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Achieving Behaviour Change for Patient safety

Dr Judith Dyson

Academic Improvement Fellow

Quality Improvement

Background

Lets first consider behaviour

• Health behaviour

• Patients concordance

• Implementation

What determines our behaviour?

What strategies do we generally employ to change?

Evidence tells us

• We need to assess individual barriers and levers

• We need to tailor our strategies according to these

• We need a theoretical approach to assessment and the intervention

• (Michie et al., 2005, Baker et al., 2010, MRC guidelines for complex interventions)

Psychological theory is useful

• Interventions designed based on theory have greater effects on behaviour than those that are not (Webb et al.,

2010; Taylor, Conner, & Lawton, 2012)

But tricky

Domain Meaning

Knowledge Does the person know they should be doing behaviour X? Do they understand?

Skills Does the person know how to do the behaviour (X)? How easy or difficult is it?

Beliefs about capabilities

How easy is it for the person to do X? Have they previously encountered problems? How confident are they that they can overcome difficulties?

Motivation and goals

How much do they want to do X? How much do they feel the need to do X? Are there incentives to do X? Are there competing priorities?

Environment To what extent do physical or resource factors hinder X? Time?

Beliefs about consequences

What do they think will happen if they do X? What are the costs/consequences of doing X? Does the evidence suggest that doing X is a good thing?

Emotion Does doing X evoke an emotional response? To what extent do emotional factors help or hinder X? How does emotion affect X?

Social influences To what extent do social influences help or hinder X? Will the person observe others doing X?

Memory/attention Can the person remember to do behaviour X? Do they usually do X?

Action planning Does the person put plans in place to ensure they do the behaviour?

Made Easy - the TDF Theoretical Domains Framework Michie et al. 2005

Stepped process informed by behaviour change theory and implementation literature

(Michie et al., 2005, 2008; Grol et al., 2007)

Involve stakeholders

Medical directors and

sharp end staff

Identify target

behaviour

Audit and discussion

Identify barriers

Influences on Patient Safety

Behaviours Questionnaire

(IPSBQ)

Confirm barriers and generate intervention

strategies

Focus groups

Support staff to implement and

evaluate intervention

Joint approach

Re-auditing

Further progress The Theoretical Domains Framework Implementation (TDFI) approach

(Taylor et al., 2013)

Questionnaire results Barriers ‘to using pH as the first line method for checking tube position’

Barrier

Mean (SD)

H1

n = 99

Mean (SD)

H2

n =105

Mean (SD)

H3

n =23

Mean (SD)

all hospitals

n = 227

Inter-item

correlation

Knowledge 2.02 (0.70) 2.33 (0.75) 2.08 (0.76) 2.17 (0.74)** 0.64

Skills 2.37 (0.79) 2.64 (0.72) 2.74 (0.87) 2.53 (0.78)** 0.62

Social and professional identity 2.04 (0.73) 1.96 (0.64) 2.16 (0.79) 2.01 (0.69) 0.23

Beliefs about capabilities 2.44 (0.77) 2.55 (0.83) 2.52 (0.97) 2.50 (0.81) 0.43

Beliefs about consequences 2.35 (0.70) 2.38 (0.70) 2.39 (0.48) 2.37 (0.68) 0.45

Motivation and goals 2.40 (0.66) 2.40 (0.60) 2.65 (0.69) 2.42 (0.64) 0.21

Cognitive processes, memory

and decision making 2.36 (0.68)

2.47 (0.74)

2.19 (0.67)

2.39 (0.71) 0.23

Environmental context and

resources 2.55 (0.85)

2.69 (0.69)

2.68 (0.62

2.63 (0.76) 0.47

Social influences 2.84 (0.76) 2.89 (0.73) 2.71 (0.75) 2.85 (0.74) 0.22

Emotion 2.41 (0.65) 2.75 (0.55) 2.35 (0.62) 2.56 (0.63)* 0.62

Action Planning 2.32 (0.66) 2.38 (0.62) 2.42 (0.54) 2.36 (0.63) 0.43

Focus group results: interventions matched to barriers and BCTs (H1)

Barrier Strategy Behaviour change technique*

Social

influences

• Information presented at clinical governance

meetings by experts in the area

• Awareness day held within the Trust

• Posters with pictures of senior staff performing

correct behaviour

• Persuasive source

• Information about health

consequences, and social/

environmental consequences

• Prompts, cues, social support

(unspecified)

Emotion • Screensaver contained messages to elicit

anticipated regret and to reframe perspective on

behaviour

• Anticipated regret

• Salience of consequences

• Framing/reframing

Environmental

context and

resources

• Radiology and ward protocols to empower staff

• Instructions, flow chart, measurement tool, who

placed NG, place to record pH values, etc.

• Splashscreen placed on intranet with prompt about

pH testing and link to all relevant documentation

• Prompts, triggers, cues

• Adding objects to the

environment

Bcap (and

knowledge and

skills)

• Practical training complete for current FY1s

• E-learning package developed for junior doctors

• Instruction on how to perform a

behaviour

• Behavioural practice/rehearsal

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of patients with NG feeding tubes who had pH testing as the first line test method following

insertion

% total numbers

% minus theatre

March 2011:revised

Sept & Oct 2011: project

presented at 4 clinical audit

meetings

October 2011; FY1

doctors attend

June 11: new

trust NGT

documentation

February 4th 2012;

screen saver

launched with an

awareness day

Junior doctor

Practice change results

Audit information

Hospital 1 Hospital 2 Hospital 3 Hospital 4

(Control)

Pre Post Pre Post Pre Post Pre Post

Number of sets of notes

audited 49 48 43 44 44 40 53 46

pH of aspirate from stomach 18% 63% 12% 73% 14% 33% 45% 46%

Patient sent for X-ray 49% 23% 77% 9% 41% 40% 25% 20%

Tube placed in radiology 0 0 0 0 36% 10% 0 0

Information not documented 33% 15% 9% 18% 9% 18% 30% 46%

Target behaviour: Using pH as the first line method for checking tube position

Other examples using framework

• Hand hygiene (Dyson et al., 2013)

• Low back pain management in primary care (French et al., 2012)

• Management of mild traumatic brain injury in the emergency department (Knott et al., 2014)

• Tobacco cessation counselling by oral health professionals (Amemori et al., 2013)

• Midwives engaging with pregnant women in discussions about smoking (Boenstock et al., 2012)

• Development of an intervention to promote activity in care homes (ongoing work at BIHR)

Putting it into practice

• The improvement academy

• Behaviour change workshops

• The toolkit

• My role within the academy

Workshops

Where to find the toolkit

The 6 steps

Me

Worked examples

www.improvementacademy.org

My role

• “It’s all about urine”

• Electronic monitoring of HH

• Safer dispensing

• Medicines on care transfer

• Sepsis bundle

• Restructuring of teams

• Falling

“It’s all about urine”

• Background

– UTI second largest group of HCAIs in the UK (HPA 2009)

– Concern with inappropriate antibiotic prescription for suspected UTIs

– Maurice did an audit . . . . . . . . .

Steps 1 and 2

Identifying the behaviour – not easy

• Inappropriate dip stick testing (e.g. catheter, e.g. no UTI symptoms)

• Antibiotic prescribing without MSU

• Antibiotic prescribing not in line with policy (e.g. Cefalexin 2nd line due to C diff being Rx 1st line)

• Not all positive dipstick results followed up by MSU

• Prescriptions for antibiotics 3 days or less. . . . .

Understanding Barriers

Validity and Reliability

What do you think the barriers are?

• Sending an MSU after a dipstick when nursing assistants discover leucocytes and nitrates?

Next steps

Devising interventions

Defined and with examples

Behaviour change techniques for specific barriers

Implement. . . .Evaluate

Evaluate

• Table (behaviour change)

• Run chart (behaviour change)

• Barriers before and after

• Impact on outcomes (e.g. MRSA, falls)

Is this approach helpful? Weaknesses?

• It is for us

• ?difficult to navigate and understand

• Formal evaluation

• There is more info’ . . . . balance

• Keeping things current

Is this approach helpful? Strengths

• Flexibility e.g number of domains included/relevant

• Flexibility – use for patient interventions (exercise, MOLES, PEEP)

• Flexibility – in reverse (e.g. PEEP, another (local) electronic HH monitoring study)

• Large body of evidence, literature, experience – further pushing the boundaries

• The future . . . . further spread . . . your thoughts

Thank you

Any questions?

Feel free to contact me: Judith Dyson J.Dyson@hull.ac.uk

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