A behaviour change approach to patient safety

Experts in behaviour change have teamed up with patient safety specialists to work on an exciting project which aims to help NHS organisations implement patient safety alerts. We are using evidence-based methods to identify and address barriers to implementation using a psychological framework of behaviour change. Working with staff in their clinical environment provides a rare and detailed insight into the practicalities of applying evidence based research in a hospital setting. As the project has evolved, we have attempted to produce both useful tools and accurate reflections of our experiences. We hope that these outputs will help those interested in improving patient safety practices in their own hospital/health service to apply these methods in practice.

What is a patient safety alert?

Patient safety alerts are issued by the National Patient Safety Agency (NPSA) to the National Health Service (NHS) in response to analysis of reported patient safety incidents and other safety knowledge. Alerts include descriptions of the identified problem, instructions about the actions which health organisations and/or health professional staff must take, and a timescale by which actions should be completed. Compliance is mandatory and is self-reported by each organisation. However, implementation of NPSA alerts is rarely straightforward and compliance can be difficult to demonstrate and sustain.

The traditional approach to achieving compliance with patient safety alerts

The traditional approach to implementing patient safety alerts often involves a top-down approach whereby guidance is disseminated to staff with the assumption that this will automatically deliver change. However, this approach often fails to deliver the required behaviour change and consequently many organisations fail to adhere to patient safety alert guidelines. We argue that behaviour change is difficult to achieve because the causes of behaviour are complex and change is often contested and resisted by the target audience (Leistikow et al, 2007). As such, there needs to be consideration of a range of technical, psychological and socio-cultural factors when designing an implementation package.

An alternative approach to achieving compliance with patient safety alerts

There is increasing recognition that theories of behaviour and behaviour change should be used to inform the design of interventions to change behaviour (NICE, 2007, Michie et al., 2008). For example, interventions that make extensive use of theory tend to have larger effects on behaviour than interventions that make less extensive use or no use of theory (Webb et al., 2010; Taylor et al., 2011). In this project we will build on on-going work which uses a theoretical framework of behaviour change (Michie et al., 2005) to support the implementation of evidence based patient safety practices by:

  •   Identifying the specific behaviours that are in need of change
  •  Identifying the root of the problem by assessing the barriers staff face
  • Tackling specific barriers using appropriate behaviour change methods
  • Working with staff to design and implement interventions
  • Continually monitoring process/outcome measures
  • Sharing learning between Trusts to ensure best practice becomes common practice

Who are we working with?

We are working with five NHS organisations, each of which selected up to two alerts to focus on:

  • Bradford Teaching Hospitals NHS Foundation Trust: (1) Reducing the risk of overdose with midazolam injection, (2) Reducing the risk of feeding through misplaced NG tubes
  • Leeds Teaching Hospitals NHS Trust: (1) Reducing the risk of feeding through misplaced NG tubes

The outcomes

The outcomes of the project will be finalised in March/April 2012, and a final report will be completed by August 2012. However learning from the day to day work is emerging and we are keen to share our progress as this happens.
Progress to date includes:

  • Generic version of diagnostic (barriers to implementation) questionnaire completed
  • Clinical leads and project teams for each piece of work confirmed (8 in total)
  • Measurement plans for individual alerts agreed with organisations
  • Baseline data and initial use of diagnostic questionnaire currently being undertaken for six of the eight projects: over 200 questionnaire responses (across three trusts) to date on barriers to implementing NG tubes alert
  • Sharing between the five organisations facilitated informally on an on-going basis.

Using one of the alerts as the example we have pulled together the lessons learnt and resources developed to share immediately. Find out more about the outcomes using our work around reducing the harm caused by misplaced nastrogastric feeding tubes. We will develop similar information for all the alerts (across the 5 trusts) as and when the information is available.

How can you get involved?

For further information about how your organization could get involved or learn from this work please contact: [email protected]

References

Leistikow, I.P., Kalkman, C.J., & de Bruijn, H. (2011). Why patient safety is such a tough nut to crack. BMJ, 342:d3447.
Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D., & Walker, A. (2005). Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality & Safety in Health Care, 14(1), 26-33.
Michie, S., Johnston, M., Francis, J., Hardeman, W., & Eccles, M. (2008). From theory to intervention: mapping theoretically derived determinants to behaviour change techniques. Applied Psychology: An international review, 57(4), 660-680.
NICE (2007). How to change clinical practice: understand, identify an overcome barriers to change. National Institute for Health and Clinical Excellence. http://www.nice.org.uk/media/AF1/73/HowToGuideChangePractice.pdf. Accessed on 28.11.11.
Taylor, N., Conner, M., & Lawton, R. (2011). The impact of theory on worksite physical activity interventions: a meta-analysis and meta-regression. Health Psychology Review, i-First online article.
Webb, T. L., Joseph, J., Yardley, L., & Michie, S. (2010). Using the internet to promote health behaviour change: a meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. Journal of Medical Internet Research, 12(1), e1.

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