Abstract
To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. Observation was conducted for 300hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.
Highlights
Sub-optimal care of the deteriorating ward patient was first reported in the academic literature over 20 years ago (McQuillan et al, 1998)
The afferent limb is modelled on evidence that at least 60% of patients who deteriorate in hospital have antecedent changes in vital signs preceding serious adverse event (SAE) (Andersen et al, 2016; Kause et al, 2004)
Based on methodological precedent (Mackintosh, Humphrey, & Sandall, 2014), we proposed to observe for 180 hr on different days of the week and at different times of day and night, or until data saturation was achieved
Summary
Sub-optimal care of the deteriorating ward patient was first reported in the academic literature over 20 years ago (McQuillan et al, 1998). The afferent limb is modelled on evidence that at least 60% of patients who deteriorate in hospital have antecedent changes in vital signs preceding SAE (Andersen et al, 2016; Kause et al, 2004). To develop a theory-based intervention, clear specification of target behaviours is required to enable measurement of behaviour change in subsequent intervention testing (Atkins et al, 2017; Presseau et al, 2019). To specify expected behaviours of the afferent limb, a documentary analysis of policy and guidelines was carried out (Smith, Sekhon, Francis, & Aitken, 2019) using a simple behaviour specification framework incorporating five elements (action, actor, context, target, time – AACTT) (Presseau et al, 2019). To specify expected behaviours of the afferent limb, a documentary analysis of policy and guidelines was carried out (Smith, Sekhon, Francis, & Aitken, 2019) using a simple behaviour specification framework incorporating five elements (action, actor, context, target, time – AACTT) (Presseau et al, 2019). 3 | THE STUDY
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