How to use the nominal group and Delphi techniques

Nurse-led sequential multiple assignment randomized trial of nudging intervention for early antiretroviral therapy initiation among patients with HIV/AIDS: Implementation study protocol

AIMS

In China, more than 30% of patients have not initiated treatment within 30 days of HIV diagnosis. Delayed initiation has a detrimental influence on disease outcomes and increases HIV transmission. The study aims to evaluate the effectiveness of a nurse-led antiretroviral therapy initiation nudging intervention for people newly diagnosed with HIV in China to find the optimal intervention implementation strategy.

METHODS

A Hybrid Type II sequential multiple assignment randomized trial will be conducted at four Centers for Disease Control and Prevention in Hunan, China. This study will recruit 447 people newly diagnosed with HIV aged ≥18 years and randomly assign them into two intervention groups and one control group. On top of the regular counselling services and referrals, intervention groups will receive a 4-week, 2-phase intervention based on the dual-system theory and the nudge theory. The control group will follow the currently recommended referral procedures. The primary outcomes are whether treatment is initiated, as well as the length of time it takes. The study outcomes will be measured at the baseline, day 15, day 30, week 12, week 24 and week 48. Generalized estimating equations and survival analysis will be used to compare effectiveness and explore factors associated with antiretroviral therapy initiation. Both qualitative and quantitative information will be collected to assess implementation outcomes.

DISCUSSION

Existing strategies mostly target institutional-level factors, with little consideration given to patients' decision-making. To close this gap, we aim to develop an effective theory-driven nudging strategy to improve early ART initiation.

IMPACT

This nurse-led study will help to prevent delayed initiation by employing implementation science strategies for people newly diagnosed with HIV. This study contributes to the United Nations' objective of ending the AIDS pandemic by 2030.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300070140. The trial was prospectively registered before the first participant was recruited.

PATIENT AND PUBLIC INVOLVEMENT

The nudging intervention was finalized through the Nominal Group Technique where we invited five experts in the related field and five people living with HIV to participate.

Quality indicators for appropriate in-hospital pharmacotherapeutic stewardship: An international modified Delphi study

AIMS

In-hospital prescribing errors may result in patient harm, such as prolonged hospitalisation and hospital (re)admission, and may be an emotional burden for the prescribers and healthcare professionals involved. Despite efforts, in-hospital prescribing errors and related harm still occur, necessitating an innovative approach. We therefore propose a novel approach, in-hospital pharmacotherapeutic stewardship (IPS). The aim of this study was to reach consensus on a set of quality indicators (QIs) as a basis for IPS.

METHODS

A three-round modified Delphi procedure was performed. Potential QIs were retrieved from two systematic searches of the literature, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. In two written questionnaires and a focus meeting (held between the written questionnaire rounds), potential QIs were appraised by an international, multidisciplinary expert panel composed of members of the European Association for Clinical Pharmacology and Therapeutics (EACPT).

RESULTS

The expert panel rated 59 QIs and four general statements, of which 35 QIs were accepted with consensus rates ranging between 79% and 97%. These QIs describe the activities of an IPS programme, the team delivering IPS, the patients eligible for the programme and the outcome measures that should be used to evaluate the care delivered.

CONCLUSIONS

A framework of 35 QIs for an IPS programme was systematically developed. These QIs can guide hospitals in setting up a pharmacotherapeutic stewardship programme to reduce in-hospital prescribing errors and improve in-hospital medication safety.

Updated core competencies in pharmacoepidemiology to inform contemporary curricula and training for academia, government, and industry

PURPOSE

The first paper to specify the core content of pharmacoepidemiology as a profession was published by an ISPE (International Society for Pharmacoepidemiology) workgroup in 2012 (Jones JK et al. PDS 2012; 21[7]:677-689). Due to the broader and evolving scope of pharmacoepidemiology, ISPE considers it important to proactively identify, update and expand the list of core competencies to inform curricula of education programs; thus, better positioning pharmacoepidemiologists across academic, government (including regulatory), and industry positions. The aim of this project was to update the list of core competencies in pharmacoepidemiology.

METHODS

To ensure applicability of findings to multiple areas, a working group was established consisting of ISPE members with positions in academia, industry, government, and other settings. All competencies outlined by Jones et al. were extracted from the initial manuscript and presented to the working group for review. Expert-based judgments were collated and used to identify consensus. It was noted that some competencies could contribute to multiple groups and could be directly or indirectly related to a group.

RESULTS

Five core domains were proposed: (1) Epidemiology, (2) Clinical Pharmacology, (3) Regulatory Science, (4) Statistics and data science, and (5) Communication and other professional skills. In total, 55 individual competencies were proposed, of which 25 were new competencies. No competencies from the original work were dropped but aggregation or amendments were made where considered necessary.

CONCLUSIONS

While many core competencies in pharmacoepidemiology have remained the same over the past 10 years, there have also been several updates to reflect new and emerging concepts in the field.

Construction of key quality indicators for aged care facilities in China: A two-tier Delphi study: Key aged care quality indicators in ACF by Delphi method

AIM

To construct key quality indicators for aged care facilities in China.

BACKGROUND

Evaluating the care quality in aged care facilities is problematic. Evaluation of nursing care quality is important for improving nursing and self-supervision in aged care facilities. However, a few regulations and studies regarding care quality evaluation have been implemented in China.

DESIGN AND METHOD

This two-tier Delphi study aimed to achieve consensus on key quality indicators for aged care facilities in China. The entry pool was determined by literature review and research team discussion, followed by a discussion by a panel of experts to establish the items of the Delphi study. Finally, key care quality indicators were established through a two-round Delphi study. This study followed the SQUIRE 2.0 guidelines.

RESULTS

The initial 16 quality indicators of the entry pool was developed based on a literature review and a group discussion. Sixteen quality indicators were reduced to eight after the expert discussion. After two rounds of expert consultation, the eight quality indicators became nine, which were then evaluated for importance, formula rationality, and operability using Kendall's harmony coefficients (first round: 0.150, 0.143 and 0.169, respectively; second round: 0.209, 0.159 and 0.173, respectively).

CONCLUSIONS

Key quality indicators provide quantifiable evidence for evaluating the care quality in aged care facilities, but their applicability needs continuous improvement.

RELEVANCE TO CLINICAL PRACTICE

Nine key quality indicators were selected from numerous indicators for measuring the care quality in aged care facilities, supporting the evaluation of the care quality and self-supervision for aged care facilities.

ELDERLY OR PUBLIC CONTRIBUTION

No elderly or public contribution.

Prescribing hand strengthening exercise for patients with rheumatoid arthritis; clinical cues influencing occupational therapists' and physiotherapists' judgements

OBJECTIVE

To explore the clinical judgements of therapists in prescribing the intensity of hand strengthening exercise in rheumatoid arthritis (RA).

METHODS

Phase I: Eleven therapists knowledgeable in treating patients with RA subjectively identified seven clinical cues. These were incorporated into 54 hypothetical patient case scenarios.

PHASE II

Therapists with ≥2 years post-registration experience and current or recent experience in treating patients with RA were asked to assess 69 case scenarios in total (54 + 15 repeats) and judge what intensity of hand strengthening exercise they would prescribe using the OMNI-Resistance Exercise Scale of perceived exertion. Using responses to the repeated cases, the Cochran-Weiss-Shanteau index of expertise was used to identify therapists who prescribed more consistently. Multiple regression was used to determine which clinical cues were most strongly associated with the intensity of exercise prescribed. A sub-group analysis explored differences between consistent and inconsistent prescribers.

RESULTS

Fifty-three therapists took part. Thirty completed all 69 case scenarios. Across all therapists, the three most important clinical cues associated with lower intensity of exercise prescribed were (1) Patient's reported pain intensity whilst practising the exercise (β = -1.150, p < 0.001), (2) Disease activity (β = -0.425, p < 0.001) and (3) average hand pain over the last week (β = -0.353 p < 0.001). Twelve therapists were categorised as consistent prescribers. This group relied on fewer clinical cues (three vs. seven) when judging what intensity of exercise to prescribe.

CONCLUSION

This study provides insights into how therapists prescribe hand exercises. Intensity of hand strengthening exercise was influenced by three key clinical cues, including pain intensity and disease activity.

Developing a research tool to detect iatrogenic adverse events in psychiatric health care by involving service users and health professionals

WHAT IS KNOWN ON THE SUBJECT

Most health professionals working in psychiatric care will experience adverse events (AE) such as service user suicide or violence, during their career Norway lacks measures to capture potential iatrogenic injuries, such as risk assessment measures, to evaluate patient records for AEs in both inpatient and outpatient psychiatric clinics in hospitals WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: We have described an approach to the validation of a research tool between different national contexts; a process that went beyond language translation We have incorporated the understanding of health professionals and service users; to bring together the lifeworld of the patient with the professional definition of AEs, triggers and risk areas of AEs in a psychiatric context. The service users' experiences resulted in modifications to the tool.

WHAT ARE THE IMPLICATIONS FOR NURSES

Applying the 'Global Trigger Tool-Psychiatry' in Norway and Sweden can help mental health nurses to prevent iatrogenic harm and reduce the occurrence of AEs through the identification of potential triggers. Implementing 'Global Trigger Tool-Psychiatry' might help mental health nurses to improve patient safety in Norway and Sweden.

ABSTRACT

INTRODUCTION: There is little consensus on cross-cultural and cross-national adaptation of research instruments.

AIM/QUESTION

To translate and validate a Swedish research tool (GTT-P) to detect iatrogenic adverse events in psychiatric health care by involving service users and health professionals in the process.

METHOD

The GTT-P, designed to identify events in patient records that were triggers for adverse events, was translated to Norwegian using a cross-cultural adaptation approach. This involved two focus groups with clinical staff, one of which involved service users, and a joint discussion at a Dialogue Conference to generate consensus on the definition of the triggers of potential adverse events identifiable in patient records.

RESULTS

We highlight both the differences and commonalities in defining the nature of risks, the adverse events and the triggers of such events. The Dialogue Conference resulted in three modifications of the tool, based on service users' experiences. Service user involvement and co-production was essential for both the translation and adaptation of the research instrument.

DISCUSSION

We have described an approach to the validation of a research tool between different national contexts; a process that went beyond language translation. This approach enables a more nuanced understanding of potential risks within a psychiatric context as it engages differences in the care delivery. Applying the GTT-P in hospital-based psychiatric care might help to identify processes that need to be changed in order to promote patient safety and a safer work environment for mental health nurses.

IMPLICATIONS FOR PRACTICE

When translating and validating the GTT-P from Swedish to Norwegian, we have considered the knowledge and experiences of both service users and health professionals. The application of the GTT-P can promote greater patient safety in hospital settings.

Revising the Pragmatics Profile using a modified Delphi methodology to meet the assessment needs of current speech-language therapists

BACKGROUND

Non-standardized assessment tools are preferred when assessing communication of individuals with developmental disabilities. Currently, there are limited tools available for assessing this population. Informant report tools such as the Pragmatics Profile (PP) of Everyday Communication Skills are beneficial in gathering a representative view of an individual's communication. However, the PP is out of print and outdated, requiring revisions to meet contemporary assessment needs of speech-language therapists (SLTs).

AIMS

To seek consensus from an international panel regarding revising the Pragmatic Profile by (1) updating language and terminology, and (2) development of an online tool.

METHODS & PROCEDURES

A total of 13 experienced SLTs and researchers in the disability field participated in a modified Delphi study including an initial online meeting followed by an anonymous four-round survey. Participants reviewed the relevance and wording of questions in the original preschool, school-age and adult versions to create a single combined version of the PP. In each Delphi round, the level of consensus was calculated and qualitative comments were analysed using thematic analysis.

OUTCOMES & RESULTS

A revised online version of the PP was created including 64 questions. Qualitative analysis illuminated key concepts in the creation of a revised form including the need for plain and age-neutral language, which is inclusive of all communication modalities and physical impairments, and identifies behaviours that have the potential to be communicative acts. Using conditional logic, users are navigated to the appropriate questions based on the intentionality level of the individual rather than their age.

CONCLUSIONS & IMPLICATIONS

This study resulted in the revision of a valued assessment tool appropriate for current disability service provision that identifies communication along the continuum of intentionality rather than age.

WHAT THIS PAPER ADDS

What is already known on this subject Non-standardized tools are appropriate when assessing communication of individuals with developmental disabilities. However, there are limited published tools suitable for this population with several of them out of print, making it difficult to conduct a holistic assessment. What this study adds to the existing knowledge This study resulted in the creation of an online PP based on experts' opinion. The revised PP modified the primary focus of the tool from age- to skill-based whereby questions are targeted according to intentionality level. Revisions included plain language, and inclusion of all communication modalities and physical impairments via a series of prompts to ensure that the information provided by informants is accurate and relevant. What are the potential or actual clinical implications of this work? The revised PP adds to the toolkit of an SLT working with individuals with a developmental disability and allows for accurate reporting of functional communication. Guided by experts' opinion, the revised PP is likely to be highly valued in the increasingly technological world in which we live.

Optimising management of complex regional pain syndrome to improve clinical outcomes throughout the therapy care pathway in England: Protocol for a qualitative interview and observational study with patients and clinicians

INTRODUCTION

Complex Regional Pain Syndrome (CRPS) is a disabling and distressing chronic pain condition characterised by a range of sensory, motor, autonomic and trophic symptoms. Guidelines recommend early referral for therapies that promote movement of the painful limb. However, evidence suggests a lack of defined therapy pathways for CRPS.

AIMS

The current study aims to explore CRPS therapy management in centres of excellence in England, and outside of these settings, to understand what facilitates and hinders best practice. The overall aim is to develop a draft stratified package of care to expedite patient access to optimal CRPS therapy across the management pathway.

METHODS AND ANALYSIS

Semi-structured interviews will be conducted with therapists working in CRPS centres of excellence and with therapists in other settings. Observations of therapy interventions in CRPS centres of excellence and interviews with patients who have received this care, will also help to identify potential key care package components. Interview data will be analysed using thematic analysis, mapped to the Theoretical Domains Framework (TDF), and Intervention Mapping Adapt (IMA) framework. Observations will be described and documented using the TDF headings.

CONCLUSION

A triangulation protocol for qualitative health research will be used to integrate all data. Online stakeholder events will be held using consensus methods to agree a draft package of care for future implementation following further refinement, testing and evaluation.

CLINICAL TRIAL REGISTRATION

The trial was registered with ISRCTN registry on 24 February 2022 (ISRCTN16917807).

Identifying characteristics of a skilled communicator in the clinical encounter

BACKGROUND

In medical communication research, there has been a shift from 'communication skills' towards 'skilled communication', the latter implying the development of flexibility and creativity to tailor communication to authentic clinical situations. However, a lack of consensus currently exists what skilled communication entails. This study therefore aims to identify characteristics of a skilled communicator, hereby contributing to theory building in communication research and informing medical training.

METHOD

In 2020, six nominal group technique (NGT) sessions were conducted in the context of the general practitioner (GP) training programme engaging 34 stakeholders (i.e. GPs, GP residents, faculty members and researchers) based on their experience and expertise in doctor-patient communication. Participants in each NGT session rank-ordered a 'Top 7' of characteristics of a skilled communicator. The output of the NGT sessions was analysed using mixed methods, including descriptive statistics and thematic content analysis during an iterative process.

RESULTS

Rankings of the six sessions consisted of 191 items in total, which were organised into 41 clusters. Thematic content analysis of the identified 41 clusters revealed nine themes describing characteristics of a skilled communicator: (A) being sensitive and adapting to the patient; (B) being proficient in applying interpersonal communication; (C) self-awareness, learning ability and reflective capacity; (D) being genuinely interested; (E) being proficient in applying patient-centred communication; (F) goal-oriented communication; (G) being authentic; (H) active listening; and (I) collaborating with the patient.

CONCLUSIONS

We conceptualise a skilled communication approach based on the identified characteristics in the present study to support learning in medical training. In a conceptual model, two parallel processes are key in developing adaptive expertise in communication: (1) being sensitive and adapting communication to the patient and (2) monitoring communication performance in terms of self-awareness and reflective capacity. The identified characteristics and the conceptual model provide a base to develop a learner-centred programme, facilitating repeated practice and reflection. Further research should investigate how learners can be optimally supported in becoming skilled communicators during workplace learning.

The added value and unintended negative consequences of public involvement processes in the planning, development and implementation of community health services: Results from a thematic synthesis

PURPOSE

Public involvement is widely considered a means to improve health and quality of health services. The research literature reveals ambiguities concerning added value and unintended negative consequences of public involvement processes. The aim of this study is to identify, synthesise and present an overview of added value and unintended negative consequences of public involvement processes in the planning, development and implementation of community health services.

METHODS

Data from 36 peer-reviewed articles retrieved from a systematic search in the CINAHL, Cochrane Library, Embase, PsycINFO, PubMed, ProQuest, and Scopus databases in October 2019 and updated in April 2021 were extracted. A three-step thematic synthesis was conducted involving (1) line-by-line text coding, (2) developing descriptive themes and (3) generating analytical themes.

RESULTS

Two main themes along with their corresponding themes provided an overview of the added value of public involvement processes at the individual, service and political levels. Unintended negative consequences concerning individual resources, uncertainty about the effect of involvement and power differences were revealed.

CONCLUSION

Added value of public involvement processes is primarily reported on an individual and service level. The added value seems to be accompanied by unintended negative consequences. Training of professional facilitators and recruitment of participants that come from vulnerable groups could help promote equality in public involvement. Unintended negative consequences need to be further explored in future evaluations in order to achieve the desired goals of public involvement.

Adapting community child and family health service models for rural and other diverse settings: A modified Delphi study to identify key elements

Inequity in health outcomes is pervasive, with poorer health outcomes identified in rural, regional and remote communities. An international call to action emphasises the need for service models adapted for less well-resourced settings. The aim of this study was to identify key elements of a framework for the adaptation of specialist community-based child and family health (CFH) service models for rural and other under-resourced settings. A modified Delphi study was undertaken with a 12-person expert panel in CFH including Australian and international professionals and parents from rural and remote communities. The study was informed by the WHO Framework for Strengthening Health Service Systems building blocks, the outcomes of an integrative review of literature and a Participatory Action Research study. Experts assessed 107 potential elements for service model development and rated them for importance when adapting service models for different contexts. Round 1 of the Delphi generated considerable consensus with 80 of the 107 potential elements identified as necessary for the service model adaptation framework. A further 17 elements for CFH service models were added in round 2. While multiple varied elements are important for adapting CFH service models for diverse settings, some elements had common themes. Experts highlighted the importance of community engagement and participation; utilising both data and local knowledge to develop a robust understanding of the community context; and the need for a flexible approach to funding and modes of service delivery to address barriers to implementation and access.

Development of standard definitions and grading for Maternal and Fetal Adverse Event Terminology

OBJECTIVE

Adverse event (AE) monitoring is central to assessing therapeutic safety. The lack of a comprehensive framework to define and grade maternal and fetal AEs in pregnancy trials severely limits understanding risks in pregnant women. We created AE terminology to improve safety monitoring for developing pregnancy drugs, devices and interventions.

METHOD

Existing severity grading for pregnant AEs and definitions/indicators of 'severe' and 'life-threatening' conditions relevant to maternal and fetal clinical trials were identified through a literature search. An international multidisciplinary group identified and filled gaps in definitions and severity grading using Medical Dictionary for Regulatory Activities (MedDRA) terms and severity grading criteria based on Common Terminology Criteria for Adverse Event (CTCAE) generic structure. The draft criteria underwent two rounds of a modified Delphi process with international fetal therapy, obstetric, neonatal, industry experts, patients and patient representatives.

RESULTS

Fetal AEs were defined as being diagnosable in utero with potential to harm the fetus, and were integrated into MedDRA. AE severity was graded independently for the pregnant woman and her fetus. Maternal (n = 12) and fetal (n = 19) AE definitions and severity grading criteria were developed and ratified by consensus.

CONCLUSIONS

This Maternal and Fetal AE Terminology version 1.0 allows systematic consistent AE assessment in pregnancy trials to improve safety.