Table 1

Application of ethical considerations to QI project examples

Project 1: low risk to patients and staff Improving the efficiency of invoicing processes for the procurement of agency nursing staff
Description Providing agency nursing staff typically requires creating formal and informal agreements with local and national specialist recruitment agencies. Improving the flow of the payment process for nursing agencies decreases the number of queries and increases the speed and efficiency of processing payments. This project also aimed to increase relationships between nursing agencies and healthcare organisations.
Improvement activities	Ethical considerations
System diagnostic using available data.	No direct patient involvement.
Analysis of human factors.	Staff engagement required as individual performance data and human factors analysis required.
Process mapping.	Publication of data anonymised.
Tests of change included: (1) Ensured that all managers sourced agency workers through the staffing solutions team; (2) All shifts were added to the appropriate system; (3) Raised awareness to all appropriate managers that all agency shifts should be adjusted and finalised.
End to end process re-engineering.

Project 2: potential moderate risk to patients and staff Well-being Wednesdays: nurse-led clinic for improving physical healthcare in a general adolescent inpatient unit23
Description Young people with mental illness are at high risk of physical health complications. The reason for this includes not seeking treatment for physical health issues, engaging in unhealthy behaviours (eg, drug use, smoking, poor sleep, poor diet and sedentary behaviour), and side effects associated with certain medication for psychiatric treatment. The project aim was to establish a well-being clinic to improve the efficiency and quality of physical healthcare and health promotion offered to young people.
Improvement activities	Ethical considerations
Carry out a system diagnostic using patient data via clinical audit for baseline measures, multidisciplinary staff engagement and patient engagement in codesigning the Well-being Wednesday Clinic.	Balance patient involvement in codesign when exploring feasibility against possible safeguarding concerns, particularly when patients are acutely unwell and detained under the Mental Health Act (MHA) 1983.
	Staff engagement to open discussions around capacity, capability and confidence in additional professional duties associated with physical health.
	Compliant with the Data Protection Act (2018).
Tests of change included: (1) Establishment of a well-being Wednesday physical health clinic with associated physical parameters and measures; (2) Modified the clinic, established a well-being board and created specific physical health plans and blood test protocols; (3) Made links to other associated services (eg, school nurses, sexual health) and further specific training (eg, phlebotomy, ECG and vaccinations) to enhance the offerings. A second nurse was appointed to lead the clinic.	Promote the benefits of additional checks to patients and empower their participation in their own physical health. Ensure buy-in from the team regarding the importance of physical health measures. Provide training and related policies to improve the competence and confidence of staff. Feedback to ensure the clinic is ‘fit for purpose’ and avoid duplication of administrative tasks. Increased documentation detracts from direct care. Involve related services to ensure patient care being immediate staff’s professional boundaries.

Project 3: Potential high risk to patients, families, public and staff Absconding: Reducing failure to return in adult mental health wards24
Description When patients fail to return from Section 17 (MHA, 1983) leave or informal time away from the ward as part of their planned recovery process, it may result in negative consequences to patients, family and staff. Tests of change to promote positive risk-taking included a signing in and out book, individual safe leave forms, patient information leaflets, appointment cards with agreed return times and contact numbers, intentional rounding, and visual procedural guidance for staff. These tests of change increased the rates of patients returning from leave at the agreed time.
Improvement activities	Ethical considerations
Carry out a system diagnostic using patient data, patient experiences, ward observations, process mapping with the staff team.	Direct patient involvement in co-design when patients are acutely unwell and detained under the MHA 1983. Mental Capacity Act implications for practice, including issues of capacity to consent to participate. Recording of participation and consent.
	Staff engagement to open discussions about ward culture regarding leave procedures standards and the importance of managing and negotiating leave well and collecting data in practice. Recording of participation and consent.
	Ensure family engagement in the re-designed process, including enhanced safety checks with family and possible impact.
	Compliant with the Data Protection Act (2018).
Tests of change included: (1) Signing in and out record; (1) Individually completed safe leave forms for discussion at ward rounds; (2) Improved patient information leaflets; (3) Appointment cards to prompt return to the ward; (4) Intentional rounding to assertively manage the leave process every hour.	Balance of autonomy versus security in the context of individualised risk assessment and the advocacy-paternalism continuum. Clearly communicate the new procedure with compassion. Tensions between staff and patients may arise during early implementation.
	The organisational policy was rewritten to clarify the definition of missing and absent without official leave to protect staff and patients. Agreement between Police and staff to ensure a standard response time and action for every patient who fails to return. Standardised practice increases the time for direct care.
	Increased documentation time detracts from direct care.
	Use of plain English and all necessary languages in the information.
	Provided unidentifiable ‘appointment cards’ in case of loss during the leave period.
	Intentional rounding may be perceived as intrusive or irritating for patients. It, therefore, requires a sensitive approach.

QI, quality improvement.