Melbourne School of Health Sciences Collected Works - Research Publications
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ItemUnderstanding context: A concept analysis(sic)(sic)(sic)(sic):(sic)(sic)(sic)(sic)(WILEY, 2019-12)AIMS: To conduct a concept analysis of clinical practice contexts (work environments) in health care. BACKGROUND: Context is increasingly recognized as important to the development, delivery, and understanding of implementation strategies; however, conceptual clarity about what comprises context is lacking. DESIGN: Modified Walker and Avant concept analysis comprised of five steps: (1) concept selection; (2) determination of aims; (3) identification of uses of context; (4) determination of its defining attributes; and (5) definition of its empirical referents. METHODS: A wide range of databases were systematically searched from inception to August 2014. Empirical articles were included if a definition and/or attributes of context were reported. Theoretical articles were included if they reported a model, theory, or framework of context or where context was a component. Double independent screening and data extraction were conducted. Analysis was iterative, involving organizing and reorganizing until a framework of domains, attributes. and features of context emerged. RESULT: We identified 15,972 references, of which 70 satisfied our inclusion criteria. In total, 201 unique features of context were identified, of these 89 were shared (reported in two or more studies). The 89 shared features were grouped into 21 attributes of context which were further categorized into six domains of context. CONCLUSION: This study resulted in a framework of domains, attributes and features of context. These attributes and features, if assessed and used to tailor implementation activities, hold promise for improved research implementation in clinical practice.
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ItemHow actionable are staff behaviours specified in policy documents? A document analysis of protocols for managing deteriorating patients(WILEY, 2019-11)BACKGROUND: To optimise care of deteriorating patients, healthcare organisations have implemented rapid response systems including an "afferent" and "efferent" limb. Afferent limb behaviours include monitoring vital signs and escalating care. To strengthen afferent limb behaviour and reduce adverse patient outcomes, the National Early Warning Score was implemented in the UK. There are no published reports of how National Early Warning Score guidance has translated into trust-level deteriorating patient policy and whether these documents provide clear, actionable statements guiding staff. AIM: To identify how deteriorating patient policy documents provide "actionable" behavioural instruction for staff, responsible for actioning the afferent limb of the rapid response system. DESIGN: A structured content analysis of a national guideline and local policies using a behaviour specification framework. METHODS: Local deteriorating patient policies were obtained. Statements of behaviour were extracted from policies; coded using a behaviour specification framework: Target, Action, Context, Timing and Actor and scored for specificity (1 = present, nonspecific; 2 = present, specific). Frequencies and proportions of statements containing elements of the Target, Action, Context, Timing and Actor framework were summarised descriptively. Reporting was guided by the COREQ checklist. RESULTS: There were more statements related to monitoring than escalation behaviour (65% vs 35%). Despite high levels of clear specification of the action (94%) and the target of the behaviour (74%), context, timing and actor were poorly specified (37%, 37% and 33%). CONCLUSION: Delay in escalating deteriorating patients is associated with adverse outcomes. Some delay could be addressed by writing local protocols with greater behavioural specificity, to facilitate actionability. RELEVANCE TO CLINICAL PRACTICE: Numerous clinical staff are required for an effective response to patient deterioration. To mitigate role confusion, local policy writers should provide clear specification of the actor. As the behaviours are time-sensitive, clear specification of the time frame may increase actionability of policy statements for clinical staff.
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ItemDEveloping a Complex Intervention for DEteriorating patients using theoretical modelling (DECIDE study): Study protocol(WILEY, 2019-09)AIM: To develop a theory-based complex intervention (targeting nursing staff), to enhance enablers and overcome barriers to enact expected behaviour when monitoring patients and responding to abnormal vital signs that signal deterioration. DESIGN: A mixed method design including structured observations on hospital wards, field notes, brief, unrecorded interviews and semi-structured interviews to inform the development of an intervention to enhance practice. METHODS: Semi-structured interviews will be conducted with nursing staff using a topic guide informed by the Theoretical Domains Framework. Semi-structured interviews will be transcribed verbatim and coded deductively into the 14 Theoretical Domains Framework domains and then inductively into "belief statements". Priority domains will be identified and mapped to appropriate behaviour change techniques. Intervention content and mode of delivery (how behaviour change techniques are operationalized) will be developed using nominal groups, during which participants (clinicians) will rank behaviour change techniques/mode of delivery combinations according to acceptability and feasibility. Findings will be synthesised to develop an intervention manual. DISCUSSION: Despite being a priority for clinicians, researchers and policymakers for two decades, "sub-optimal care" of the deteriorating ward patient persists. Existing interventions have been largely educational (i.e. targeting assumed knowledge deficits) with limited evidence that they change staff behaviour. Staff behaviour when monitoring and responding to abnormal vital signs is likely influenced by a range of mediators that includes barriers and enablers. IMPACT: Systematically applying theory and evidence-based methods, will result in the specification of an intervention which is more likely to result in behaviour change and can be tested empirically in future research.
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ItemCan we do better? Bridging the research to practice gap in patient blood management–optimizing ‘audit & feedback’ and the challenges of undertaking a national cluster‐randomized controlled trial(Wiley, 2019-02)Audit and Feedback (A&F) is a frequently used quality improvement strategy, which aims to improve patient care and outcomes. The impact of A&F has been subjected to research scrutiny; systematic reviews document only modest and variable effects, despite the likely high costs of A&F programmes, such as those undertaken nationally. To understand and enhance A&F, a programme of research termed AFFINITIE ‘Development & Evaluation of Audit and Feedback INterventions to Increase evidence‐based Transfusion practice'; http://www.ccf.nihr.ac.uk/ PGfAR/about/Pages/Abstract.aspx?ID=12588) has been completed. AFFINITIE adopted a multidisciplinary approach that applied behavioural theory and evidence to optimize the design and delivery of feedback on transfusion practice. These interventions were then tested by embedding them in the context of transfusion national audits in two national randomized cluster trials. The audit topics were preoperative surgery management and use of blood in patients with haematological malignancies. Emerging findings included the scope to improve the design of feedback reports by the inclusion of additional behaviour change techniques and increasing the specificity and relevance of feedback (i.e. clarity around who the feedback is targeted at, providing feedback only on behaviours relevant to audit standards, selecting fewer, more concrete, and relevant standards). Other findings recognized the importance of robust data collection based on agreed and clearly stated standards. Also, given wide variation in how hospitals received, shared and responded to feedback, a consequent need was identified to better support hospitals to plan their response to feedback, including disseminating the reports to all relevant stakeholders with agreement on selecting local goals and plans.
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ItemBarriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners: a theory-informed interview study(BMC, 2016-01-29)BACKGROUND: General dental practitioners (GDPs) regularly prescribe antibiotics to manage dental infections although most infections can be treated successfully by local measures. Published guidance to support GDPs to make appropriate prescribing decisions exists but there continues to be wide variation in dental antibiotic prescribing. An interview study was conducted as part of the Reducing Antibiotic Prescribing in Dentistry (RAPiD) trial to understand the barriers and facilitators of using local measures instead of prescribing antibiotics to manage bacterial infections. METHODS: Thirty semi-structured one-to-one telephone interviews were conducted using the Theoretical Domains Framework (TDF). Responses were coded into domains of the TDF and sub-themes. Priority domains (high frequency: ≥50 % interviewees discussed) relevant to behaviour change were identified as targets for future intervention efforts and mapped onto 'intervention functions' of the Behaviour Change Wheel system. RESULTS: Five domains (behavioural regulation, social influences, reinforcement, environmental context and resources, and beliefs about consequences) with seven sub-themes were identified as targets for future intervention. All participants had knowledge about the evidence-based management of bacterial infections, but they reported difficulties in following this due to patient factors and time management. Lack of time was found to significantly influence their decision processes with regard to performing local measures. Beliefs about their capabilities to overcome patient influence, beliefs that performing local measures would impact on subsequent appointment times as well as there being no incentives for performing local measures were also featured. Though no knowledge or basic skills issues were identified, the participants suggested some continuous professional development programmes (e.g. time management, an overview of published guidance) to address some of the barriers. The domain results suggest a number of intervention functions through which future interventions could change GDPs' antibiotic prescribing for bacterial infections: imparting skills through training, providing an example for GDPs to imitate (i.e. modelling) or creating the expectation of a reward (i.e. incentivisation). CONCLUSIONS: This is the first theoretically informed study to identify barriers and facilitators of evidence-based management of patients with bacterial infections among GDPs. A pragmatic approach is needed to address the modifiable barriers in future interventions intended to change dentists' inappropriate prescribing behaviour.
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ItemSpecifying active components of educational interventions to promote adherence to treatment in glaucoma patients: application of a taxonomy of behavior change techniques(DOVE MEDICAL PRESS LTD, 2015)PURPOSE: In response to recent calls for clearer specification of behavior change interventions, the purpose of this study was to apply a system of taxonomy for behavior change techniques (BCTs) to two educational interventions to improve adherence to glaucoma eye drops. Clarification of constituent BCTs will promote easy and reliable application of the interventions in clinical settings and research. METHODS: A published taxonomy of BCTs was used to code two interventions (group and individual) to increase adherence to eye drops. Intervention materials were coded by assigning a BCT label to each text unit. We noted the frequency with which each BCT occurred, compared the interventions in terms of the BCTs that were delivered, and identified whether the taxonomy was sufficient to describe the intervention components. RESULTS: The individual intervention consisted of 94 text units. Fifty-seven were identified as targeting behavior change and coded using 18 BCTs, many coded more than once. In the group intervention, 165 units of text were identified, and 125 were coded using 22 BCTs. The most frequently coded BCT was "provide information about behavior-health link" in the group intervention and "prompt barrier identification" in the individual intervention. The interventions included similar BCTs. All text units targeting behavior change were codable into BCTs. CONCLUSION: The similarity of the two interventions may have implications for the cost-effectiveness of the interventions. The taxonomy was found sufficient to describe both interventions. This level of specification can be used to ensure that precisely the same intervention that has been pilot tested is reproducible in the clinical setting and in any further research.
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ItemBarriers and facilitators to early rehabilitation in mechanically ventilated patients-a theory-driven interview study(BMC, 2018-01-23)BACKGROUND: Despite a supportive evidence base and a push to implement, the uptake of early rehabilitation in critical care has been inconsistent. The objective of this study was to explore barriers and facilitators to early rehabilitation for critically ill patients receiving invasive mechanical ventilation. METHODS: Using the Theoretical Domains Framework (TDF) of behavior change, we conducted semi-structured interviews exploring barriers and facilitators to early rehabilitation among four purposively sampled ICU clinician groups (nurses, rehabilitation professionals, respiratory therapists, and physicians). The TDF is a comprehensive framework of 14 "construct domains," synthesized from 33 theories of behavior that was developed to study determinants of behavior and to design interventions to improve evidence-based healthcare practice. A topic guide was developed and piloted based on the TDF and expert knowledge. Interviews were audio-recorded and transcribed verbatim. Transcripts were content analyzed by coding items into domains and then synthesized into more specific, over-arching themes or "beliefs." An expert consensus group used structured decision rules to classify beliefs as high, moderate, or low in importance. RESULTS: We interviewed 40 stakeholders from the four clinician groups and identified 135 separate beliefs. Of these, 19 were classified as high, 40 as moderate, and 76 of low importance as barriers or facilitators. All beliefs classified as highly important fell within one of seven TDF domains: skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, environmental context/resources, social influences, and behavioral regulation. Beliefs of lower importance fell under the following seven domains: knowledge; optimism; reinforcement; intention; goals; memory, attention, and decision processes; and emotion. Quantitative differences in stated beliefs about early rehabilitation between professional groups were not common. CONCLUSIONS: This study identified important barriers and facilitators to early rehabilitation in critical care patients. Domains identified as important should be considered when designing interventions to increase uptake of early rehabilitation.
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ItemA feasibility study of a theory-based intervention to improve appropriate polypharmacy for older people in primary care.(Springer Science and Business Media LLC, 2018)BACKGROUND: A general practitioner (GP)-targeted intervention aimed at improving the prescribing of appropriate polypharmacy for older people was previously developed using a systematic, theory-based approach based on the UK Medical Research Council's complex intervention framework. The primary intervention component comprised a video demonstration of a GP prescribing appropriate polypharmacy during a consultation with an older patient. The video was delivered to GPs online and included feedback emphasising the positive outcomes of performing the behaviour. As a complementary intervention component, patients were invited to scheduled medication review consultations with GPs. This study aimed to test the feasibility of the intervention and study procedures (recruitment, data collection). METHODS: GPs from two general practices were given access to the video, and reception staff scheduled consultations with older patients receiving polypharmacy (≥4 medicines). Primary feasibility study outcomes were the usability and acceptability of the intervention to GPs. Feedback was collected from GP and patient participants using structured questionnaires. Clinical data were also extracted from recruited patients' medical records (baseline and 1 month post-consultation). The feasibility of applying validated assessment of prescribing appropriateness (STOPP/START criteria, Medication Appropriateness Index) and medication regimen complexity (Medication Regimen Complexity Index) to these data was investigated. Data analysis was descriptive, providing an overview of participants' feedback and clinical assessment findings. RESULTS: Four GPs and ten patients were recruited across two practices. The intervention was considered usable and acceptable by GPs. Some reservations were expressed by GPs as to whether the video truly reflected resource and time pressures encountered in the general practice working environment. Patient feedback on the scheduled consultations was positive. Patients welcomed the opportunity to have their medications reviewed. Due to the short time to follow-up and a lack of detailed clinical information in patient records, it was not feasible to detect any prescribing changes or to apply the assessment tools to patients' clinical data. CONCLUSION: The findings will help to further refine the intervention and study procedures (including time to follow-up) which will be tested in a randomised pilot study that will inform the design of a definitive trial to evaluate the intervention's effectiveness. TRIAL REGISTRATION: ISRCTN18176245.
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ItemA pilot study of the S-MAP (Solutions for Medications Adherence Problems) intervention for older adults prescribed polypharmacy in primary care: study protocol(BMC, 2019-10-22)BACKGROUND: Adhering to multiple medications as prescribed is challenging for older patients (aged ≥ 65 years) and a difficult behaviour to improve. Previous interventions designed to address this have been largely complex in nature but have shown limited effectiveness and have rarely used theory in their design. It has been recognised that theory ('a systematic way of understanding events or situations') can guide intervention development and help researchers better understand how complex adherence interventions work. This pilot study aims to test a novel community pharmacy-based intervention that has been systematically developed using the Theoretical Domains Framework (12-domain version) of behaviour change. METHODS: As part of a non-randomised pilot study, pharmacists in 12 community pharmacies across Northern Ireland (n = 6) and London, England (n = 6), will be trained to deliver the intervention to older patients who are prescribed ≥ 4 regular medicines and are non-adherent (self-reported). Ten patients will be recruited per pharmacy (n = 120) and offered up to four tailored one-to-one sessions, in the pharmacy or via telephone depending on their adherence, over a 3-4-month period. Guided by an electronic application (app) on iPads, the intervention content will be tailored to each patient's underlying reasons for non-adherence and mapped to the most appropriate solutions using established behaviour change techniques. This study will assess the feasibility of collecting data on the primary outcome of medication adherence (self-report and dispensing data) and secondary outcomes (health-related quality of life and unplanned hospitalisations). An embedded process evaluation will assess training fidelity for pharmacy staff, intervention fidelity, acceptability to patients and pharmacists and the intervention's mechanism of action. Process evaluation data will include audio-recordings of training workshops, intervention sessions, feedback interviews and patient surveys. Analysis will be largely descriptive. DISCUSSION: Using pre-defined progression criteria, the findings from this pilot study will guide the decision whether to proceed to a cluster randomised controlled trial to test the effectiveness of the S-MAP intervention in comparison to usual care in community pharmacies. The study will also explore how the intervention components may work to bring about change in older patients' adherence behaviour and guide further refinement of the intervention and study procedures. TRIAL REGISTRATION: This study is registered at ISRCTN: 10.1186/ISRCTN73831533.
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ItemRethinking Strategies for Positive Newborn Screening Result (NBS plus ) Delivery (ReSPoND): a process evaluation of co-designing interventions to minimise impact on parental emotional well-being and stress(BMC, 2019-09-04)BACKGROUND: Newborn blood spot (NBS) screening seeks to prevent ill health, disability and death through early diagnosis and effective intervention. Each year, around 10,000 parents of babies born in England are given a positive NBS result indicating their child may be affected or carriers of one of the nine conditions currently screened for. Despite guidance, these results are inconsistently delivered to parents across geographical regions. There is evidence that many parents are dissatisfied with how NBS results are communicated to them and that poor communication practices can lead to various negative sequelae. The purpose of this study is to co-design, implement and undertake a process evaluation of new, co-designed interventions to improve delivery of initial positive NBS results to parents. METHODS: This mixed-methods study will use four phases with defined outputs. Family Systems Theory will form the theoretical basis for the study. The principles and methods of experience-based co-design will underpin intervention development. Normalisation Process Theory will underpin the process evaluation of the interventions co-designed to improve the delivery of positive NBS results to parents. An economic analysis will determine resource use and costs of current practice and of implementing the new co-designed interventions. The nominal group technique will be used to inform the selection of suitable outcome measures for a future evaluation study. DISCUSSION: The main output of the proposed study will be co-designed interventions for initial communication of positive NBS results to parents ready to be evaluated in a definitive evaluation study.The interventions, co-designed with parents, will help to minimise potential negative sequelae associated with poor communication practices by considering parental and staff experiences as well as healthcare challenges such as finite resources. In addition, information about indicative costs associated with different communication strategies will be determined.It is anticipated it may also be possible to extrapolate principles of good communication practices from the present study for the delivery of bad news to parents for children newly diagnosed with other conditions including cancer and other chronic conditions such as diabetes or epilepsy. TRIAL REGISTRATION: ISRCTN 15330120 date of registration 17/01/2018.