of blinding of the neurologist and physiotherapist who performed the analysis. This calls into question the reliability and generalisability of this study however, demographic data on comparison did not show any statistical significance.
Similarly Eggers et al. (2018) saw improvements in PDQ-39 scores although the makeup of the MDT only consisted of neurologist, PD nurse and movement disorders specialists with therapies utilised on the perimeter as support. Unlike Farrazzoli et al. (2018) all domains including stigma showed significant improvements suggesting participants felt empowered in relation to disease acceptance and coping. This is possibly due to a more balanced randomisation (n=150 control and intervention) and outpatient design which as previously identified has a more realistic approach.
It is of interest that a systematic review by Tan et al. (2014) predating the studies by Ferrazzoli et al. (2018) and Eggers et al. (2018) found the evidence to be inconclusive in respect of MDT intervention having a positive effect on QoL. Comparable with other systematic reviews within this analysis evidence retrieved was scant with only nine studies included. It is worth noting that all nine articles were focused on MDT intervention with QoL being an addendum to this. Trend et al. (2002) again features for its inclusion of the Hospital Anxiety and Depression scale (HADS) developed by Zigmond and Snaith (1983) which is used to gauge emotional health. Universally recognised not just for Parkinson’s
HADS does provide a snapshot into an individual’s well-being and as such is often linked to QoL. As the Tan et al. (2014) study predates more recent research which has focused directly on QoL in relationship to MDT input in Parkinson’s it is perhaps unsurprising that findings were inconclusive. As recommendations suggested further research was needed which appears to be emerging.
In order to gain an understanding of the impact on QoL of being engaged in MDT interventions a qualitative study by Murdock et al. (2015) used interviews to explore meaning behind being involved in therapy. Themes that emerged were in the main related to emotional and psychological benefits as a result of being engaged in therapies which provided the opportunity for social interaction. Participants felt that being involved in MDT interventions improved their overall well-being which in turn had a positive impact on perceived QoL. It was noted that it was not so much the act of participation but rather the group interaction and peer support which were of greater significance. Validity can be questioned as this was a purposive sample recruited as a result of belonging to Parkinson’s UK the charity. These limitations impact on reliability of the results as participants were not representative of a wider population as a consequence of their involvement in an organisation which may have exerted an influence on the results.
The impact of QoL on functionally ability is being increasingly considered as essential in health care. It is believed that when measuring functional ability that QoL should be viewed in tandem to this, as together they provide different yet complimentary information that can assist clinicians in decision making and assessment (Post 2014).There continues to be disagreement in the exact definition of what constitutes QoL. Despite this consensus of opinion is that any measure of healthcare should consider social, psychological, mental and functional parameters if it is to be considered reliable (Whitehurst et al. 2012).
Concluding remarks of the Literature Review
In summary there is a paucity of literature which is specifically related to the management of atypical syndromes and what is available is generally methodologically flawed providing a weak evidence base. A recurring theme throughout all the studies is the need for further research not only in relation to best practice in management of atypical syndromes but also across all spheres of Parkinson’s. A significant discrepancy amongst all the studies is a lack of standardisation regarding what constitutes a multidisciplinary team and utilisation of a variety of different outcome measures. This makes it challenging to draw comparisons between studies and identify the merits of the interventions.
Despite a limited availability of credible evidence related to atypical Parkinson’s syndromes it was generally considered that integrated MDT models are beneficial to both functional ability and QoL across all Parkinson’s conditions. Interestingly outpatient models reaped the same rewards as in-patient models with the added bonus that they were less costly. There was also consideration that education and training assist in maintaining motivation and participation. An integrated MDT outpatient model has been identified as prudent strategy to address the project aim of providing improved follow up for people with atypical Parkinson’s syndromes. It is anticipated that by utilising this approach outcomes for both functional and QoL will improve.
Chapter 3
Methodology
It has been established that people with atypical forms of Parkinson’s have complex multidimensional needs which require a different management approach not presently served through current out-patient services (Chapter 2). The paucity of literature pertaining to this group of patients is reflective of services which treat all Parkinson’s conditions collectively regardless of trajectory or treatment (Hohler et al. 2012). As stated the aim of this service improvement is to develop an integrated multidisciplinary follow up service for people with atypical Parkinsonism within a day hospital setting to address and potentially resolve variability and delays to care.
Guidelines are explicit in emphasising the importance of collaborative working (NICE 2017,
WG 2017) underpinned by a patient-centred approach. This concept was envisioned by Welsh government in their document ‘Health and Care Standards(WG 2015) which structures the provision of high quality, safe and reliable care with the person at its core (Fig. 3.1). The frameworks seven quality themes are intended to work collectively fostering a culture of integrated care focused on the person, their family and holistic needs. Fig.3.1 (WG 2015 p.7) As highlighted in chapter 1 Parkinson’s services have been slow in adopting integrated approaches to follow up care ( Parkinson’s UK 2017) which as identified in the literature review is an essential component when managing people with Parkinson’s syndromes (Bukki et al. 2016, Clerici et al. 2017, Frundt et al. 2018). The current system is not only failing to meet national guidelines (NICE 2017) but the vision of the Welsh Government to provide coproductive services, pooling expertise to deliver effective and sustainable outcomes for an improved user experience (WG 2015). This project has the capacity to achieve this. Firstly, utilising the availability of an established multidisciplinary set up, which in this case is via day hospital services, ensures the ethos of co-productive working is already in place. Secondly, by employing staff who already have knowledge and expertise with Parkinson’s syndromes working within this environment, the project is helping to maximise current available resources and ensure the provision of care is evidence-based. Thirdly, providing follow-up as part of an integrated structure resolves fragmented referrals for MDT input resulting in more timely intervention which is an integral component when providing care for people with these rapidly progressive conditions (NICE 2017). Finally, utilising a service where geographical boundaries do not exist ensures equality of care particularly when patient numbers are small and there is a risk with sustainability. It is worth noting that patient-centred care is dependent on robust governance, leadership and accountability being in place to underpin the delivery of high quality safe care (WG 2015). As the service improvement lead the PDNS role has provided the underpinning knowledge, skills and expertise which is required to co-ordinate complex decisions and drive the implementation process forward (National Leadership and Innovation Agency for Healthcare (NLIAH) 2010). These qualities are an integral part of any advanced practice role and when being viewed in the capacity of leader and valuable resource (NLIAH 2010). It is also worth considering that as this project is based within an already established service leadership currently exists and as such will require careful cooperation and refining to work in conjunction with the new service. Quality improvement is a core principle in the NHS and a key driver of services. Since the inception of the concept of quality in the government white paper ‘The new NHS: modern. Dependable (Department of Health (DOH) 1997) the term clinical governance has become synonymous with provision of high standards of care. Embedded within the culture of delivering current and future services Welsh government has continued to produce key documents (Together for Health (WG) 2011, Achieving Excellence: The Quality Delivery Plan for the NHS in Wales 2012-2016 (WG) 2012, Safe Care, Compassionate Care (WG) 2013) which lay the foundations for redesign of services with quality at the very core. The values which inspire this vision comprise of:
• Putting quality and safety above all else: providing high value evidence based care for our patients at all times
• Integrating improvement into everyday working and eliminating harm, variation and waste
• Focusing on prevention, health improvement and inequality as key to sustainable development, wellness and wellbeing for future generations of the people of Wales
• Working in true partnerships with partners and organisations and with our staff
• Investing in our staff through training and development, enabling them to influence decisions and providing them with the tools, systems and environment to work safely and effectively
(WG 2013 p.7)
An integral component to the delivery of this is staff taking ownership and being engaged with the process. Initiatives have been put in place including “1000 lives plus” and “Fundamentals of Care” to continually encourage staff to remain focussed on maintaining standards. Supported by Welsh government “Doing well, Doing better” (WAG 2010) outlined that improving clinical quality and patient experience is directly dependant on change being initiated and embraced at grass roots level. Primarily the goal for organisations is to assess that they are “doing the right thing, in the right way, in the right place, at the right time and with the right staff” (WG 2013 p.8). This is central to quality improvement and driving reductions in harm, waste and variation which this project directly links to.
In “doing the right thing” the traditional model of outpatient follow-up will be replaced by an integrated multidisciplinary service which as identified in the literature review (chapter 2) is key. Importantly time is of the essence when managing people with atypical Parkinson’s syndromes (Hohler et al. 2012). Utilising multiple therapies within one location is a more efficient use of resources addressing waste and variation in referral and time to treatment that current services are restricted to. Furthermore, the absence of structured follow-up means patients can slip through the net and become lost in the system increasing the risk of harm as symptoms will not be effectively managed.
The literature review identified that cohesive, integrated services provided the best outcomes for people with atypical Parkinson’s ensuring care is delivered “in the right way”. This system not only addresses variation in referral for treatment by establishing a single point of access for MDT, but helps to facilitate staff delivering care have the knowledge and skills pertinent to managing these rare syndromes. This is an important factor in patient safety and reducing the risk of harm. As education and training are integral components to the delivery of care and emergent themes throughout the literature it is pertinent that staff are in possession of evidence based skills. It not only fosters improved standards of care but contributes to nurses fulfilling their professional obligation to maintain quality by drawing on the best evidence available to inform their practice and apply their skills effectively (NMC 2018). This is an important consideration as maintaining quality standards are dependent on having “the right staff” for the job. Supporting professional development in this way can provide the opportunity for staff retention and sustainability of services over the longer term.
It is perhaps the final two components “the right place” and “the right time” that completes the loop for quality standards to be achieved according to WG (2013) but importantly is integral to the success of this project. These rapidly progressive conditions have a limited window for intervention in comparison to other Parkinson’s conditions (Ludolph et al. 2019). By developing a service that provides prompt treatment can potentially reduce the risk not only of variation and waste but possible harm from resulting delays to treatment. Cohesive MDT services have been shown to be the treatment of choice in the absence of any available pharmaceutical intervention (Frundt et al. 2018). Although there has been disagreement in where the best location is for this to be delivered (Clerici et al. 2017, Frundt et al. 2018) it has been considered that outpatient MDT models provide equally as effective outcomes but with the added incentive that they are more cost effective (Frundt et al. 2018). Therefore introducing an integrated MDT service into an outpatient day hospital setting that involves staff with the knowledge and skills to manage these rare Parkinson’s syndromes, not only fulfils evidence based standards for care of these patients but government legislation for quality improvement within the NHS (WG 2011, WG 2012,WG 2013).
Using different approaches to care by fundamentally rethinking care pathways and service delivery in accordance with best available evidence based literature is instrumental for any healthcare project pursuing to execute change. The NHS Institute for Innovation and Improvement (2017) was established to support a culture of metamorphosis within the NHS to nurture change by encouraging creative thinking, partnership working, ownership and evidence based approaches in order to provide better quality services and patient experience. To assist this process they supply a range of quality improvement tools for guidance which can be tailored to the needs of each individual project. Several of these were considered for this service improvement but were discounted as they did not gel with the aim of the project due to a lack of relationship with facilitating the change. The ‘Six Hats(De Bono 1985) and ‘Discovery models are beneficial in transforming team mindsets and thinking with the ‘Theory of Constraints’ and ‘Six Sigmamodels focused on improving processes by looking at obstructions and deficits. As this service improvement is set within an already established team and structure these values are already in place. As such ‘The Model for Improvement (NHS Wales “1000 lives” improvement 2014) seemed a better fit in providing support for introducing a new service within the already established framework of the day hospital MDT setting.
This model is well established and recommended for use throughout the NHS as demonstrated in ‘Improving Quality Togethera web based training programme for NHS staff in Wales (NHS Wales “1000 Lives” Improvement 2014). This has been led by “1000 lives” improvement service and focuses on teaching common and consistent approaches to improving quality that are effective and develop quickly. ‘The Model for Improvement (NHS Wales “1000 Lives” Improvement 2014) is being used to underpin these values and embed a culture of continuous quality improvement by assisting in the identification of “What isn’t working” which considers:
• Patient, family, staff and service feedback to identify flaws in the system.
• What change will give the biggest benefit?
• How much of what we are doing is repeated work, or work that could have been done in the right way the first time?
• What can be made simpler?
• Are there evidence-based interventions not happening for every patient?
NHS Wales “1000 Lives” Improvement (2014 p.32)
A key feature of ‘The Model for Improvement`( NHS Wales “1000 Lives” Improvement 2014) is the employment of three questions (Fig. 3.2) used to provide direction, our position on what currently exists against that direction and a course of action to achieve the planed aim
(Institute for Healthcare Improvement (IHI) 2014). The first question is focused on identifying what quality issues are present in order to structure an aim, ensuring that this is achievable. To determine if the change is an improvement the second question employs the use of measurement as a means to understand and assess the change. Finally, for quality to be improved changes need to be made which requires a process of generating ideas. To assist with driving this process a series of cycles utilising Plan, Do, Study Act (PDSA) provide a framework for developing, testing and implementing the change throughout the process of improvement (Fig. 3.2).
PDSA cycles can be used multiple times as a means of providing structure, continued focus and to ensure the process maintains momentum. A systematic review by Taylor et al. (2014) found a distinct lack of knowledge when it came to applying improvement tools within clinical practice. They suggested that in order for PDSA cycles to be applied effectively systematic and rigorous standards needed to be put in place by monitoring compliance throughout each cycle and reviewing documentation and data collection. This has been tightened up in recent years through Web based training and improvement guides (NHS Wales “1000 Lives” Improvement 2014) which provide support with applying these tools when formulating service improvement within clinical practice.
Fig.3.2
(NHS Wales “1000 Lives” Improvement Driver 2014)
The “PLAN” phase involves analysis of the problem in order to develop a hypothesis stemming from issues identified, how this will be implemented and data to be collected. Moving through to the “DO” phase this is where the potential solution is tested, data is gathered and observation findings are documented. During the “STUDY” phase results are examined in order to measure if the change has been effective and hypothesis supported. The “Act” phase is where implementation takes place which includes any adaptations which have been made prior to moving into a subsequent cycle. An initial small scale test is advised with gradual refinement of ideas and co-ordination of outcomes before moving through each successive cycle (NHS Wales “1000 Lives” Improvement 2014).
As recommended by ‘The Quality Improvement Guide(NHS Wales “1000 Lives” Improvement 2014) this project will incorporate the use of a ‘driver diagram to provide focus, put the change into context, be a prompt to factors which may have been missed and provide a link between the interventions planned and the aim (Fig.3.3). The diagram consists of three columns starting with a clear vision (Aim) showing the desired outcome for the service. In order for this to be achieved the next column considers the elements required to move forward (Drivers) to attain the desired goal with the third column showing the actions (Interventions) that have been employed and are integral to achieving the drivers. The ‘Model for improvement` will provide structure and direction through a series of successive PDSA cycles to guide the process (NHS Wales “1000 Lives” Improvement 2014).
The overall objective is to provide timely integrated MDT follow-up for people with atypical Parkinson’s syndromes to include comprehensive review inside a 6 week window post diagnosis.
Fig. 3.3 Driver Diagram
AIM DRIVERS INTERVENTIONS
Project Trigger
It was becoming evident that people accessing follow-up review who had been diagnosed with an atypical Parkinson’s syndrome were receiving a substandard service to meet their needs. The PDNS responsible for performing the majority of review consultations noticed a pattern of fragmented referrals to access MDT support which often led to delayed treatment or at worse being lost in the system. The project was triggered as a result of a service review audit performed yearly as a part of the responsibilities of the PDNS as a lead role within the Parkinson’s team. This highlighted gaps in people with atypical syndromes accessing MDT support and in some cases missing out on input altogether due to the disjointed referral process resulting from discrepancies within the current outpatient service. Also it was recognised that current outpatient provision was not ideal for this group of patients who as the literature suggests require timely MDT review rather than traditional six monthly follow-up consultations (Hohler et al. 2012).Further to this it was noted that people with these complex conditions required extended time within their outpatient review which was not being considered and had an impact on patient flow within the department. This was an important consideration as providing an efficient, co-ordinated and effective service by optimizing movement through the department does result in improved health outcomes and patient experience (The Health Foundation 2013).
As a caveat to the PDNS review, feedback was being received from both primary and secondary care services via community resource teams (CRT), community based therapy services, day hospitals and outpatient therapy clinics regarding delays with referral. This was impacting on their initiating effective input at the right time. The PDNS also considered the lack of cohesion with referring to different services spread across primary and secondary care as being disjointed and posing the risk that patients may not be receiving appropriate evidence based care. Having identified this as a recurring issue the PDNS made provision to explore ways to change the current system that would be in the best interests of this patient group.
The PDNS raised concerns in multidisciplinary meetings (MDM) with members of the Parkinson’s team (second PDNS, two specialist consultants and personal assistant (PA) to the team) that there were inconsistencies with management of people with atypical syndromes and that the current system did not meet evidence based standards (NICE 2017) which the team agreed. Several options were considered including training primary care teams to receive all referrals (three community resource teams (CRT) within the health board plus multiple community therapy teams) or contain all referrals within secondary services under the care of the day hospital. The later was more feasible as this fit with standards of providing an integrated service, with knowledgeable staff, that was cohesive and sustainable from both provision and maintaining evidence –based practice standards. With two day hospital sites available within the UHB having experience managing people with atypical syndromes, a scoping exercise was carried out to establish which would provide the best location for the service (Appendix 7). As a result of the scoping a site was chosen (location A), with a preliminary meeting arranged with staff to discuss the service improvement (Driver 1). It was agreed that the PDNS would lead the project on behalf of the team with the second PDNS assisting. Prior to the meeting approval for the service improvement was agreed by senior management and local UHB research and development that it met the criteria for a workbased project (Appendix 8).
What are we trying to accomplish? AIMS
It is suggested that before commencing any process of change that it is important to set out a clear aim. Langley et al. (2009) recommend in constructing this consideration should be given to the topic being worthwhile, outcome focused, measurable, involve a specific population, include clear timelines and simple to understand. With this in mind and as stated earlier the aim of this service improvement is to develop an integrated multidisciplinary follow up service for people with atypical Parkinson’s to reduce delays in accessing follow-up support. It is proposed that all patients with these rare conditions will be seen within a 6 week window for follow-up review incorporating cohesive MDT input. By reducing the time between referral and accessing MDT support it is suggested that the patient experience will be improved, access for MDT input standardised and there will be less risk of patients being lost to follow up or not accessing a full range of MDT support.
Driver 1
A preliminary meeting, as previously mentioned, was arranged to liaise with key lead stakeholders within the MDT who were based within the day hospital setting. Attendees included; second PDNS, physiotherapist (PT), Occupational therapist (OT), associate specialist doctor, speech and language therapist (SALT), senior nurse, day hospital manager and administrative clerk with the PDNS taking the lead to outline and discuss the proposed service improvement. Facilitating the meeting did not pose any problems as it was held following the morning multidisciplinary meeting where all members of the team were already present. Consultant leads for the service and PA to the team did not attend expressing that that they would take a peripheral role agreeing to assist if required. They were kept informed of progress at weekly meetings following clinic. Through a process of constructive mind mapping (Appendix 9) it was concluded that follow-up for people with atypical Parkinson’s syndromes could be delivered in a day hospital setting more effectively than a traditional outpatient environment as the infrastructure already supported an MDT model of care. Practitioners were already familiar with managing these syndromes but as it transpired through the meeting, were concerned that fragmented referrals being received from the current outpatient system were resulting in delays and a lack of cohesive input. It became apparent that the service needed a structure that incorporated timely intervention following diagnosis with homogeneous MDT support. A decision was reached that the new service could be accommodated as part of the complex Parkinson’s sessions taking place within the day hospital twice a month. This would provide capacity for people diagnosed with atypical Parkinson’s to be referred for MDT input within the proposed window of 6 weeks.
A major concern highlighted within the meeting was sustainability as patient numbers due to the rarity of these conditions are generally lower. To a degree this had already been addressed. With access to MDT being provided as part of a Parkinson’s complex service where care delivery is compatible, the ability to maintain patient numbers irrespective of being diagnosed with an atypical Parkinson’s syndrome was more feasible. At this point there was no accurate pooled data from across the UHB to indicate numbers of people diagnosed with an atypical Parkinson’s syndrome. For the purpose of the meeting and as a guide the patient list used was of those individuals currently attending their day hospital service (Table 3.1). As they already reviewed the bulk of people with an atypical Parkinsonism it was felt this would be fairly representative of the service as a whole. No inclusion or exclusion criteria were considered at this time as this list was merely used as a guide. The reason for not including patients accessing alternative services within the UHB is that their numbers had not been corroborated at this time. This retrieved higher than expected numbers especially with people diagnosed as DLB. Breakdown of these numbers revealed there were a cohort of patients not known to our service but were part of neurology or other consultant services that accessed day hospital for MDT input. Fortunately this did not pose any problems as the PDNS service was already informally providing assistance to these specialities with the support of the clinical board. This was in response to guidance recommending all patients with a Parkinson’s syndrome having access to a PDNS, which was not in place within these services (NICE 2017). However, this did raise the possibility that constraints could be placed on MDT and PDNS time if the service was saturated by these specialities. This was soon dispelled as it was noted a negligible number of patients diagnosed with atypical syndromes accessing the service from these specialities in comparison to the Parkinson’s outpatient clinic.
Table 3.1
Patient list Number of patients
DLB 25
MSA 11
PSP 6
CBD 2
Under Neurology services 3
Consideration from both the manager and senior nurse was related to impact on staff patient ratios, documentation and education. As part of the regular day hospital service systems were already in place for training, update and review of documentation and staffing. With the service already managing people with these conditions it was deemed that the proposed changes would not pose any new problems. The administrative coordinator did request amendments to the appointment letter in respect of being more explicit regarding the new service (Appendix 10). Apart from that it was deemed the service improvement would not impact on their workload or current role.
With all parties on board a further meeting was held to discuss and plan the way forward. Representation within this meeting was kept to key stakeholders. These included people from the initial meeting apart from the manager who felt their presence would not add value to the process. We arranged to keep them informed of progress via email. Subsequent meeting dates were planned at the end of each contact to maintain consistency with the process. In keeping with the principles of the ‘Model for Improvement` (NHS Wales “1000 Lives” Improvement 2014) (Fig.3.2) discussion focused on planning a strategy for measurement.
How will we know if a change is an improvement? MEASUREMENT
According to the Institute for Healthcare Improvement (IHI) (2014) it is the process of measurement that indicates if a change has been an improvement. This requires careful planning to determine that appropriate measures are used that are pertinent to gathering the data required. Unlike research, improvement projects employ much simpler approaches to data collection. This can prove to be challenging in reigning in any expectation of larger more rigid data collection as is customary with research projects. Within the planning meeting clear boundaries were agreed in order that everyone would adhere to the same brief. Being this is a service improvement project the decision was made to gather enough data so that comparison pre and post intervention could be made without risking data overload. As stated previously, on preliminary review of the available data, higher than expected numbers of patients with atypical conditions were accessing the service. However, analysis of those diagnosed in the previous year yielded a smaller cohort of patients which was felt would be more suitable for retrospective data analysis. Preferably utilising data beyond 12 months pre intervention would help iron out any discrepancies in practice which may occur as a result of medical staff rotation. On discussion it was felt this would be a mammoth task and impractical in terms of a service improvement. A more reasonable 12 month pre and 6 month post data collection was agreed would produce sufficient comparative data. These parameters would be confirmed following the first PDSA cycle (Fig.3.3) as information in respect of patient numbers to this point was not accurate.
The Institute for Healthcare Improvement (IHI) (2014) denotes that there are three sub divisions of quality improvement measurement defined as: Process measures, balancing measures and outcome measures (Table 3.2). In relation to this service improvement each of these were considered to provide further clarity and to ensure all variables were accounted for. However, undertaking any formal measure of any impact to the system was deemed outside the scope of this project, it was agreed that gathering information pertaining to stakeholder opinion would be valuable to add as a further PDSA cycle at a future date. Patient feedback is well documented as an integral component to inform practice and to facilitate a cycle of continuous service improvement (Rozenblum et al. 2013, Lee et al. 2017). Therefore, it was considered that an addendum to this project would be to gain patient opinion on accessing MDT as a follow up service versus a traditional outpatient appointment.
Table 3.2
Types of Quality Improvement Measures
Process measures Looking at parts or steps in a system and if they are performing as planned-tracking progress
Balancing measures Consider if the introduction of a change/improvement has had any unintended reactions elsewhere in the system-potential risks
Outcome measures Reflect the impact of the
change/improvement –impact and end result
Driver 2
As stated previously, data pertaining to numbers of patients with atypical Parkinson’s was incomplete. Capturing this information was agreed to be a reasonable starting point as performing a baseline audit was dependant on having a representative group of patients for inclusion. Also parameters for conducting the audit could not be set without a clear understanding of the numbers involved. This would also facilitate the process of ascertaining the extent of the project, organising responsibilities equitably in order to avoid unfair workload and to ensure data collection was accurate and representative of the service as a whole. In accordance with the ‘Model for Improvement` (NHS Wales “1000 Lives” Improvement 2014) PDSA cycle 1 was applied (Fig.3.3). It was acknowledged that a two pronged approach would be required in order to ascertain numbers of patients with an atypical Parkinsonism known to the service in order to avoid any exclusion. With access to the Parkinson’s database being restricted to consultant only for any data extraction purposes there was no option other than assigning this role to them. The lead project administration clerk was allocated the role of searching both day hospital databases. This information would be used to clarify current attendees including those from other services such as neurology and gerontology. It was accepted that there would be a crossover of information but for the purpose of a thorough search it was agreed that any duplication would be ironed out on review of the lists.
Fig.3.3 PDSA Cycle 1
ACT Plan to proceed with PLAN Gather baseline data.
implementing an MDT follow Identify patients with a up service for atypical diagnosis of atypical
Parkinson’s patients.. Parkinsonism. Extract lists
from the Parkinson’s and
Role: Lead and sub PDNS day hospital databases (x2) team/lead PT/lead/OT/lead and patient notes.
SALT/medic/senior
nurse/Admin clerk Role: Admin clerk, PDNS and
STUDY Analysis of the data.
Reflection on information obtained… Compare to
predictions…delays in follow up, fragmented referrals for MDT,
PDQ-39. Move to progress with DO:Review lists. Extract data to determine those suitable
for inclusion in retrospective audit. Carry out
retrospective audit (Oct
2017-oct 2018)
consultant
service improvement.Role: Lead and sub PDNS Role: : Lead and sub PDNS team,/ team,/ lead PT/lead OT/ lead PT/lead OT/ Lead SALT/ Lead SALT/ medic/senior medic/senior nursenurse
The initial search produced a list of 68 patients which was reduced to 57 when members of the team (ward manager, lead and second PDNS) removed replicated patients. At this stage it was necessary to scrutinise the list further in order to establish a clear list of patients for inclusion in the project. It was deemed that retrospective data analysis was dependant on patients having been diagnosed in the past 12 months and suitable to receive MDT input, in order to establish a clear baseline with which to benchmark against the service improvement. Patients were excluded based on their diagnosis pre dating the set criteria, inability to attend outpatient appointments (nursing home, housebound), having never attended outpatient services being diagnosed in the community, declined MDT input, triaged as unable to receive MDT support (frail and advanced dementia) and out of area. One patient was noted to have died three weeks post diagnosis with an unrelated condition (Table 3.3).
Table 3.3
Excluded Patient List
Reason
Numbers
Diagnosed longer than 12 months 21
Nursing Home care 3
Declined MDT input 1
Triaged as Unable to receive MDT input 3
Out of area 2
Housebound 4
Died 1
On further analysis of the remaining 22 patients three were under the neurology service. As stated earlier this did not pose any problems as the Parkinson’s consultants could access information pertaining to the service improvement using the database. It was also noted that in one patient the diagnosis was revised from MSA to PSP. As both conditions fall under the category of atypical Parkinsonism the data was still pertinent. All twenty two patients for inclusion in the project had a confirmed diagnosis of an atypical Parkinsonism. As previously stated their data would be used as a baseline to compare against evidence retrieved following the service improvement (Table 3.4).
Table 3.4
Atypical Parkinson’s Diagnosis
Patient
numbers Hoehn and Yahr stage
DLB 10 2-3
MSA 7 2-4
PSP 3 3-4
CBD 2 3-4
Breakdown of individual diagnosis identified DLB as the most common atypical syndrome. This was consistent with the figures used at the initial meeting (Driver 1) and the trend nationally (Appendix 1). It was noted that in nine of the patients co-morbidities existed that were unrelated to their atypical diagnosis (Table 3.5). However, on review these were being well managed and did not impede on their ability to participate in MDT input. Analysis of Hoehn and Yahr (1967) staging (Appendix 5) was included as this is a more accurate gauge of level of disability in Parkinson’s syndromes. Having considered all the variables it was deemed that data pertaining to the twenty two patients was suitable for inclusion. According to the NHS Health Research Authority (2019) collecting evidence in this way is an important process in obtaining clear outcome measures. These reflect the effectiveness of the improvement and resulting impact on patients. They also guide clinical decision making and can be predictors of benefit with particular interventions.
Table 3.5
Co-morbidities identified
Number of patients
Diabetes (Type 2) 3
Arthritis 5
Arial Fibrillation (AF) 1
Chronic kidney disease (CKD) 1
As previously mentioned, it had been agreed that the retrospective audit would cover a 12 month period (October-2017-October-2018) which was confirmed as part of PDSA cycle 1 (Fig.3.3). An audit of data from the 22 patients was undertaken looking at four different key parameters in recognition that information needed to be captured pertaining to:
• Length of time from first diagnostic outpatient appointment to follow up
• Was a referral for MDT input completed?
• Length of time from MDT referral to contact.
• Quality of life- Review of Parkinson’s disease questionnaire scores (PDQ-39)
(Jenkinson et al 1997).
It was intended that there would be information available to ascertain the length of time patients spent within their outpatient consultation. Unfortunately this was unavailable as the outpatient system only captures time in and out of the clinic. This time doesn’t include periods of waiting which may be protracted if the clinic is busy or there has been an unexpected delay. As there were only standardised times available of thirty minutes for a new appointment and fifteen minutes for a follow up this data was discounted. What also had to be factored in was that the service improvement would be incorporating consultation as part of an MDT structure scheduled as a two and a half hour slot. This would inevitably lead to interaction between patient and professionals being longer therefore, a fair comparison in consultation time pre and post intervention was not equitable.
Data for the audit pertaining to the twenty two patients was extracted using the outpatient databases, Parkinson’s database and patient notes which were situated in a room within the department. The data retrieved was logged on an Excel spreadsheet having been anonymised by allocating a number to each patient. This process was crucial to ensure the project not only adhered to the UHB research and development guidelines but also upheld professional principles of confidentiality (NMC 2018). Protecting patients’ personal information from improper disclosure by ensuring appropriate information sharing is central to confidentiality, maintaining trust and the provision of safe and effective care (NHS Health Research Authority 2017). These principles would be upheld throughout the project.
Consideration of the four key parameters
Length of time from first diagnostic outpatient appointment to follow up review
Outpatient clinic for the service is consistently held on the same day and at one site. This resulted in no anomalies in data being found as a result of patients being offered an alternative if the clinic was fully booked. The follow up waiting time was calculated by logging the time between the first diagnostic appointment and next follow up contact in clinic. Use of the word contact for purpose of the audit avoided any confusion related to logging a follow up appointment where a patient may not have attended. Reasons for non attendance are documented on the system as did not attend (DNA), cancelled or in-patient. The difference between the two variables was calculated and recorded to provide a follow up waiting time (in weeks) for each patient. All 22 patients returned data with a note that in 2 cases there was a delay documented as cancellation (patient unwell) and in-patient. Both were re-allocated appointments as urgent (cancelled appointment) and upon discharge (Inpatient). In consideration of this the follow up waiting time was adjusted. For the hospitalised patient their in-patient time was deducted. The cancelled patient was assigned a 1 week deduction (agreed by our doctor) as reasonable based on information from their follow up review confirming a urinary tract infection. This information was considered throughout the audit and data adjusted as required.
Was a referral for MDT input completed?
Compiling this data proved to be challenging. A trawl of the notes pertaining to the 22 patients revealed that there was no standardised practice for referral to a therapy service. In order to establish a clearer picture it was agreed that the data should be broken down to identify if a referral had been completed at diagnosis and if so whether this was for multiple or single therapy. This would be useful in determining the scale with which the service improvement would standardise practice and improve access for MDT input.
Length of time from MDT referral to contact
As an addendum to understanding referral practices it was agreed that information regarding the time between the therapy referral being sent and the patient receiving input was required. It could not be assumed that by sending a referral signified the patient had received therapy.
Quality of life- Review of Parkinson’s disease questionnaire-39 scores (PDQ-39)
The patient reported measure of health status and QoL (PDQ-39) is a validated tool to assess health related status and QoL for people with a Parkinson’s related diagnosis (Appendix). First developed by Jenkinson et al. (1997) it provides a subjective evaluation of an individuals concerns regarding daily life. Used as a regular part of clinical assessment, audit of results will be used to determine if patients perceptions of their QoL has enhanced with the service improvement.
On completion of PDSA cycle 1 (Fig. 3.3) a meeting was arranged to draw together all the information retrieved and to plan the next stage of the project, implementation of the service improvement (Driver 3).
What changes can we make that will result in an improvement? IDEAS
The Institute for Healthcare Improvement (IHI) (2014) indicates that implementing a small number of changes has the greater potential to result in improvement. Central to this is streamlining processes in order to eliminate elements that are not effective. In essence, if something does not add value remove it or change it so that it is more constructive. The baseline audit had revealed several areas for potential improvement including:
• Connecting up the patient journey.
• Cohesive referral to access MDT
• More timely intervention
• Reducing variation in the way follow up services are delivered for people with atypical Parkinsonism.
As there were areas of commonality two key outcomes emerged:
- To reduce waiting time between diagnosis and follow up appointment
- To provide timely integrated multidisciplinary MDT intervention to all people diagnosed with an atypical Parkinsonism.
Driver 3
It was agreed by the team (PDNS x 2, lead PT, Lead OT, Lead SALT, senior nurse, associate specialist doctor and administrative clerk) that introducing an integrated MDT follow up service for people with atypical Parkinsonism had the capacity to resolve issues highlighted within the baseline audit. As a result all people diagnosed with an atypical Parkinsonism would receive their follow up as part of an integrated multidisciplinary service within the day hospital setting. A move to progress with the service improvement was approved. Members of the team that would be involved in delivering the service did not require any supplementary training. As previously mentioned, they were experienced in managing patients with atypical Parkinson’s syndromes and as such there were already processes in place for maintaining their knowledge and skills. This also included education for new staff and succession planning so that there would be no interruption to service delivery. The NMC (2018) advocates that robust evidence based processes should be in place to guide practice, inform decision making and maintain standards.
Consideration of the referral process.
It had been recognised in the baseline audit that referrals for therapy input were inconsistent. It was agreed that standardising practice prior to the introduction of the service improvement was essential to ensure patients would receive timely intervention. As the discrepancy in practice originated from visiting doctors, a meeting was arranged between the PDNS team and consultant specialists to discuss rationalising the process. Feedback from the baseline audit was provided with the consultants agreeing to tighten up documentation practices in line with UHB recommendations. This would be incorporated as part of the doctors’ orientation prior to going solo in clinic. It was important to clarify this process as the service improvement was dependant on follow up incorporating, timely referral for integrated MDT support to one access point for all patients diagnosed with an atypical Parkinsonism. Further to this the administrative clerk was advised that all referrals were to be processed as urgent and receive a follow up appointment within 6 weeks as discussed as part of PDSA cycle 1 (Fig.3.3). The outpatient clinic clerk was informed by the lead PDNS of the new service with advice not to arrange any follow up clinic appointments for people diagnosed with an atypical Parkinsonism. In order to maintain patient confidentiality this would be communicated by ticking the no follow up required box on the appointments form handed to the clerk on completion of the consultation. Both clerks agreed to maintain communication in order to avoid any confusion or duplication of appointments.
Driver 4
A meeting was held with key stakeholders (lead PDNS, second PDNS, OT, PT, SALT, senior nurse, associate specialist doctor and administration clerk) to progress with implementation of the service improvement to provide an integrated MDT follow up service for people with atypical Parkinsonism. In keeping with the ‘Model for Improvement` (NHS Wales “1000 Lives” Improvement 2014) PDSA cycle 2 was executed (Fig.3.7).
Fig.3.7 PDSA cycle 2
ACT Feedback results to senior colleagues (Consultant specialists x 2,
Nurse manager, Lead nurse for day hospital services).
Consider viability of the service based on audit results.
Plan further PDSA cycle
STUDY Continue analysis of audit data pre and post intervention
Compare if data has met predictions of providing MDT follow up 6 weeks
or less ( ⅔ reduction) post service improvement. Analise access to therapies, PDQ-39.
Summerise findings and reflect.
Role: Lead and sub PDNS/Lead
OT/Lead PT/Lead SALT/ specialist medic/admin clerk.
PLAN Implementation of MDT follow up service.
Who? People with atypical Parkinsonism.
What? MDT folllow up service.
Where? Day Hospital. 2 follow up sessions per month (complex service)
When? Audit between Nov 2018-April 2019 (newly diagnosed)
DO Implement follow up service.
Collect Data (6 month period)
Audit: 1. Time between diagnosis and follow up. 2. MDT interventions
(Adapted PUKAT 2017)
Benchmark against pre audit data.
Commence analysis of results
Role: Lead and sub PDNS
The MDT follow up service was triggered on diagnosis of an atypical Parkinsonism (DLB, PSP, MSA and CBD). Where Patients fit this criteria a referral form was generated and faxed to the day hospital. This process was completed following clinic. The receiving administration clerk ensured all referrals were checked by a qualified member of staff to confirm they were eligible for the service. Patients were then assigned an MDT follow up appointment in the day hospital for no greater than 6 weeks post diagnosis. Exceptionalities to the 6 week deadline were factored in to include:
• In-patient admission
• Infection risk (Diarrhoea and vomiting, flu, other communicable infection posing a
risk)
• Away (holiday/visiting)
• Generally unwell
• Increasing disability and unable to attend outpatient appointments.
In instances where patients needed to be reallocated an appointment this was arranged as an urgent review. For people unable to attend an outpatient service a community referral was completed to the community resource team (CRT) for intervention.
With the service improvement being incorporated as part of a well established MDT structure no adaptations to therapy input were required. As previously stated, people with atypical Parkinsonism have similar MDT needs with people in the complex stage of Parkinson’s. There were issues surrounding flow which needed to be addressed. With the new service requiring patients access all MDT professionals it was agreed that each patient would be tracked during their attendance to ensure they had engaged with all MDT professionals. It was decided that the best way to do this was to use the Parkinson’s UK audit tool (PUKAT) (Parkinson’s UK 2017) as this had the capacity to document all MDT involvement. (Appendix 12). Each patient was assigned a 2 ½ hour time slot to receive MDT assessment (PDNS, PT, OT, SALT, doctor review). This would allow ½ an hour for each interaction. Future care planning was decided at the end of the day session in the multidisciplinary meeting (MDM). Documentation for each intervention once completed was placed on the UHB secure database which was accessible by all involved practitioners. The consultants were kept updated in MDM following clinic. The day hospital manager continued to receive information via email at their request.
As part of PDSA cycle 2 (Fig. 3.7) it was decided that audit data would be collected over a period of 6 months (November 18-April 19). This period was calculated to account for the rarity of these conditions and as a consequence allow enough data to be captured to validate the audit. The process of audit is considered an essential component of service improvement. It Involves measurement of clinical outcomes which are set against welldefined standards and evidence- based principles (Esposito and Canton 2014).
As previously mentioned an adapted version of the PUKAT (2017) (Appendix 12) was used to ensure all patients had received contact with MDT members. The PUKAT (2017) is a recognised tool for quality improvement which can be adapted for use in clinical practice. The tool has been guided by values underpinned by the latest NICE guidelines (2017) for management of Parkinson’s. NICE is an independent organisation established to standardise practice through evidence –based advice. The underpinning values set out in the NICE (2017) Parkinson’s guidelines advocate that Patient’s diagnosed with any Parkinson’s syndrome should have access to prompt MDT support. The full audit tool is extensive being split into different sections for each individual MDT practitioner to complete. For the purpose of this project these sections were combined for simplicity of data capture, to avoid duplication and streamline analysis. Domains deemed relevant for inclusion related to demographics (ethnicity removed), diagnosis, referral and MDT intervention. The Hoehn and Yahr staging scale (Appendix 5) was also added to the tool to provide information on the severity of disability. Sections within the modified tool (Appendix 12) would be completed by the relevant practitioner.
The audit was used to measure the impact of the service improvement post intervention making comparisons to the baseline data. The information retrieved was compiled between November 2018 to April 2019. Analysis of data both pre and post implementation will allow reflection as to whether the project has achieved its aim.
Chapter 4
Results
Driver 5 – continuation of PDSA cycle 2
Results from the audit following introduction of the service improvement represent 6 months worth of data collected from 12 patients with a confirmed diagnosis of an atypical Parkinsonism. Permission for the service improvement had been approved by the senior nurse manager prior to commencing the project. Information was collected by the lead PDNS and second PDNS team from the day hospital database. These results were compared with the baseline audit pre intervention.
During the designated period of the audit (November 2018 –April 2019) on implementation of the service improvement a total number of 12 patients were diagnosed with an atypical Parkinsonism. One patient remained under review as the exact atypical diagnosis was unclear. A further patient had their diagnosis changed from MSA to PSP at follow up.
Parallel with the baseline audit the highest proportion of patients were determined to have DLB (Table 4.1). Again co-morbidities were well managed and as such did not impact on the ability of patients to participate in MDT input. With Hoehn and Yahr (1967) staging (Appendix 5) being included as part of the audit a more accurate gauge of disease severity was identified. It was noted that patients were exhibiting the same stage of disease severity with those at baseline (Table 4.1) in all groups.
Table 4.1
Patient List Number of patients Hoehn and Yahr stage
DLB 6 2-3
MSA 3 2-4
PSP 2 3-4
CBD 1 3-4
The baseline audit (October 2017-October2018) identified that there were significant delays and variability with follow-up in the traditional outpatient service. Data from the 22 patients (Table 4.2) reports the number of days waited on average from diagnosis to follow-up appointment as 130 days. This was calculated taking the minimum follow up appointment of 42 days and maximum of 203 days giving a range of 161 days. The average (mean) follow up of 130 days was determined in conjunction with the range to identify the extent to which the current system was not meeting the needs of this patient group. It was also a useful determinant to assess the degree with which the present system waiting times needed to be reduced to meet the aim of follow up appointments within a 42 day (6 week) window. With an average interval time being calculated at 130 days a ⅔ reduction target was set (43 days) which aligned with the proposed 42 day (6 week) reduction target. Extrapolating this data is useful however, it misses the complexity of variation in distribution of follow up appointments over time. This is more clearly illustrated using a run chart (Fig. 4.1). This has been shown to be more effective when communicating the variation in a process (NHS Improvement ACT Academy 2018). It is deemed that a reduction in variation within a process makes it more reliable (NHS improvement ACT Academy 2018).
Table 4.2
Patient Number Interval between diagnostic and follow up appointment (DAYS) Patient Number Interval between diagnostic and follow up appointment (DAYS)
102 168 124 203
104 182 126 91
106 70 128 182
108 126 130 98
110 154 132 126
112 49 134 70
114 112 136 182
116 182 138 98
118 63 140 168
120 182 142 182
122 147 144 42
Average interval time between appointments (days) 130
It was identified in the baseline audit that in 4 of the 22 patients a referral for therapy input was not completed. In 1 case the patient had declined a referral but agreed at their subsequent follow up appointment having been counselled regarding the benefits. With the remaining 3 patients it was recognised that they had been reviewed by a registrar who was on a short term placement to the regular team (PD consultants x 2, PD specialist nurses x 2). As a result no referral for therapy had been initiated at their diagnostic appointment. With the 18 patients who were referred for therapy the majority had been sent for single therapy input through an outpatient route (55%). The remaining 45% were allocated for MDT input within a day hospital or via CRT (Fig. 4.2).
Fig 4.2
All 18 patients from the baseline audit were found to have received therapy. Of the 10 patients who were referred for single therapy input 6 were subject to the longest waiting time to access the service (140 + days) (Fig. 4.3). The CRT service proved to be the most responsive with the 2 patients referred accessing therapy within 1 week. However, it was noted when evaluating their notes that they did not receive MDT review as requested. All referrals to CRT are triaged in relation to achieving specific outcome measures with regard to mobility and functional ability. Documentation revealed that the 2 cases were reevaluated to receive a single therapy input OT, PT or SALT based on the severity of a presenting symptom. This increased the single therapy referral rate to 66% resulting in a reduction in MDT input to 33%. The average (mean) waiting time to access therapy was 78 days with a range of 156 days. Again significant variation in the data was seen (Fig. 4.3).
Following the introduction of the service improvement there was a more consistent pattern with accessing follow-up and MDT input (mean 16 days) which achieved the proposed target of well below 42 days (Fig.4.4). The range was calculated at 11 days. In comparison with the traditional outpatient model there was a noted reduction in follow up time from a maximum wait of 203 days pre implementation (Fig. 4.1) to a maximum wait of 22 days post service improvement with the integrated model (Fig.4.4). A total reduction of 89% in waiting time.
Fig. 4.4
All 12 patients received MDT input post intervention resulting in 100% compliance as opposed to only 33% compliance pre intervention (Fig. 4.5).This is in keeping with NICE (2017) guidelines that all people diagnosed with Parkinson’s should receive prompt access to MDT support.
Fig. 4.5
Percentage of patients who received MDT input
120%
100%
80%
60%
40%
20%
0%
MDT (PRE) MDT (POST)
PDQ-39
Following the implementation of the service improvement PDQ-39 scores identified an overall positive improvement (Fig. 4.7). The majority of the 12 patients’ scores were within the lower categories (never to sometimes) in comparison to pre intervention where the majority of the 22 patients scored in the higher categories (sometimes to always) (Fig. 4.6).
Fig. 4.7
Data to this point had identified that the service improvement had achieved targets set before implementation. Access to an integrated MDT follow-up service for people with atypical Parkinsonism had reduced waiting times to access services as well as improving engagement with MDT input.
Chapter 5
Discussion
Chapter 3 provided a detailed account describing the process of implementing the proposed change utilising the ‘Model for Improvement(NHS Wales “1000” Lives Improvement 2014) (Fig 3.2) and associated tools to plan, implement and evaluate the work-based element of the project. Results (chapter 4) provided a detailed analysis of pre and post intervention data to establish if there had been any measurable impact in relation to patient management. This chapter will address the final stage of the ‘Driver Diagram (Driver 6) by completing the process of moving through the ‘Model for Improvement(NHS Wales “1000” Lives Improvement 2014) and associated PDSA cycles to provide analysis of the service improvement. Evaluation of the results will be used to identify key findings which will be discussed in relation to the aims of the project later in the chapter. The following summary details the outcome of the change and information retrieved during the workbased part of the project. Driver 6 Analysis A baseline audit of 22 patients performed prior to the introduction of the service improvement revealed that between October 2017 and October 2018 patients waited an average (mean) of 130 days for a follow up appointment in clinic. Out of the 22 patients 18 were referred for therapy input with 55% (10 patients) referred for single therapy in outpatients and 45% (8 patients) being referred for MDT input either in day hospital or with the CRT. These figures were adjusted as 2 people allocated MDT input via CRT were only given single therapy following their triage reducing the MDT figure to 33%. There was an average (mean) 78 day wait to access therapy with a significant rate of variability in length of time patients waited to receive input (Fig. 4.3). Hoehn and Yahr (1967) staging of progression was between 2-4 both pre and post intervention demonstrating patients were in various stages of advancing disease. A total of 12 people were diagnosed with an atypical Parkinsonism during the designated period of post intervention data collection (November 2018-April 2019) receiving their follow up appointment as part of the new integrated MDT day hospital service. The effectiveness of the service improvement was evaluated by auditing the time from diagnosis of atypical Parkinsonism to accessing the integrated MDT follow up service, reviewing the pattern of variation in referral and assessing the percentage of patients who received MDT intervention. The results identified that there was an 89% reduction in waiting time to access therapy which also referred to follow up review as this is an integrated service, the variation in referral to access MDT went from 156 days to 11 days and of the 12 patients included in the audit 100% received MDT input in comparison to only 33% pre intervention Results from PDQ-39 (Jenkinson 1997) identified that pre implementation over 200 responses for ‘always indicating that their condition impacted on daily life (Fig. 4.6). In comparison, post intervention this reduced to below 60 (Fig. 4.7). This seems to indicate that having more timely intervention and integrated MDT follow-up support positively impacted on perception of improved QoL.
A key aim of this project was the development of an integrated follow up service within an MDT day hospital setting to address and potentially resolve variability and delays to care.
The literature identified that integrated MDT follow up services have the best outcomes for people diagnosed with these conditions (Bukki et al. 2016, Clerici et al. 2017, Frundt et al. 2018). This consensus of opinion exists despite there being some discrepancy in what constituted MDT and place of service delivery (in-patient or outpatient/community) (Hohler et al. 2012). The rarity of these conditions was reflected in the low numbers included within the studies which aligned to figures within the workbased project. However, as the service improvement is a small scale change and evaluation size is not relevant. The literature reflected this as the limited number of participants did not affect service delivery as studies utilised MDT services which were already in place (Hohler et al. 2012, Frundt et al. 2018).
The baseline audit of the workbased project identified significant variability in waiting time for patients accessing a traditional follow up appointment in clinic (range 0-161 days), which was paralleled with referral wait times to access therapy (range 0-156 days). The variability in waiting time was noted to be a combination of fitting in with traditional outpatient models of referral for follow up, and a lack of consistency in the type of therapy referral initiated. Inconsistency was noted throughout the literature with a lack of standardisation regarding the model of service delivery. Marck et al. (2013) identified with the concept of a traditional outpatient model, whereas other studies took a broader view including various
MDT therapists as part of their service (Traistaru et al. 2017, Clerici et al. 2017, Frundt et al. 2018). It was noted in all the studies that there was no specified time frame given in respect of accessing MDT therapy input. This is significant as atypical Parkinson’s syndromes are rapidly progressive. In studies by Hohler et al. (2012) and Monticone et al. (2015) reference was made to Hoehn and Yahr (1967) staging of disease progression which identified with moderate to complex phase disease (2.5-5). There was no indication that disease stage had any impact on engagement with MDT. This pattern was similar to that seen in the workbased project (chapter 4).
The significance of MDT support was noted in a study by Bukki et al. (2016) who demonstrated a 68% improvement in stabilisation of symptoms as a result of care being provided as an in-patient MDT model. Similarly, benefits were seen in outpatient models with improvements in survival (p< 0.001) plus the added bonus that provision of care was less costly (Rooney et al. 2014, Frundt et al. 2018). Variation in referral practices had a resulting impact on the type of therapy a patient received and wait time. This was found in the workbased project prior to the service improvement. Patients who were reviewed by a visiting clinician were less likely to receive a referral for MDT input and in 4 cases did not receive any form of therapy referral at diagnosis. Given that guidelines recommend people with Parkinson’s syndromes have better access to MDT support (NICE 2017), streamlining the system to ensure uniformity is essential. Providing timely access to services is a fundamental underpinning factor within care of patients with atypical Parkinsonism due to a rapid disease trajectory and limited available treatment options (Ludolph et al. 2009). As highlighted within the work based project only 33% of patients’ pre intervention accessed MDT. This was not only the result of variable referral but dependant on local services (CRT team) system for triage. Therefore, the ability of patients to access services that are appropriate needed to be considered in terms of those adhering to recognised guidelines (WG 2013, NICE 2017).
Where patients with atypical Parkinsonism have accessed MDT services there have been demonstrated improvements in functional ability. Bukki et al. (2016) noted that 68% of patients symptoms stabilised or improved with 47% being deemed fit for discharged. Falls reduction and improvement in survival were also noted (Clerici et al. 2017, Frundt et al. 2018). With the local projects retrospective baseline audit identifying that 66% of patients had received only single therapy input it appeared to indicate a discrepancy in the application of best practice guidelines (NICE 2017). However, it could also be argued that the variable process of referral to therapy (55% single therapy and 45% MDT through two separate services) itself had an unintentional consequence that may have led to disparities in care.
Evaluation of the service improvement
As demonstrated within the local project a comparison of audit data performed retrospectively one year pre intervention and six months post identified improvements in all measured parameters (referral time to therapy, MDT input, health and QoL status). It is worth noting that due to time constraints a six month post intervention time frame was imposed to ensure completion of this workbased project. Extending this period to one year post intervention would highlight any extraneous influences and establish if the momentum of improvement was sustained.
There is a paucity of literature available which relates directly to the care of people with atypical Parkinsonism which in itself is a reflection of the rarity of these conditions.
However, of the studies that are available there is a relationship to the project in applying MDT models of care in the management of these conditions (Monticone et al. 2015, Bukki et al. 2016, Clerici et al. 2017, Frundt et al. 2018). It is noted that there were discrepancies in service delivery between in-patient models of care versus outpatient services. Both delivered the same outcomes in terms of functional and QoL improvements yet from a financial perspective the outpatient model proved more cost effective (Trend et al. 2002, Rooney et al. 2014, Frundt et al. 2018). Furthermore, it was identified that outpatient models have a more realistic approach as patients are exposed to their normal daily routines whilst receiving treatment as opposed to being under hospitalised conditions. The workbased project related to these models of care in that delivery of the service took place within a day hospital setting where follow up was incorporated inclusive of MDT therapy. It is also worth highlighting that even when patients received more intense forms of therapy consistent levels of input were maintained irrespective of stage in disease progression (Hohler et al. 2012, Monticone et al. 2015). Similarly, this was identified in the local project that people at different stages of disease (Hoehn and Yahr (1967) stage 2.5-4) were able to engage in MDT input.
The local service improvement noted 100% of patients accessing MDT input post implementation in comparison to 33% pre implementation. Time from referral to accessing therapy reduced by 89% with range falling from 156 days to 11 days signifying a more even distribution of referrals. A time frame between diagnosis to accessing MDT input was not identified in any of the studies. They used Hoehn and Yahr (1967) staging of disease progression to gauge patient complexity (2.5-5) which despite having a slightly wider range did compare to the local project (Hohler et al. 2012, Monticone et al. 2015).
There was a lack of consistency throughout the literature pertaining to the makeup of an MDT model of care (Marck et al. 2013, Traistaru et al. 2017, Frundt et al. 2018) Services ranged from what would be considered to be a clinic based set up (Parkinson’s specialist nurse, movement disorders specialist) to those involving wider members of the therapy team (PT, OT, SALT). As the project was utilising an established service within the day hospital the model of care was already in place. Prizer and Browner (2012) in their limited systemic review identify the need for more research in order to establish what truly constitutes an effective MDT service. It was interesting to note that outcome measures improved regardless of makeup of the service. In studies by Monticone et al. (2015) and Traistaru et al. (2017) where falls risk measures were assessed both identified an improvement in reduction of falls despite the programs being provided as an in-patient and outpatient service.
Within the local project the PDQ-39 identified that the post intervention group associated with increased levels of well being as a result of their symptoms having less impact on their daily management. This was confirmed with the majority of responses ranging between the never to sometimes categories as opposed to the pre intervention group who identified with sometimes to always. This tool was utilised in the majority of studies to report health related outcome measures in terms of the provision of MDT input (Marck et al. 2013, Ferrazzoli et al. 2018, Eggers et al. 2018). However, Murdock et al. (2013) used a qualitative approach through interviews to explore the emotional and psychological benefits of MDT support. The act of being involved in therapy with peer support and social interaction was found to have a direct correlation with feelings of overall well being which in turn positively affected perceived QoL.
Using the ‘Model for Improvement` (NHS Wales “1000” Lives Improvement 2014) was a fundamental component of the project ensuring the process of improvement maintained a steady momentum. The use of 3 questions and PDSA cycles gave rise to careful planning of the process and facilitated evaluation and reflection especially whilst moving forward through the stages.
This local project involved the engagement of a well established multidisciplinary team and as such it was important to identify roles and responsibilities early on in order to avoid conflicts of interest. The PDNS facilitated the lead role which was assigned to the second PDNS during periods of absence. Regular meetings were held to ensure stakeholders maintained their impetus and involvement in the process. Fortunately, any issues related to staffing were managed by the nurse manager and as such sickness and absence did not impact on the process. Any new members of the MDT who joined during the project were trained in accordance with their standards of practice. As therapy of patients with atypical Parkinsonism fell within complex management this training was already in place. This also helped to dispel any concerns related to sustainability of the service as input could be delivered as part of their complex service. Reference was made to the NICE (2017) guidelines in order to clarify management and to establish any common denominators of care within current service provision. With only 12 people receiving a diagnosis of an atypical Parkinsonism during the 6 month period of the project it was felt there would be very little impact on the service.
The formalised system that is now in place providing follow up for people diagnosed with an atypical Parkinsonism has enabled the service to provide more responsive care at an earlier stage in the disease trajectory. A further benefit has been improvements in documentation with regular updating of the databases to account for deceased and community based patients. This has resulted in a more robust and accurate system of reporting and log of patients with atypical Parkinson’s syndromes. In terms of this service being prevalent within the context of the wider population it may be feasible in terms of complex chronic disease management although this concept has not been validated.
Chapter 6
Conclusion
This work-based project was designed to address variability and delays in follow up management for people diagnosed with rare atypical Parkinson’s syndromes with the development of an integrated MDT follow up service within a day hospital setting. Outpatient services were not designed to meet the needs of this patient group and as such their pattern of follow up and referral for MDT input fit within the regular routine of the service. This lack of structured management resulted in patients experiencing delays and variability in accessing support. Early access to MDT input is vital as these conditions are rapidly progressive and the window of opportunity to provide support is limited in comparison to other Parkinson’s syndromes. The current outpatient system was also failing to meet best practice guidelines of providing prompt access to MDT support (NICE 2017).
Throughout this project a systematic approached was employed to address the aims and objectives and assist the planning, implementation and evaluation of the service improvement. Comprehensive literature review provided insight and clarity into the degree with which MDT input can benefit long term management both physically and psychologically. This confirmed the extent with which discrepancies within current practice were impacting on patient management with people diagnosed as having an atypical Parkinsonism.
The ‘Model for Improvement` (NHS Wales “1000” Lives Improvement 2014) and associated PDSA cycles were used to provide a structured systematic approach to developing, testing and implementing the change. Incorporating the service within an already established framework of the day hospital setting employed the expertise of MDT professionals who were already skilled in the management of these rare conditions therefore evidence based practice and knowledge was already in place. Sustainability was a concern but this was addressed with the decision to include the service as part of the complex Parkinson’s management days where patients needs mirrored those of people with atypical
Parkinsonism. Audit criteria were used throughout the process as a means of measuring the impact of the service improvement and associated success of the change.
A systematic literature review retrived a paucity of articles related to the management of people with atypical Parkinson’s which somewhat reflects the rarity of these conditions. MDT models of care were found to provide the best outcomes although what constituted the structure of MDT was inconsistent. However, the majority did identify with having a physiotherapist, OT, PDNS and specialist medic as a standard. There were associated improvements in QoL indicators as a result of integrated MDT support although this was generally based on PDQ-39 (Jenkinson et al. 1997) questionnaire results looking at health status as having an impact. Despite this, there were elements identified that did relate to the project. These were related to stabilisation or functional improvement with symptoms, self management strategies, integrated therapy support and education.
The changes introduced as part of this work based project demonstrate the benefits of collaborative working and putting the patient at the centre of everything that we do (WG 2015). Developing a system beyond the boundaries of the traditional outpatient service promoted improved communication particularly with streamlining referral practices but also developed an improved MDT model of care. This had positive repercussions with patient care as they accessed one service that addressed all their management needs.
It is acknowledge that adaptations to the follow up service will continue with future PDSA cycles. People with atypical Parkinsonism represent a small proportion of the total number of people diagnosed with a Parkinson’s syndrome. However, the trajectory and lack of available medical treatments results in management being based around non pharmacological options. Variability and delays in accessing MDT support and follow up have been addressed within current available resources. With careful planning and utilisation of a service that already had robust structures in place has resulted in patients with atypical Parkinsonism receiving the care they need and deserve.
Recommendations for practice.
The following are recommendations for future practice as a result of the work based project
- PDSA cycle 3 Quality of life feedback
- 6 month audit of the service to exclude any extraneous data
- Continue the cycle of regular meetings with the MDT team
- Presentation of results to consultant specialist with update on progress.
- Share practice with the wider team. Liaise with day hospital 2 with a view to roll out the service cross site.
- Present at the Parkinson’s excellence network meeting both at local and national level
- Benchmark with other PD specialist nurse services through meetings and forums
- Poster presentation at specialist nurse conference
- Abstract and poster presentation for Movement Disorders society world congress
- Further research into the relationship between co-morbidity and atypical Parkinson’s syndromes
- Research into the impact of autonomic symptoms and relationship to physical symptoms
- Advanced care planning in relation to MDT support.
Appendix 1
Epidemiology
Mean age of onset Median Survival Incidence Prevalence
(Age
Adjusted)
MSA 56 yrs 5.1yrs 3 per 100,000 4.4 per 100,000
PSP 65 yrs 2.6 yrs 1.1 per 100,000 6.4 per 100,000
CBD 64 yrs 2.6 yrs 1 per 100,000 2 per 100,000
DLB 75 yrs 3.3 yrs 5.9 per 100,000 1.6 per 1000
IPD 69 yrs 7.8 yrs 15-20 per
100,000 160 per
100,000
Source: PSP Association (2018), Macleod and Counsell (2015), NICE (2017) Appendix 2
The Health Foundation four principles of person centred care (2016).
• Affording people dignity, compassion and respect
• Offering coordinated care, support or treatment
• Offering personalised care, support or treatment
• Supporting people to recognise or develop their own strengths and abilities to enable them to live an independent and fulfilling life
Appendix 3
PRISMA (2009) Flow Diagram
Appendix 4
Author and Date Aim Study Design Setting and Sample size Main findings Strengths and Limitations Codes/Themes
1 Frundt et al. 2018 To evaluate the effect of a Parkinson’s day clinic as a new treatment for patients with complex
Parkinson’s syndromes Service
improvement
Hamburg-Germany Day unit
Convenience sample
184 patients of which:
169-Parkinson’s
5 Atypical Syndromes 10 Unconfirmed diagnosis (either Parkinson’s or Atypical)
Improvement in motor and non-motor scores
Reduced time accessing
MDT input from referral
Therapy optimisation:
• Upgraded
treatment plans
• Inclusion of counselling and support
• Improved
interdisciplinary communication
and co-operation
A more cohesive service as therapies delivered
within one location
Positive patient service evaluation recognising benefits to quality of life overall.
Use of recognised universally accredited tools for motor and
non-motor scores
Clearly defined
demographics
Limitations:
Only short term outcome results were presented therefore a placebo effect cannot be ruled out.
Scores were not always completed by the same person therefore bias cannot be excluded Patients only referred via Multidisciplinary
intervention
Single point of access
Time reduction (Referral to
accessing input)
Improved
communication
Cohesive services
Neurology and accessing one single locationnon
generalisability
2 Murdock et al.
2015
To explore how people with advanced Parkinson’s value engagement in occupational activities to enhance their daily lives Qualitative studyPhenomenological approach Ulster
Convenience sample
Included various
Parkinson’s syndromes
Interviews conducted within patient’s home and suitable venue convenient to the participants.
A total of 10
participants-6 male and
4 female
Need to improve access to occupational therapy to people living with a life limiting neurodegenerative conditions
The experience of engaging in occupation was deemed more important than the outcome.
Close links were identified with palliative care models with this approach being deemed relevant from
diagnosis
Earlier and quicker access to MDT support is essential due to rapid disease trajectory and resulting changes to symptoms.
Convenience sample-bias
All participants were recruited being active members of the Parkinson’s UK organisation which may have influenced who volunteered. High risk of bias
Small sample size
Team support Early
engagement
with MDT
Palliative care
model (Holistic)
Continuity of care throughout all stages of disease
3 Hohler et al. 2012 To investigate the effectiveness of an in-patient
multidisciplinary movement
disorders program in improving functional status for patients with atypical
Parkinsonism. A pretest-posttest design
Outcome measures:
FIM motor score used-18 item
assessment of disability
2 minute walk
test (TMW)
Timed “up and
go” (TUG)
Berg balance score (BBS)static
balance
Finger tap test(FT) Boston-USA
Convenience sample
A total of 91
participants
25 Vascular
parkinsonism
19 MSA
4 PSP
43 Combination CBD, DLB, Drug induced,
toxin exposure, unknown Improvements shown in outcome scores (except
FT) with MDT alone
Mean values
FIM increased from 41.370.8
TUG decreased from 81.5
secs to 42 secs
TMW increased from
138.9 ft to 202.5 ft
BBS increased from 22 to
29.5
FT Left 60.2 to 71.7
FT Right 68.3 to 79.3
Concentrated
multidisciplinary input in
conjunction with medication changes improves functional status
Atypical syndromes require Integrated services which current outpatients cannot provide
No current standard Good spread of
Atypical
syndromes
Patients at a higher level of disability suggesting functional gains can be achieved
in patients with complex
conditions
Objective measure calculated at both peak and trough medication dosesrobust
Validated tools
used
Limitations identified:
Convenience
sample
Lack of a control
group
Focused MDT input
In-patient rehabilitation more effective than outpatient models
Functional benefits to patients with atypical complex late stage disease
protocol for MDT available Intervention by MDT and medication changes were simultaneous making it difficult to ascertain if MDT intervention, medication adjustments or both improved
the results
Intensive input may have
resulted in a Placebo effect
No long term
follow up data
4 Traistaru et al. 2017 To evaluate the
efficiency of a
complex rehabilitation program with reducing symptoms and improving
quality of life in patients with Parkinsonism Randomised
controlled trial
(RCT) Romania
Rehabilitation hospital
2 groups (E study group and control)
27 participants:
Control 11 men
2 women Significant changes seen between control and study groups across all scores-study groups achieved greatest improvement.
Functional ability maximised with focused MDT input in one location
Randomisationdata anonymity is
more robust
Use of valid
accredited tools
Equal male to
female split
Pre diagnostic Improved functional ability with an integrated
program
Structured exercises following validated scoring tools
Study 11 men
3 women
Comprehensive geriatric assessment and imaging performed to support
diagnosis
Scores-
BBS,TUG,TMW,NEADL
(Nottingham Extended
Activities of daily living) Transferable across all age and gender groups test and neuroimaging to secure the diagnosis of Parkinsonism for inclusion in the trial.
Limitations:
Small sample size
Psychological outcomes not assessed-no
patient feedback
6 week programbased on Parkinson’s model. Limited validated evidence regarding appropriate length of
intervention
and methods Increased time in contact with patient group
5 Clerici et al. 2017 To analyse the effectiveness of an intensive multidisciplinary RCT Italy
Rehabilitation hospital
Improvements in functional ability across both groups virtually equal Randomisation of groups-reduces
bias
Functional benefits with focused MDT
input
program within a rehabilitation setting in patients with PSP to identify if this improves their functional ability and management. Convenience sample-24 consecutive people with PSP admitted to movement disorders rehabilitation hospital
Computer generated group randomisation-24 each group
Groups assigned to either robotic device Lokomat plus MDT or treadmill using visual cues and auditory feedback plus MDT (traditional treatment for people with Parkinson’s)
Decreases in falls
Improvement in balance
Goal based multidisciplinary treatments are most effective for people with
PSP
Rehabilitation MDT based settings provide the most effective management pathways Validated scores used both physical and
cognitive
No statistically significant differences in groups from
baseline
Limitations:
No Control group
Patients with cognitive impairment were included which may have affected the
results
Small sample size
No follow up data
Increased contact and time benefits management
Rehabilitation environment most effective in meeting patients needs
6 Bukki et al. 2016 To determine healthcare service usage of patients diagnosed with PSP and CBD and the role of Retrospective analysis Munich
Palliative care unit
Systematic hand searching of documents of patients diagnosed Multidisciplinary short term intervention was
effective
Environments that support integrated MDT provide improved Demographics presented Longitudinal data
collection
Standardised data collection tools Collaborative MDT/Palliative care services provide improved
continuity of management in
palliative care services with PSP or CBD who attend outpatient clinic
Pharmacological and nonpharmacological
interventions recorded
38 PSP
3 CBD
Data collected over 6 ½ years
Limited patient numbers pose
difficulties with sustainability and financial support functional outcomes
Inclusion of palliativemore holistic model with better outcomes used
Limitations: Retrospective design
Small sample size
Restricted data collection which did not reflect different settings for care rare Parkinson’s
syndromes
Preservation of long term
function
Early intervention
7 Eggers et al. 2018 To assess if patient-centred integrated healthcare improves the
quality of life of patients with Parkinson’s RCT Cologne, Germany
Eligibility screening- clear
inclusion/exclusion
criteria
300 participants
Data collection over 3 ½ years
Equal split between treatment and control groups Integrated care improved patient outcomes in comparison to traditional
outpatient services
Motor and non-motor scores improved in the
intervention group
Improved MDT collaboration
Need to establish integrated support no clear conclusions as to Research staff performed
randomisation
Valid data collection tools
used
Limitations:
Selection biasneurologist who was familiar with
the patients
Patient
empowerment
Integrated care
MDT support
Focused MDT intervention versus standard outpatient treatment
Validated data collection tools used location- home/hospital
Findings not conclusive as interventions were not performed by the same
therapies
Barriers identified included cost constraints and sustainability Generalisability restricted – differing healthcare
systems
High drop-out
rate
Therapists were not included as regular team members in consultations
8 Calvert et al. 2013 To evaluate the health related quality of life and access to supportive care in patients with rare long term neurological conditions Cross-sectional survey UK
266 participants (56 specialist clinics, 210 through charities and
support networks)
Have a rare long term
neurological condition
Completion of an online or paper based survey
Questions on social care, secondary care, consultations and health-related quality of life. 40% of people with PSP, MSA, MND and HD had access to a care coordinator. Despite this there were significant reductions in health
related quality of life in
these groups
Symptoms experienced were severe but access to services was poor suggesting their needs require a higher level of professional input.
MDT involvement was not
consistent
Validated tools
used
Demographics
clearly presented
Limitations:
Non-randomised sample
Large portion of patients recruited via the charitable organisationslikely bias being more motivated to take part.
Increased access to MDT support is linked with improved health-care
quality of life
People with rare neurological conditions require coordinated care.
It was identified that carer views needed to be included as many patients are supported solely by
them
Suggested further
research was needed
No disease rating scales usedunable to assess severity of disease
No clear indication of current MDT input for comparisons to be made on what was perceived as needed for support
9 Prizer and
Browner. 2012 To establish the effectiveness of integrated care models in managing Parkinson’s syndromes Systematic review 2 studies found on literature search. No available literature directly related to interdisciplinary care in
Parkinson’s syndromes. Comparable studies used which related to short-term multidisciplinary team management within an outpatient department Statistically significant
improvements seen from baseline (both used health
related quality of life measures HRQoL)
Follow-up review performed directly after the period of intervention in both studies therefore unable to conclude if the effects of treatment were sustained
Outpatient
multidisciplinary models deemed easier to implement Limitations:
No inclusion or exclusion criteria included
Lack of available evidence-only 2 studies included as a result of the
search
No clear search parameters
identified
Streaming of care MDT support valuable in improving
HRQoL
Education
Educational components were considered an essential component.
Further studies warranted but recognition that this may be difficult due to:
Disease duration
Progression
Variability of symptoms
Standardising treatments
Inconsistencies in treatment
Weak evidence
10 Johnston and Chu. 2010 To determine the short and long term effectiveness of outpatient multidisciplinary care programs for people with Parkinson’s syndromes Systematic review 4 studies included-2 of the studies involved short term outcomes the remaining 2 looked at longer term outcomes over 4-6 months Demographics were
similar for all studies
Inconsistent reporting of medication cycles
throughout all studies
Measuring scales and outcomes used lacked cohesiveness
2 longer term studies used gait as an outcome measure-one study showed no significant 2 independent reviewers used to screen the studies Inclusion and exclusion criteria
clearly stated
Limitations:
Limited studies
2 of the studies were old and sample size was Outpatient MDT effective
Follow up
needed
Cohesiveness
change the other showed a trend towards improvement (8 sessions 2 per week x 4 weeks no change-1 day 6 hours per week for 6 weeks TMW 20.1 secs decreased to 9.4
secs)Mean values used
2 Short term studies showed MDT input had impacted positively on gait, speed and stride length (13 x 2 hour sessions >gait, stride speed-1 day of 6 hour sessions over 6 weeks TMW 14.67 secs to 1.66
secs) Mean values used
Common measure for depression used-no
consistency in results
Follow up monitoring is
essential
small
11 Monticone et al. 2015 To evaluate the effects of an inpatient MDT programme on ADL’s and QoL for people with RCT Lissone-Italy
Rehabilitation unit
Computer generated randomisation. Principle Improved functional status in experimental group. 51% increase in BBS score (falls risk) showing reduction for falls risk. Unclear trend in Clear inclusion and exclusion criteria.
Demographics
clearly defined. Focused MDT intervention improves functional ability.
complex PD. investigator and statistician blinded to treatment. 70 participants. Equal split. All complex PD.
30-90 minute MDT intervention over 8 weeks. Experimental group received the addition of education and psychologist support.
Intervention delivered to groups post medication administration. control (20% increase with 17% decline).
Improvement maintained 1 year post intervention for experimental group.
Addition of psychologist and education for experimental group deemed to attribute to this.
Validated tools used.
Computer randomisation and blinding of principle investigator and statistician.
Limitations
Participants modified the programme
during the 1 year post period (skewing of results possible).
Medication administration more stringently monitored possibly contributing to functional improvement.
Financial support of 20,000 Euros by Italian Education and psychology input.
Healthcare. ? lacks transferability.
12 van der Marck et al. 2013 To establish if an
MDT/specialist team approach offers better outcomes than stand alone care by a neurologist. RCT Ontario-Canada
Centre for movement
disorders
Computer generated randomisation.
Equal split 1:1
100 participants (51 to intervention and 49 to control).
Analysis over an 8 month period.
Control group received
3 contacts with neurologist only. Intervention group were able to access PD nurse, social worker and specialist medical support regularly. Improvements noted in intervention group with PDQ-39 (3.4 point improvement) and UPDRS (4 point improvement).
Increased access to support noted to be significant with PD nurse receiving the most contacts (86%) social worker (69%) specialist (59%). Most PD nurse contacts via telephone.
Comparison made against only 3 contacts with the neurologist.
Inclusion and exclusion criteria clearly described. Validated tools used.
Demographics clearly presented.
Limitations
Participants in early disease stage may lack transferability.
Consideration as to the meaning of
MDT approach ( No
physiotherapist, OT , SALT representation) Increased access to MDT support is linked with improved health-care quality of life.
Continuous interaction.
13 Rooney et al. 2015 To determine if a centralised MDT setting improves outcomes Retrospective analysis Republic of Ireland (ROI) and Northern Ireland
(NI).
Data extracted from the Survival improvements noted (p<0.001) with MDT intervention compared to stand alone community worker. Demographics clearly presented.
Large sample.
MDT support improves outcomes.
Single point of
compared to a stand alone community specialist support worker. population based ALS registers between January 2005 and December 2010.
Comparisons made within the two healthcare systems between those attending an MDT centralised clinic and receiving stand alone community specialist support worker input.
719 total cases included.
Complex decision-making from multiple practitioners considered as being the reason for improvement.
More consistent intervention within MDT clinics seen as providing the most effective support. 5 year longitudinal study made for greater data analysis.
Limitations
ROI MDT clinic noted younger onset attendees.
Differences noted between ROI and NI MDT clinic approaches.
In the ROI clinic the impact of individual MDT disciplines could not be quantified.
Precise advantage of MDT input could not be established only hypothesised.
access. Cohesiveness.
14 Trend et al. 2002 To evaluate the short-term
effectiveness of an MDT ObservationalPre-post test study. UK
Rehabilitation centre.
Improvements noted across all domains both physical and
psychological. People with Validated tools used.
To reduce bias MDT support improves both physical and psychological
programme for people with PD 118 participants. Majority (101) recruited from the neurology clinic, (12) self referred
and (5) from geriatricians.
Attended one day per week for six weeks receiving MDT input (physiotherapy, OT, SALT and PD nurse specialist).
Comparison between baseline start of the
programme and week six.
complex disease gained more from treatment. 95.4% agreed knowledge and understanding of PD had improved.
Recognised that multiple
professional’ best suited to manage complex conditions. patients and therapists did not have access to baseline scores.
Demographics
and results clearly presented.
Limitations
No control group…..placebo effect.
Element of self reporting with assessments…Risk of bias.
One off programme with no follow up so difficult to gauge long term effects.
Further research needed. health.
Education and knowledge.
15 Gage and Storey 2004 To review the
effectiveness of
MDT
interventions for people with Systematic review 44 studies included within 51 papers. Range of MDT interventions delivered in clinical setting or patient home. Majority of the interventions delivered as single therapy.
Consistent age range 2 independent reviewers used to screen the studies Inclusion and exclusion criteria MDT integrated care improves both physical and psychological
PD and future research needs. identified.
Only 1 study involved a full MDT intervention service.
25 studies related to
physiotherapy input
10 studies related to SALT input
4 studies related to OT
3 involved psychological intervention
1 involved education.
2 studies identified as providing the most robust evidence related to the use of validated tools, follow up post
intervention and utilised a larger cohort of participants. clearly stated
Limitations
Limited studies related to MDT integrated care (only 1 found as incorporating all MDT disciplines)
The majority of studies only provided a follow up review post treatment. Unable to quantify the effects of MDT input over a longer term. function.
Follow up needed.
Sustainability.
Appendix 5
Stage Hoehn and Yahr Scale Modified Hoehn and Yahr Scale
1 Unilateral involvement only usually with minimal or no functional disability Unilateral involvement only
1.5 – Unilateral and axial involvement
2 Bilateral or midline involvement without impairment of balance Bilateral involvement without impairment of balance
2.5 – Mild bilateral disease with recovery on pull test
3 Bilateral disease: mild to moderate disability with impaired postural reflexes; physically independent Mild to moderate bilateral disease; some postural instability; physically independent
4 Severely disabling disease; still able to walk or stand unassisted Severe disability; still able to walk or stand unassisted
5 Confinement to bed or wheelchair unless aided Wheelchair bound or bedridden unless aided
Original Hoehn and Yahr Scale (1967)
Modified Hoehn and Yahr scale (Goetz et al 2004)
Appendix 6
Unified Parkinson’s Disease Rating Scale
III. Motor Examination
Speech
0= Normal.
1 = Slight loss of expression, diction and/or volume.
2 = Monotone, slurred but understandable; moderately impaired.
3 = Marked impairment, difficult to understand.
4 = Unintelligible.
Facial Expression 0= Normal.
1 = Minimal hypomimia, could be normal “Poker Face.”
2 = Slight but definitely abnormal diminution offacial expression
3 = Moderate hypomimia; lips parted some ofthe time.
4 = Masked or fixed facies with severe or complete loss of facial expression; lips parted 1/4 inch or more.
Tremor at Rest (head, upper and lower extremities) 0= Absent.
1 = Slight and infrequently present.
2 = Mild in amplitude and persistent. Or moderate in amplitude, but only intermittently present.
3 = Moderate in amplitude and present most of the time.
4 = Marked in amplitude and present most of the time.
Action or Postural Tremor of Hands 0= Absent.
1 = Slight; present with action.
2 = Moderate in amplitude, present with action.
3 = Moderate in amplitude with posture holding as well as action.
4 = Marked in amplitude; interferes with feeding. Rigidity (judged on passive movement of major joints with patient relaxed in sitting position. Cogwheeling to be ignored.) 0= Absent.
1 = Slight or detectable only when activated by mirror or other movements.
2 = Mild to moderate.
3 = Marked, but full range of motion easily achieved.
4 = Severe, range of motion achieved with difficulty.
Finger Taps (Patient taps thumb with index finger in rapid succession.) 0= Normal.
1 = Mild slowing and/or reduction in amplitude.
2 = Moderately impaired. Definite and early fatiguing.
May have occasional arrests in movement.
3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement.
4 = Can barely perform the task.
Hand Movements (Patient opens and closes hands in rapid succesion.) 0= Normal.
1 = Mild slowing and/or reduction in amplitude.
2 = Moderately impaired. Definite and early fatiguing.
May have occasional arrests in movement.
3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement.
4 = Can barely perform the task.
Rapid Alternating Movements of Hands
(Pronation-supination movements of hands, vertically and horizontally, with as large an amplitude as possible, both hands simultaneously.) 0= Normal.
1 = Mild slowing and/or reduction in amplitude.
2 = Moderately impaired. Definite and early fatiguing.
May have occasional arrests in movement.
3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement. 4 = Can barely perform the task.
Unified Parkinson’s Disease Rating Scale
Leg Agility (Patient taps heel on the ground in rapid succession picking up entire leg. Amplitude should be at least 3 inches.) 0= Normal.
1 = Mild slowing and/or reduction in amplitude.
2 = Moderately impaired. Definite and early fatiguing. May have occasional arrests in movement.
3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement. 4 = Can barely perform the task.
Arising from Chair (Patient attempts to rise from a straightbacked chair, with arms folded across chest.) 0= Normal.
1 = Slow; or may need more than one attempt.
2 = Pushes self up from arms of seat.
3 = Tends to fall back and may have to try more than one time, but can get up without help. 4 = Unable to arise without help.
Posture o = Normal erect.
1 = Not quite erect, slightly stooped posture; could be normal for older person.
2 = Moderately stooped posture, definitely abnormal; can be slightly leaning to one side.
3 = Severely stooped posture with kyphosis; can be moderately leaning to one side.
4 = Marked flexion with extreme abnormality of posture.
Gait
0= Normal.
1 = Walks slowly, may shuffle with short steps, but no festination (hastening steps) or propulsion. 2 = Walks with difficulty, but requires little or no assistance; may have some festination, short steps, or propulsion.
3 = Severe disturbance of gait, requiring assistance. 4 = Cannot walk at all, even with assistance.
Postural Stability (Response to sudden, strong posterior displacement produced by pull on shoulders while patient erect with eyes open and feet slightly apart.
Patient is prepared.) 0= Normal.
1 = Retropulsion, but recovers unaided.
2 = Absence of postural response; would fall if not caught by examiner.
3 = Very unstable, tends to lose balance spontaneously. 4 = Unable to stand without assistance.
Body Bradykinesia and Hypokinesia (Combining slowness, hesitancy, decreased arm swing, small amplitude, and poverty of movement in general.) 0= None.
1 = Minimal slowness, giving movement a deliberate character; could be normal for some persons. Possibly reduced amplitude.
2 = Mild degree of slowness and poverty of movement which is definitely abnormal. Alternatively, some reduced amplitude.
3 = Moderate slowness, poverty or small amplitude of movement.
4 = Marked slowness, poverty or small amplitude of movement.
Fahn et al (1987)
Appendix 7
Scoping exercise Date: 22/10/2018
Domains Location A
YES NO Location B
YES NO
Access
• Parking close to entrance
• Parking restrictions in operation
• Wheelchair accessible
• Steps
• Ramp
• Automatic doors
• Lift
Facilities
• Number of toilets
• Wheelchair accessible
toilets
• Hoist /stedy accessible
toilets
• Handrails
• Wheelchair accessible waiting area
• Food and drink
available
• Special dietary requirements can be catered for
• Wheelchair accessible physiotherapy gym
• Wheelchair accessible OT area
• Wheelchair accessible
SALT room
• Number of rooms with a bed/couch
• Number of
consultation rooms • Treatment room
• Waiting/communal
area
8
9
6
2
2
2
Environmental Flooring:
• Rubber flooring
• Flat
• Damage visible
• Trip Hazard
• Patterned
Space:
• Obstacles…pillars
• Number of sinks in the
clinical area
• Width of corridors can accommodate hoist/stedy
• Waiting area can accommodate hoist/stedy
• MDT clinical spaces can accommodate hoist/stedy
• Consultation rooms can accommodate hoist/stedy
• Hand rails
• Clear signage
• Bright lighting
• Good ventilation
• Number of emergency
exits
• MDM meeting room
10
4
4
X1
2
Resources
• Computer access
• Information literature
• Availability for
PowerPoint
• Communal waiting area can accommodate
group teaching
sessions
• Information boards
• Telephones
• Availability of specialised gym equipment
Limited
Additional Facilities
• Relaxation room
• Adapted kitchen area
• Adapted bedroom area
• Teaching room
• On site X-Ray
• On-site Pharmacy
• Access to emergency services…A+E/MEAU
3 days a week
Appendix 8
From: Anna Jones [mailto:JonesA23@cardiff.ac.uk] Sent: 27 February 2020 08:31 To:
Subject: WBP NRT 079 Dissertation – R&D Approval
Dear Tracy
Thank you for supplying the information relating to your workbased project. Please insert this email into your appendix as confirmation that the project meets with the service improvement/ evaluation criteria for your respective health board/ NHS trust.
Please do not include your proposal or any identifiable information in your project.
With thanks and good luck with your project.
Kind regards
Anna
Dr. Anna Jones
Senior Lecturer
Interim Director of Learning & Teaching (PGT) and CPD
Please note that I do not expect a response to this email outside of your normal working hours
School of Healthcare Sciences
College of Biomedical and Life Sciences
Cofion cynnes
Anna
Dr. Anna Jones
Uwch Ddarlithydd
Cyfarwyddwr Dros Dro Dysgu ac Addysgu (OlRaddedig) a DPP
Nid wyf yn disgwyl ymateb i’r ebost hwn y tu allan i’ch oriau gwaith arferol
Ysgol y Gwyddorau Gofal Iechyd
Coleg y Gwyddorau Biofeddygol a Bywyd
Prifysgol Caerdydd
Cardiff University
Room 3.41, 3rd Floor, Ty Dewi Sant
Heath Park, Cardiff,CF144XN
Tel: +44(0)29 206 87874
Email: jonesa23@cardiff.ac.uk
Online:www.cardiff.ac.uk/
Twitter: @CUHealthSci
Mae Prifysgol Caerdydd yn elusen gofrestredig. Rhif 1136855
Cardiff University is a registered charity. No 1136855
Yn falch o fod ymhlith y 10 prifysgol orau yn y DU a’r 100 prifysgol orau yn y byd. Y Brifysgol orau yng Nghymru 2018
Proud to be a top 10 UK and world top 100 university. Welsh University of the Year 2018
10 Orau/Top 10, 100 Orau/Top100: Academic Ranking of World Universities 2017 The Times/The Sunday Times Good University Guide 2018
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Appendix 9
Mind Map
Appendix 10
Xxxxxxxxx REHABILITATION DAY HOSPITAL
Xxxxxx University Health Board
Tel. No.
Fax No Dr xxxxxxx : Physician Ref:
: Co-ordinators
The xxxxxxxxx Parkinson’s service has arranged a follow-up appointment at our complex/atypical Parkinson’s multidisciplinary clinic. This is a collaborative initiative organised by the Parkinson’s service and xxxxxxxxx Rehabilitation Day Hospital, aimed to meet the needs of people with Complex Parkinson’s conditions, and their carers.
We would be grateful if you could attend this session on:
The aim of this session is to provide multidisciplinary review as well as information and support. This will be delivered by professionals in their speciality providing an opportunity to engage with our service.
Please contact us to discuss transport arrangements and special requirements.
We look forward to meeting you on the day.
PARKINSON’S TEAM
Xxxxxxxx REHABILITATION DAY HOSPITAL
Appendix 11
Appendix 12
Tracking/audit Sheet (adapted from PUKAT 2017)
Use this to record your patient cases
Date:
Date referral sent:
Date referral received:
Referral received within 6 weeks of diagnosis Yes No
Descriptive Data
1.1 Patient identifier
1.2 Gender • Male
• Female
• Other/patient prefers not to say
1.3 Year of birth
1.4 Contact details
1.5 Date of diagnosis
1.6 Confirmed diagnosis • MSA
• PSP
• CBD
• DLB
1.7 Parkinson’s phase Hoehn and Yahr (1967) stage
1.8 Living Alone • Yes
• No
• No, at a Residential home
• No, at a nursing home
1.9 Is there evidence of a documented Parkinson’s and related medication reconciliation at each visit? •
• Yes No
Specialist review
2.0 Prior to the current appointment, has the patient been reviewed by a specialist within the
last year? (Doctor or
PDNS) •
• Yes No
2.1 Time since most recent medical review (PDNS/doctor) •
•
• Less than 6 months
6-12 months
More than a year
• More than 2 years
• Never
2.3 Reviewed by doctor/PDNS during attendance •
• Yes No
2.4 Vital sign recordings • B/P
• Weight
• Pulse
• Temp
2.5 PDQ-39 Score
Multidisciplinary Input
3.1 Evidence of PDNS assessment/input •
• Yes No
• No, but declined
3.2 Evidence of physiotherapy assessment/input •
•
• Yes
No
No, but declined
• No, but clear documentation no therapy required
• No, but no achievable physiotherapy goals
3.3 Evidence of
Occupational therapy assessment/input •
•
• Yes
No
No, but declined
• No, but clear documentation no therapy required
• No, but no achievable occupational therapy goals
3.4 Evidence of
Speech and language assessment/input •
•
• Yes
No
No, but declined
• No, but clear documentation no therapy required
• No, but no achievable speech and language goals
Glossary
Alpha-synuclein A human protein that is abundant in the brain which is mainly found at the tips of neurones in specialised structures called presynaptic terminals.
Amyotrophic lateral sclerosis (ALS) Also referred to as motor neurone disease (MND) or Lou Gehrig’s disease causes death of neurones controlling voluntary muscles.
Autonomic changes An effect on the autonomic nervous system which can impact on the function of automatic processes including breathing, digestion, blood pressure, heart rate, urination.
Basal ganglia A group of structures found deep within the cerebral hemispheres of the human brain which main role is the control of movement.
Camptocormia Also known as bent spine syndrome (BSS) it is an abnormal spinal flexion with bending forward of the lower joints of the spine in a standing position.
Cerebellum A structure within the human brain which coordinates voluntary movements resulting in smooth and balanced muscular activity.
Cerebral cortex The outer wrinkliest layer that surrounds the brain that consists of tightly packed neurons.
Cueing A sensory prompt using verbal and visual stimulus to assist with movement.
DaT scan Dopamine Transporter scan is an imaging technique which uses an injected radioactive agent which is tracked under imaging to visualise dopamine transporter levels in the brain.
Dopaminergic neurons A cell group in the central nervous system (CNS) that makes the neurotransmitter dopamine.
Echolalia The meaningless repetition of speech.
Frontoparietal Refers to both frontal and parietal bones of the skull.
Magnetic Resonance Imaging (MRI) A medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body.
Normal pressure hydrocephalus (NPH) An accumulation of cerebrospinal fluid (CSF) that causes ventricles in the brain to become enlarged.
Palilalia A speech disorder causing involuntary repetition of words, phrases or sentences.
Pons A major division of the brainstem which is primarily responsible for sleep, respiration, swallowing, bladder control, hearing, equilibrium, taste, eye movement, facial expressions, facial sensation and posture.
Pull test Also referred to as Retropulsion Test it is a commonly used clinical assessment of postural instability. It evaluates the ability of a person to recover from a backward pull on the shoulders.
Putamen A large structure located within the brain which is involved in the complex feedback loop that prepares and aids in movement of the limbs.
Substantia nigra A relatively small structure present within the midbrain which plays an important role in the regulation of movements.
Tauopathy A term which refers to the cluster of tau proteins also referred to as neurofibrillary tangles which are abundant in the neurons of the CNS.
Tau proteins A group of six highly soluble protein isoforms (similar to each other and perform similar roles) that are primarily responsible for maintaining the stability of microtubules (tubular structures) in axons (long threadlike parts of a nerve cell).
Vascular Parkinsonism A condition which presents with the clinical features of Parkinson’s but is the result of cerebrovascular disease causing small strokes.
Vertical saccades A quick simultaneous movement of both eyes between two or more fixed points in the same direction.
References
All Party Parliamentary Group for Parkinson’s disease (APPG). (2009) Please Mind the Gap: Parkinson’s disease services today: Inquiry into access to health and social care services for people with Parkinson’s disease and their carers. London: APPG. Available from: https://cdn.ps.emap.com/wpcontent/uploads/sites/3/2009/07/APPG_Report_Please_Mind_the_Gap.pdf
[Accessed: 18 November 2018].
Aveyard, H. (2012) Doing a Literature Review in Health and Social Care: A Practical Guide.2nd ed. Berkshire: Open University Press.
Bhogal, P., Mahoney, C., Jager, H.R. (2013) ‘The common dementias: a pictorial review’.
European Radiology. 23 (12), 3405-3417. Available from: doi: 10.1007/s00330-013-3005-9.
[Accessed: 19 September 2018].
Booth, A. (2010) On hierarchies, malarkeys and anarchies of evidence. Health Information and Libraries Journal. 27 (1), 1471-1842. Available from: https://doi.org/10.1111/j.14711842.2010.00879.x [Accessed: 4 January 2019].
Buccheri, R.K., Sharifi, C. (2017) Critical Appraisal Tools and Reporting Guidelines for Evidence-Based Practice. Worldviews on Evidence-Based Nursing. 14 (6), 463-472. Available from: doi: 10.1111/wvn.12258. [Accessed: 4 December 18].
Bukki J., Nubling G., Lorenzl S. (2016) Managing Advanced Progressive Supranuclear Palsy and Corticobasal Degeneration in a Palliative Care Unit: Admission Triggers and Outcomes.
American Journal of Hospice and Palliative Medicine. 33 (5), 477-482.
Cacioppo, S., Grippo, A.J., London, S., Goossens, L., Cacioppo, J.T. (2015) Loneliness: Clinical Import and Interventions. Perspectives on Psychological Science. 10 (2), 238-249.
Clerici, L., Ferrazzoli, D., Maestri, R., Bossio, F., Zivi, L., Canesi, M., Pezzoli, G., Frazzitta, G.
(2017) Rehabilitation in progressive supranuclear palsy: Effectiveness of two multidisciplinary treatments. PLoS ONE. 12 (2), 1-12. Available from: https://doi.org/10.1371/journal.pone.0170927 [Accessed: 16 December 2018].
Critical Appraisal Skills Programme. (2018) CASP Appraisal Checklists. Available from: https://casp-uk.net/casp-tools-checklists/ [Accessed: 2 December 2018].
De Bono, E. (1985) Six Thinking Hats. London: Penguin Books.
Department of Health (DOH). (1997) The new NHS: modern.depenable. Available from:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/266003/newnhs.pdf [Accessed: 23 October 2018].
Dharamsi, S., Charles, G. (2011) Ethnography: Traditional and criticalist conceptions of a qualitative research method. Canadian Family Physician. 57 (3), 378-379.
Eggers, C., Dano, R., Schill, J., Fink, G.R., Hellmich, M., Timmermann, L. (2018) Patientcentered integrated healthcare improves quality of life in Parkinson’s disease patients: a randomised controlled trial. Journal of Neurology. 265 (4), 764-773.
Esposito, P., Canton, A.D. (2014) Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology. World Journal of Nephrology. 3 (4), 249-255. Available from: doi: 10.5527/wjn.v3.i4.249. [Accessed: 15 October 2018].
Fahn, S., Elton, R.L. UPDRS Development Committee. (1987) The Unified Parkinson’s Disease
Rating Scale. In: Fahn, S., Marsden, C.D., Calne, D.B., Goldstein, M. eds. Recent
Developments in Parkinson’s Disease. 2nd ed. New Jersey, USA: Macmillan, pp.153-163.
Ferrazzoli, D., Ortelli, P., Zivi, L., Cian, V., Urso, E., Ghilardi, M.F., Maestri, R., Frazzitta, G. (2018) Efficacy of intensive multidisciplinary rehabilitation in Parkinson’s disease: a randomised controlled study. Journal of Neurology, Neurosurgery and Psychiatry. 89 (8), 828-835.
Flabeau, O., Meissner, W.G., Tison, F. (2010) Multiple system atrophy: current and future approaches to management. Therapeutic Advances in Neurological Disorders. 3 (4), 249-263.
Frundt, O., Mainka, T., Schonwald, B., Muller, B., Dicusar, P., Gerloff, C., Buhmann, C. (2018) The Hamburg Parkinson’s day-clinic: a new treatment concept at the border of in- and outpatient care. Journal of Neural Transmission. 125 (1), 1461-1472. Available from: https://doi.org/10.1007/s00702-018-1918-9. [Accessed: 16 January 2019].
Gage, H. and Storey, L. (2004) Rehabilitation for Parkinson’s disease: a systematic review of available evidence. Clinical Rehabilitation. 18 (5), 463-482. Available from: doi:10.1191/0269215504cr764oa. [Accessed: 7 November 2018].
Gerrish K. and Lathlean, J. (eds.) (2015) The Research Process in Nursing. 7th ed. New Jersey, USA: Wiley-Blackwell.
Global Burden of Disease (GBD) Study. (2015) Global, regional and national burden of neurological disorders during 1900-2015: a systematic analysis for the Global Burden of
Disease Study. The Lancet. 388 (10053), 1448-1449. Available from:
https://doi.org/10.1016/s0140-6736(16)31743-3 [Accessed 3 November 2018].
Goetz, C.G., Poewe, W., Rascol, O., Sampaio, C., Stebbins, G.T., Counsell, C., Giladi, N.,
Holloway, R.G., Moore, C.G., Wenning, G.K., Yahr, M.D., Seidl, L. (2004) Movement Disorder
Society Task Force Report on the Hoehn and Yahr Staging Scale: Status and Recommendations. The Movement Disorder Society Task Force on Rating Scales for
Parkinson’s Disease. Movement Disorders 19 (9), 1020-1028.
Goetz, C.G., Tilley, B.C., Shaftman, S.R., Stebbins, G.T., Fahn, S., Martinez-Martin, P., Poewe,
W., Sampaio, C., Stern, M.B., Dodel, R., Dubois, B., Holloway, R., Jankovic, J., Kulisevsky, J.,
Lang, A.E., Lees, A., Leurgans, S., LeWitt, P.A., Nyenhuis, D., Olanow, C.W., Rascol, O., Schrag, A., Teresi, J.A., van Hilten, J.J., LaPelle, N. (2008) Movement Disorder Societysponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): Scale presentation and clinimetric testing results. Movement Disorders. 23 (15), 2129-2170.
Available from: https://doi.org/10.1002/mds.22340 [Accessed 7 November 2018].
Goldstein, C., Weijer, C., Brehaut, J.C., Campbell, M.K., Fergusson, D.A., Grimshaw, J., Hemming, K., Horn, A., Taljaard, M. (2018) Accommodating quality and service improvement research within existing ethical principles. Trials. 19 (334), 1-6. Available from: https://doi.org/10.1186/s13063-018-2724-2 [Accessed: 16 January 2019].
Hoehn, M.M. and Yahr, M.D. (1967) Parkinsonism: onset, progression, and mortality.
Neurology. 17 (5), 427- 442. Available from:
https://n.neurology.org/content/neurology/17/5/427.full.pdf [Accessed 15 October 2018].
Hohler, D. A., Tsao, J.M., Katz, D.I., DiPiero, T. J., Hehl, C.L., Leonard, A., Allen, V., Gardner,
M., Phenix, H., Saint-Hilaire, M., Ellis, T. (2012). Effectiveness of an Inpatient Movement Disorders Program for Patients with Atypical Parkinsonism. Parkinson’s Disease. 26 (2), 144150. Available from: https://doi.org/10.1155/2012/871974 [Accessed: 16 December 2018].
Institute for Healthcare Improvement (IHI). (2014) Comparing Lean and Quality
Improvement. Available from:
https://lidz.nl/wpcontent/uploads/2018/01/IHIComparingLeanandQIWhitePaper-002.pdf [Accessed 4 January 2019].
Jenkinson, C., Fitzpatrick, R., Peto, V., Greenhall, R., Hyman, N. (1997) The Parkinson’s Disease Questionnaire (PDQ-39): development and validation of a Parkinson’s disease summary index score. Age and Ageing.26 95) 353-357.
Johnston, M. and Chu, E. (2010) Does attendance at a multidisciplinary outpatient rehabilitation program for people with Parkinson’s disease produce quantitative short term or long term improvements? A systematic review. NeuroRehabilitation. 26 (4), 375-383.
Available from: doi:10.3233/NRE-2010-0575. [Accessed: 19 September 2018].
Lamb, R., Rohrer, J.D., Lees, A.J., Morris, H. R. (2016). Progressive Supranuclear Palsy and
Corticobasal Degeneration: Pathophysiology and Treatment Options. Current Treatment Options in Neurology. 18 (42), 1-18.
Langley, G.J, Moen, R., Nolan, K.M., Nolan, T.W., Norman, C.L., Provost, L.P. (2009) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: John Wiley & Sons.
Lee, J., Choi, M., Yoo, Y. (2017) A Meta-Analysis of Nonpharmacological Interventions for People With Parkinson’s Disease. Clinical Nursing Research. 26 (5), 608-631.
Lindop, F., Brown, L., Graziano, M., Jones, D. (2014). Atypical Parkinsonism: Making the case for a neuropalliative rehabilitation approach. International Journal of Therapy and Rehabilitation.21 (4), 176-182.
Litvan, I. (2005) Atypical Parkinsonian Disorders: Clinical and Research Aspects. New Jersey:
Humana Press.
Low, V., Ben-Shlomo, Y., Coward, E., Fletcher, S., Walker, R., Clarke, C.E. (2015) Measuring the burden and mortality of hospitalisation in Parkinson’s disease: A cross-sectional analysis of the English Hospital Episodes Statistics database 2009-2013. Parkinsonism and Related Disorders. 21 (5), 449-454.
Ludolph, A.C., Kassubek, J., Landwehrmeyer, B.G., Mandelkow, E., Mandelkow, E.M., Burn,
D.J., Caparros-Lefebvre, D., Frey, K.A., De Yebenes, J.G., Gasser, T., Heutink, P., Hoglinger, G.,
Jamrozik, Z., Jellinger, J.A., Kazantsev, A., Kretzschmar, H., Lang, A.E., Litvan, I., Lucas, J.J.,
McGeer, P.L., Melquist, S., Oertel, W., Otto, M., Paviour, D., Reum, T., Sint-Raymond, A.,
Steele, J.C., Tolnay, M., Tumani, H., Van Swieten, J.C., Vanier, M.T., Vonsattel, J.P., Wagner, S., Wszolek, Z.K. (2009) Tauopathies with parkinsonism: clinical spectrum, neuropathologic basis, biological markers and treatment options. European Journal of Neurology. 16 (3), 297309.
Marck, M.A. van der., Bloem, B.R., Borm, G.F., Overeem, S., Munneke, M., Guttman, M.
(2013) Effectiveness of Multidisciplinary Care for Parkinson’s disease: A Randomised, Controlled Trial. Movement Disorders. 28 (5), 605-611.
McKeith,I.G., Boeve,B.F., Dickson, D.W., Halliday, G., Taylor, J.P, Weintraub, D., Aarsland, D.,
Galvin, J., Attems, J., Ballard, C.G., Bayston, A., Beach, T.G., Blanc, F., Bohnen, N., Bonanni,
L., Bras, J., Brundin, P., Burn, D., Chen-Plotkin, A., Duda, J.E., El-Agnaf, O., Feldman, H.,
Ferman, T.J., Ffytche, D., Fujishiro, H., Galasko, D., Goldman, J.G., Gomperts, S.N., Graff-
Radford, N.R., Honig, L.S., Iranzo, A., Kantarci, K., Kaufer, D., Kukull, W., Lee, V.M.Y.,
Leverenz, J.B., Lewis, S., Lippa, C., Lunde, A., Masellis, M., Masliah E., McLean, P.,
Mollenhauer, B., Montine, T.J., Moreno, E., Mori, E., Murray, M., O’Brian, J.T., Orimo, S.,
Postuma, R.B., Ramaswamy, S., Ross, O.A., Salmon, D.P., Singleton, A., Taylor, A., Thomas,
A., Tiraboschi, P., Toledo, J.B., Trojanowski, J.Q., Tsuang, D., Walker, Z., Yamada, M., Kosaka,K. (2005) ‘Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium’. Neurology. 65 (12), 1863-1872.
Meijer, F.T.A, Goraj, B., Bloem, B.R., Esselink, R.A.J. (2017) Clinical Application of Brain MRI in the Diagnostic Work-up of Parkinsonism. (2017) Journal of Parkinson’s Disease. 7 (2), 211217.
Monticone, M., Ambrosini, E., Laurini, A., Rocca, B., Foti, C. (2015) In-Patient
Multidisciplinary Rehabilitation for Parkinson’s disease: A Randomised Controlled Trial.
Movement Disorders. 30 (8), 1050-1058.
Murad, M.H., Asi, N., Alsawas, M., Alahdab, F. (2016) New Evidence Pyramid. Evidence Based Medicine. 21 (4), 125-127. Available from: https://dx.doi.org/10.1136/ebmed-2016110401 [Accessed: 4 December 2018].
Murdock, C., Cousins, W., Kernohan, W.G. (2015) “Running water won’t freeze”: How people with advanced Parkinson’s disease experience occupation. Palliative and Supportive Care. 13 (5), 1363-1372.
National Institute for Health and Care Excellence (NICE). (2017) Parkinson’s disease in adults: diagnosis and management. NICE guideline NG71. Available from:
https://www.nice.org.uk/guidance/ng71/evidence/full-guideline-pdf-4538466253 [Accessed: September 2018].
National Leadership and Innovation Agency for Healthcare (2010) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales. Available from:
https://www.wales.nhs.uk/sitesplus/documents/829/NLIAH%20Advanced%20Practice%20F ramework.pdf [Accessed: 18 November 2018].
Neurological Conditions Implementation Group. (2017) Neurological Conditions Delivery
Plan. Welsh Government. Available from:
https://gov.wales/topics/health/nhswales/plans/neurological [Accessed: 2 December 2018].
NHS Health Research Authority. (2019) Planning and improving research: Best PracticeOutcome Measures. Available from: https://www.hra.nhs.uk/planning-and-improvingresearch/best-practice/outcome-measures/ [Accessed: 4 January 2020].
NHS Health Research Authority. (2017) UK policy framework for health and social care research. Available from: file:///C:/Plots/Final_Accessibility_uk-policy-framework-healthsocial-care-research_.pdf [Accessed: January 16 2019].
NHS Improvement ACT Academy. (2018) Online library of Quality, Service Improvement and
Redesign tools: Run Charts. Available from:
https://improvement.nhs.uk/documents/2157/run-charts.pdf [Accessed: 2 December 2019].
NHS Institute for Innovation and Improvement. (2017) Thinking Differently. Available from:
https://improvement.nhs.uk/documents/1485/thinking_differently.pdf [Accessed: 23
October 2018].
NHS Wales “1000 Lives” Improvement. (2014) The Quality Improvement Guide: The
Improving Quality Together Edition. Available from:
http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Quality%20Improveme nt%20Guide%20-%203rd%20edition%20%28IQT%29%20WEB.pdf [Accessed: 19 September 2019].
Nursing and Midwifery Council (NMC). (2018). The Code. Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available from:
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf [Accessed: 16 January 2019].
Parahoo, k. (2014). Nursing Research: Principles, Process and Issues. 3rd ed. Hampshire:
Palgrave Macmillan.
Parkinson’s UK. (2018) The Incidence and Prevalence of Parkinson’s In The UK: Results from the Clinical Practice Research Datalink Summary report. Available from:
https://www.parkinsons.org.uk/sites/default/files/2018-
01/CS2960%20Incidence%20and%20prevalence%20report%20branding%20summary%20re
port.pdf [Accessed: 4 January 2019].
Parkinson’s UK. (2017) The UK Parkinson’s Audit 2017-Identifying Improvements and
Opportunities for Change. Available from: https://www.parkinsons.org.uk/professionals/news/uk-parkinsons-audit-2017-identifyingimprovements-and-opportunities-change [Accessed: 18 November 2018].
Peel, C.L., Chand, D., Thomas, S., Wilkinson, N.C.M. (2019). Developing a staged Year of Care model for progressive supranuclear palsy. British Journal of Neuroscience Nursing. 8 (3),
129-136.
Polit, D. and Beck, C. T. (2018) Essentials of Nursing Research: Appraising Evidence for Nursing Practice.9th ed. Philadelphia, USA: Lippincott Williams and Wilkins.
Portillo, M.C. and Cowley, S. (2010). Working the way up in neurological rehabilitation: the holistic approach of nursing care. Journal of Clinical Nursing. 20 (11), 1731-1743.
Post, B., van der Eijk, M., Munneke, M., Bloem, B.R. (2011) Multidisciplinary care for
Parkinson’s disease: not if, but how! Postgraduate Medical Journal. 87 (1031), 575-578.
Post, M. (2014) Definitions of Quality of Life: What Has Happened and How to Move On.
Rehabilitation. 20 (3), 167-180. Available from: https://doi.org/10.1310/sci2003-167 [Accessed: 4 December 2018].
PRISMA (2015) Transparent Reporting of Systematic Reviews and Meta-Analysis (PRISMA) website. Available from: http://www.prisma-statement.org/ [Accessed: 4 December 2018].
Prizer, P. L., Browner, N. (2012) The Integrative Care of Parkinson’s Disease: A systematic Review. Journal of Parkinson’s Disease. 2 (2), 79-86. Available from: doi;10.3233/JPD-201212075. [Accessed: 4 January 2019].
Rebeiz, J.J., Kolodny, E.H., Richardson, E.P. (1968) ‘Corticodentatonigral Degeneration with
Neuronal Achromasia’. Archives of Neurology. 18 (1), 20-33. Available from:
Doi:10.1001/arch-neur.1968.0047034003. [Accessed: 19 September 2018].
Rooney, J., Byrne, S., Heverin, M., Tobin, K., Dick, A., Donaghy, C., Hardiman, O. (2015) A multidisciplinary clinic approach improves survival in ALS: a comparative study of ALS in Ireland and Northern Ireland. Journal of Neurology, Neurosurgery and Psychiatry. 86 (5), 496-501. Available from: doi:10.1136/jnnp-2014-309601. [Accessed: 2 December 2018].
Rozenblum, R., Donze, J., Hockey, P.M., Guzdar, E., Labuzetta, M.A., Zimlichman, E., Bates,
D.W. (2013) The Impact of Medical Informatics on Patient Satisfaction: A USA –based Literature Review. International Journal of Medical Informatics. 82 (3), 141-158.
Schrag, A., Wenning, G.K., Quinn, N., Benshlomo, Y. (2008) Survival in multiple system atrophy. Movement Disorders. 23 (2), 264-269
Schulz-Schaeffer, W.J. (2010) The synaptic pathology of a-synuclein aggregation in dementia with Lewy bodies, Parkinson’s disease and Parkinson’s disease dementia. ACTA Neuropathologica. 120 (2), 131-143. Available from: doi:10.1007/s00401-010-0711-0.
[Accessed: 23 October 2018].
Steele, J.C., Richardson, J.C., Olszewski, J. (1964) A Hetrogenous Degeneration Involving the
Brain Stem, Basal Ganglia and Cerebellum with Vertical Gaze and Pseudobulbar Palsy, Nuchal Dystonia and Dementia. Archives of Neurology. 10 (4), 333-359. Available from:
doi:10.1001/arch-neur.1964.00460160003001. [Accessed: 18 November 2018].
Szekely, B.C., Kosanovich, N.N, Sheppard, W. (1982) Adjunctive Treatment in Parkinson’s Disease: Physical Therapy and Comprehensive Group Therapy. Rehabilitation Literature. 43
(4), 72-76.
Tan, S. B., Williams, A. F., Kelly, D. (2014) Effectiveness of multidisciplinary interventions to improve the quality of life for people with Parkinson’s disease: A systematic review.
International Journal of Nursing Studies. 51 (1), 166-174.
Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., Reed, J.E. (2014) Systematic review of the application of the plan-do-study-act method to improve quality in healthcare.
British Medical Journal Quality Safety. 23 (4), 290-298.
The Health Foundation. (2013) Quality improvement made simple: What everyone should know about health care quality improvement. The Health Foundation. Available from: https://www.health.org.uk/sites/default/files/QualityImprovementMadeSimple.pdf [Accessed: 15 October 2018].
The Health Foundation. (2015) ‘Shaping the future: A strategic framework for a successful NHS. The Health Foundation. Available from: www.health.org.uk/puplication/shapingfuture#sthash.NgOAhVGC.dpufwww.health.org.uk/publication/shaping-future [Accessed: 16 December 2018].
The Multiple System Atrophy Coalition 1989-2019. (2019) The History of Multiple System Atrophy: Formally Shy-Drager Syndrome (SDS). Available from:
https://www.multiplesystematrophy.org/about-msa/history-multiple-system-atrophyformerly-shy-drager-syndrome-sds/ [Accessed: 4 January 2019).
The Wales Audit Office Study Team. (2018) Management of Follow-Up Outpatients Across Wales. Wales Audit Office. Available from: https://www.audit.wales [Accessed: 14 February 2019].
Tiwari, D., Amar, K. (2008) A case of corticobasal degeneration presenting with alien limb syndrome. Age and Ageing. 37 (5), 600-601. Available from: https://doi.org/10.1093/ageing/afn103 [Accessed: 16 January 2019].
Tokumaru, A.M., Murayama, S.S, Kazutomi, K., Sakiyama, Y., Toyoda, M., Yamakawa, M., Terada, H. (2009) ‘Imaging-Pathologic Correlation in Corticobasal Degeneration’. American
Journal of Neuroradiology. 30 (10), 1884-1892. Available from: https://doi.org/10.3174/ajnr.A1721 [Accessed: 2 December 2018].
Traistaru, R., Kamal, D., Kamal, C., Rogoveanu, O., Bumbea, A.M. (2017) Rehabilitation in elderly patients with Parkinsonism. Civilization and Sport. 18 (4), 185-191.
Trend, P., Kaye, J., Gage, H., Owen, C., Wade, D. (2002) Short-term effectiveness of intensive rehabilitation for people with Parkinson’s disease and their carers. Clinical Rehabilitation. 16
(7), 717-725.
Waltz, C.F., Strickland, O.L., Lenz, E.R. (2010) Measurement in Nursing and Health Research.
4th ed. New York: Springer.
Welsh Assembly Government (WAG). (2010) Doing Well, Doing Better: Standards for Health
Services in Wales. Available from:
http://www.wales.nhs.uk/sites3/Documents/919/ENGLISH%20WEB%20VERSION.pdf [Accessed: 4 January 2019].
Welsh Government (WG). (2015) Health and Care Standards. Available from: https://gov.wales/sites/default/files/publications/2019-05/health-and-care-standards-april-
2015.pdf [Accessed: 18 November 2018].
Welsh Government (WG). (2017) Neurological Conditions Delivery Plan: High standard of care for everyone with a neurological condition. Available from:
https://gov.wales/sites/default/files/publications/2019-02/neurological-conditions-deliveryplan-july-2017.pdf [Accessed: 19 September 2018].
Welsh Government (WG). (2019) NHS Activity and Performance Summary March/April 2019. Available from: https://gov.wales/sites/default/files/statistics-and-research/2019-05/nhsactivity-and-performance-summary-march-and-april-2019-764.pdf [Accessed: 6 May 2019].
Welsh Government (WG). (2011) Together for Health: A Five Year Vision for the NHS in Wales. Available from: http://www.wales.nhs.uk/sitesplus/documents/829/togetherforhealth.pdf [Accessed: 18 November 2018].
Welsh Government (WG). (2012) Achieving Excellence: The Quality Delivery Plan for the NHS in Wales. Available from:
http://www.wales.nhs.uk/sitesplus/documents/1064/Achieving%20Excellence%20%E2%80 %93%20The%20Quality%20Delivery%20Plan%20for%20NHS%20Wales%202012%20-16.pdf [Accessed: 4 December 2018].
Welsh Government (WG). (2013) Safe Care, Compassionate Care: A National Governance Framework to enable high quality care in NHS Wales. Available from: http://www.wales.nhs.uk/sitesplus/documents/1064/Safe%20Care%20Compassionate%20C are%20-%20English%20Final%20version%20for%20publication%20%20January%202013%20%282%29.pdf [Accessed: 4 December 2018].
Welsh Government (WG). 2015. My Health in My Hands: Public and Patient Guide to Individual Care Plans for People with Long Term Conditions. Available from:
https://gov.wales/docs/dhss/publications/150324long-termen.pdf [Accessed: 4 January 2019].
Whiffin, C.J., Hasselder, A. (2013) Making the Link Between Critical Appraisal, Thinking and Analysis. British Journal of Nursing. 22 (14), 831-835.
Whitehurst, D.G.T, Noonan, V.K., Dvorak, M.F.S., Bryan, S. (2012) A review of preferencebased health-related quality of life questionnaires in spinal cord injury research. Spinal Cord. 50 (9), 646-654. Available from: https://doi.org/10.1038/sc.2012.46 [Accessed: 10 March 2019].
Zigmond, A.S, Snaith, R.P. (1983) The Hospital Anxiety and Depression Scale. Acta
Psychiatrica Scandinavica. 67 (6), 361-370. Available from: https://psycnet.apa.org/doi/10.1111/j.1600-0447.1983.tb09716.x [Accessed: 16 January 2019].
Criminal justice
10 pages + well-structured + cited references
Description
This is a literature-based criminology dissertation.
A socio-cultural analysis of attitude toward punishment and rehabilitation between the UK and Sweden.
What are the differences in the rehabilitation of prisoners between the UK prison system and the Swedish prison
system and are they culturally dependent?
A critical comparison of that underlying culture.
Can the UK system learn something from the Swedish system?
A source that was recommended to me is a chapter about socialisation in a book called Sociology – by Fulcher
and Scott.
If you find there to be more/better sources on Norway rather than Sweden, you can use Norway instead if you
wish. But please pick only one to focus on and compare with the UK.
Please ensure any direct quotes used are cited with page numbers.
Please see the file attached to see the word count structure.
How can Bitcoin and cryptocurrencies be decentralized, governed, and regulated in the United Kingdom and across the world
How can Bitcoin and cryptocurrencies be decentralized, governed, and regulated in the United Kingdom and
across the world
Task Details/Description:
Using the concepts and theories referencing the following
Anderson, L. et al. (2015). A Guide to Professional Doctorates in Business and Management. Chapter 1. Sage.
Van de Ven, A. (2007). Engaged Scholarship. Chapter 1. Oxford
Van de Ven, A. (2007). Engaged Scholarship. Oxford. Chapters 3–4.
Van de Ven, A. (2007). Engaged Scholarship, p. 163. Oxford.
The Vitae Researcher Development Framework (RDF) website.
Anderson, L. et al. (2015). A Guide to Professional Doctorates in Business and Management. Chapter 6. Sage.
The Vitae Researcher Development Framework (RDF) website.
Anderson, L.M., Gold, J., Stewart, J.D. and Thorpe, R. (2015). Professional Doctorates in Business and
Management. Sage.
Cunliffe, A.L. (2004). On Becoming a Critically Reflexive Practitioner. Journal of Management Education, 28,
pp. 407–426.
Cunliffe, A.L. and Easterby-Smith, M. (2004). From Reflection to Practical Reflexivity. Organizing Reflection.
Ashgate.
Dall’Alba, G. (2009). Learning Professional Ways of Being: Ambiguities of Becoming. Educational Philosophy
and Theory, 41, pp. 34–45.
Pollner, M. (1991). Left of Ethnomethodology: The Rise and Decline of Radical Reflexivity. American
Sociological Review, 370.
Van de Ven, A. (2007). Engaged Scholarship. Chapter 2. Oxford.
Anderson, L. et al. (2015). A Guide to Professional Doctorates in Business and Management. Chapters 2–5
(Section A: Designing and constructing DBA research). Sage
Write a report which will reflect upon how the research “ How can Bitcoin and cryptocurrencies be
decentralised, governed, and regulated in the United Kingdom and across the world “will deliver impact to the
financial services organisation and end consumer and the practice of management.
For this report:
Use the concept of the scholar-practitioner. You may have read about different modes of research in which you
are both researching a complex problem in an organizational setting, whilst at the same time potentially working
within and effecting change in the financial services organization.
In this report , you are asked to reflect on how the research, “ How can Bitcoin and cryptocurrencies be
decentralized, governed, and regulated in the United Kingdom and across the world “will impact on the financial
organization(s) and the end consumer you are working with, and more generally, how might the research impact
on the practice of management in general.
Please use relevant theories and concepts that are well known and included in the referencing reading outlined
above.
Demonstrate in the report how the research design will deliver this impact.
Presentation Requirements:
• Word Count: 2000 words (excluding references)
• Font Size: Times New Roman size 12
• Line Spacing: 2 (Double space)
• Format Harvard
• Tables: APA style
Does participation in eight sessions of a brief mindfulness exercise effect depression, anxiety and stress scores in university students undertaking first year psychology?
Overview of tasks
Task: Lab Report
Length: No more than 1700 words in total, part A 750 words and part B another 950 words approximately.
Microsoft Word document (No PDFs)
Details of the task
Concept and Goal
The aim of this laboratory study is to investigate whether participation for eight days in a brief mindfulness
intervention alters depression, anxiety and stress levels in university students. We have collected data during two
classes, and in between you have been asked to undertake a 10 minute (brief) mindfulness exercise each day,
focussing on your breathing. You should have also collected data from one participant who has not undertaken the
mindfulness program. The collected data will be analysed and written up in the form of a laboratory report.
Background
Mindfulness describes the practise of paying non-judgemental and accepting attention to what is happening in the
present moment. Mindfulness therapies are designed to guide a person to direct their attention specifically towards
what is happening “right now”, and moving the mind back towards the present should it drift. It has its roots in
Eastern religious practises, and is often used to induce deep relaxation. This type of therapy has grown substantially
in recent times and is widely researched and used by psychologists to treat a diverse range of disorders. This picture
provides a good illustration of mindfulness (from http://www.transition.hw.ac.uk/mindfulness/).
In this research activity, we will investigate whether participation in eight sessions of a 10 minute mindfulness
exercise affects scores on a questionnaire that measures symptoms of depression, anxiety, and stress. Outcomes will
be compared both before (at baseline) and after (post-mindfulness) students have taken part in the exercise. Baseline
student data will also be compared to results collected from a community sample who have not specifically
undertaken mindfulness (control data). This will allow us to assess whether our student cohort started the program at
levels of depression, anxiety and stress that are equal to, lower, or higher than the community sample.
Research Questions
- Do university students undertaking first year psychology show similar scores on a measure of depression,
anxiety and stress compared to control participants? - Does participation in eight sessions of a brief mindfulness exercise effect depression, anxiety and stress scores
in university students undertaking first year psychology?
