Abstract
BackgroundThere is evidence of unsafe care in healthcare systems globally. Interventions to implement recommended practice often have modest and variable effects. Ideally, selecting and adapting interventions according to local contexts should enhance effects. However, the means by which this can happen is seldom systematic, based on theory, or made transparent. This work aimed to demonstrate the applicability, feasibility, and acceptability of a theoretical domains framework implementation (TDFI) approach for co-designing patient safety interventions.MethodsWe worked with three hospitals to support the implementation of evidence-based guidance to reduce the risk of feeding into misplaced nasogastric feeding tubes. Our stepped process, informed by the TDF and key principles from implementation literature, entailed: involving stakeholders; identifying target behaviors; identifying local factors (barriers and levers) affecting behavior change using a TDF-based questionnaire; working with stakeholders to generate specific local strategies to address key barriers; and supporting stakeholders to implement strategies. Exit interviews and audit data collection were undertaken to assess the feasibility and acceptability of this approach.ResultsFollowing audit and discussion, implementation teams for each Trust identified the process of checking the positioning of nasogastric tubes prior to feeding as the key behavior to target. Questionnaire results indicated differences in key barriers between organizations. Focus groups generated innovative, generalizable, and adaptable strategies for overcoming barriers, such as awareness events, screensavers, equipment modifications, and interactive learning resources. Exit interviews identified themes relating to the benefits, challenges, and sustainability of this approach. Time trend audit data were collected for 301 patients over an 18-month period for one Trust, suggesting clinically significant improved use of pH and documentation of practice following the intervention.ConclusionsThe TDF is a feasible and acceptable framework to guide the implementation of patient safety interventions. The stepped TDFI approach engages healthcare professionals and facilitates contextualization in identifying the target behavior, eliciting local barriers, and selecting strategies to address those barriers. This approach may be of use to implementation teams and policy makers, although our promising findings confirm the need for a more rigorous evaluation; a balanced block evaluation is currently underway.
Highlights
There is evidence of unsafe care in healthcare systems globally
We describe how the theoretical domains framework (TDF) was operationalized using co-production and implementation principles, and applied to three UK hospitals to improve the implementation of a patient safety guideline promoting safe nasogastric feeding
Target behavior Following discussions with the implementation teams and ward staff, and assessment of audit results (Table 2), each hospital decided that the target behavior for change would be for staff to check pH first line
Summary
There is evidence of unsafe care in healthcare systems globally. Interventions to implement recommended practice often have modest and variable effects. Other harm results from deviations from guidelines and policies; only between 50 and 70% of patients receive recommended care [6,7]. Interventions to change professional behavior have modest and variable effects [8]. This variability is problematic because it limits the ability to predict with any confidence whether an intervention will work for a given problem and context [9]. The reported modest effects may be the result of problems with the ways by which interventions are selected. The theory underpinning healthcare professional behavior change interventions is seldom explicated, thereby limiting the ability to generalize from one context to another [11]. Standardized ‘top down’ interventions may lack flexibility to respond to local barriers and circumstances [12,13]
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