Using theories of behaviour change to transition multidisciplinary trauma team training from the training environment to clinical practice

Trauma nursing competency in the emergency department: a concept analysis

OBJECTIVES

Despite numerous published concept analyses of nursing competency, the specific understanding of trauma nursing competency in emergency departments remains limited, with no clear definition. This study aimed to clarify the definitions and attributes of trauma nursing competencies in emergency departments.

DESIGN

Walker and Avant's method was used to clarify the concept of trauma nursing competency in emergency departments.

DATA SOURCES

PubMed, EMBASE, CINAHL and RISS were searched from inception to 23 April 2023.

ELIGIBILITY CRITERIA

Relevant studies that included combinations of the terms 'nurse', 'nursing', 'emergency', 'trauma', 'competency', 'capability' and 'skill' were selected. We restricted the literature search to English and Korean full-text publications, with no limit on the publication period; grey literature was excluded.

DATA EXTRACTION AND SYNTHESIS

This study uses defining attributes, antecedents and consequences extracted through data analysis. To aid comprehension of the model, related and contrary cases of the concept were created, and empirical referents were defined.

RESULTS

After excluding duplicates, irrelevant studies, incomplete texts and articles unrelated to the context and study population, 15 of the initial 927 studies were included. Five additional studies were added after a manual search of the references. The final concept analysis therefore included 20 studies. The attributes of trauma nursing competency for emergency nurses included 'rapid initial assessments considering injury mechanisms', 'priority determinations based on degrees of urgency and severity', 'clinical knowledge of trauma nursing', 'skills of trauma nursing', 'interprofessional teamwork' and 'emotional care'.

CONCLUSIONS

The concept analysis revealed that it is possible to promote the enhancement and development of trauma nursing competency in emergency departments across various contexts, such as clinical practice, education, research and organisational settings. This could ultimately improve trauma nursing quality and treatment outcomes.

What and when to debrief: a scoping review examining interprofessional clinical debriefing

INTRODUCTION

Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.

METHODS

Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.

RESULTS

Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.

CONCLUSIONS

The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.

Influences of specialty identity when implementing a new emergency department in Denmark: a qualitative study

BACKGROUND

The Danish Health Authority recommended the implementation of new types of emergency departments. Organizational changes in the hospital sector challenged the role, identity, and autonomy of medical specialists. They tend to identify with their specialty, which can challenge successful implementation of change. However, investigations on specialty identity are rare in implementation science, and how the co-existence of different specialty identities influences the implementation of new emergency departments needs to be explored for the development of tailored implementation strategies. The aim of this study was to examine how medical specialty identity influences collaboration between physicians when implementing a new emergency department in Denmark.

METHODS

Qualitative methods in the form of participants' observations at 13 oilcloth sessions (a micro-simulation method) were conducted followed up by 53 individual semi-structured interviews with participants from the oilcloth sessions. Out of the 53 interviews, 26 were conducted with specialists. Data from their interviews are included in this study. Data were analysed deductively inspired by Social Identity Theory.

RESULTS

The analysis yielded three overarching themes: [1] ongoing creation and re-creation of specialty identity through boundary drawing; [2] social categorization and power relations; and [3] the patient as a boundary object.

CONCLUSIONS

Specialty identity is an important determinant of collaboration among physicians when implementing a new emergency department. Specialty identity involves social categorization, which entails ongoing creation and re-creation of boundary drawing and exercising of power among the physicians. In some situations, the patient became a positive boundary object, increasing the possibility for a successful collaboration and supporting successful implementation, but direct expressions of boundaries and mistrust were evident. Both were manifested through a dominating power expressed through social categorization in the form of in- and out-groups and in an "us and them" discourse, which created distance and separation among physicians from different specialties. This distancing and separation became a barrier to the implementation of the new emergency department.

Evidence-Based Pearls: How the Healthy Work Environment Effects Multidisciplinary Trauma Teams

Trauma remains a leading cause of death among adults. Care of the trauma patient requires highly skilled trauma teams. Trauma care begins in the field, then presents to the emergency room, proceeds to intensive care in many cases, and finally reaches recovery and rehabilitation. For patients, it can be a long road. To be effective, multidisciplinary trauma teams must expertly drill and practice skills, communicate among team members in closed loops, make split decisions affecting patient outcomes, and see the care through to the end. Many disruptions during the course of providing trauma care can alter safe outcomes for patients. The American Association of Critical Care Nurses Six Essentials of the Healthy Work Environment are presented as a framework to provide excellence in trauma care, both for the patient and team members. The six essentials of a healthy work environment include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

Behavioural optimisation to address trial conduct challenges: case study in the UK-REBOA trial

BACKGROUND

Clinical trials comprise multiple processes at various stages of the trial lifecycle. These processes often involve complex behaviours such as recruiting vulnerable patient populations and clinicians having to deliver complex trial interventions successfully. Few studies have utilised a behavioural framework to assess challenges and develop strategies for effective trial recruitment and delivery of trial interventions. This study reports the application of an innovative methodological approach to understand core trial processes, namely recruitment and intervention delivery, using a behavioural science approach to develop strategies designed to mitigate trial process problems.

METHODS

The UK-REBOA trial aims to evaluate the clinical and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (a novel intervention) in injured patients with exsanguinating haemorrhage. A behavioural investigation ('diagnosis') was conducted using theory-informed (Theoretical Domains Framework, TDF) semi-structured interviews with site staff from the UK-REBOA trial to examine trial processes which could be improved in relation to trial recruitment and delivery of the intervention. Interviews were analysed using the TDF to identify influences on behaviour, which were then mapped to techniques for behaviour change and developed into potential solutions.

RESULTS

The behavioural diagnosis of the challenges experienced during trial processes highlighted factors relevant to a range of TDF domains: Skills, Environmental context and resources, Beliefs about capabilities, Beliefs about consequences, Social influences, and Memory, attention, and decision-making processes. Within the solution development phase, we identified 24 suitable behaviour change techniques that were developed into proposed solutions to target reported process problems with the aim of changing behaviour to improve recruitment and/or intervention delivery. Proposed solutions included targeted changes to trial training content, suggestions to restructure the environment (e.g. reinforced the purpose of the trial with information about the social and environmental consequences) and other strategies to reduce barriers to recruitment and intervention delivery.

CONCLUSIONS

This study demonstrates the feasibility of applying a behavioural approach to investigate ('diagnose') behavioural trial process problems and subsequently develop and implement targeted solutions ('treatment') in an active trauma trial. Understanding the factors that affected behaviour, attitudes and beliefs in this trauma trial allowed us to implement theoretically informed, evidence-based solutions designed to enhance trial practices.

TRIAL REGISTRATION

ISRCTN 16,184,981.

"What is the actual goal of the pathway?": examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

Background

Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion.

Methods

Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation.

Results

The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2–4 predominant topics that can be condensed into six overarching themes regarding clinicians’ views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes.

Conclusion

Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

Measuring nurses' perceptions of their work environment and linking with behaviour change theories and implementation strategies to support evidence based practice change

PURPOSE

Survey tools, such as the Alberta Context Tool, reliably measure context but researchers have no process to map context to clinician behaviour and develop strategies to support practice change. Therefore, we aimed to map the Alberta Context Tool to the Theoretical Domains Framework and the Behaviour Change Wheel.

METHOD

The multi-centre study used the Alberta Context Tool to collect data from a convenience sample of nurses working in two emergency departments. These findings were categorised as barriers and enablers, and then mapped to the Theoretical Domains Framework to examine for behavioural domains. Using the Behaviour Change Wheel functions, strategies were developed to target clinician behaviour change.

RESULTS

Survey response rate was 42% (n = 68). Nurses perceived a positive work environment in the dimensions of Social Capital (median 4.00, IQR 0.33), Culture (median 3.83, IQR 1.16) and Leadership (median 3.60, IQR 1.1). Low scoring dimensions included Formal Interactions (median 2.75, IQR 1.00); Time (median 2.60, IQR 1.00) Staffing (median 3.0, IQR 2.00) and Space (median 3.0, IQR 2.00). Enablers (n = 77) and barriers (n = 25) were identified in both sites. The Theoretical Domains Framework was mapped to Alberta Context Tool barriers and enablers. The behaviour change strengths included: social and professional role; beliefs about capability; goals; and emotions. Using the Behaviour Change Wheel functions, 67 strategies were developed to address barriers and enablers.

CONCLUSIONS

The Alberta Context Tool successfully measured two emergency environments identifying barriers and enablers. This approach enabled environment dimensions to be targeted with practical solutions to support evidence-based practice implementation.

Lessons From Other Disciplines About Communication, Human Performance and Situational Awareness While Wearing Personal Protective Equipment

Introduction

The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/COVID-19) has quickly accelerated into a pandemic. As COVID-19 has swept across the globe, health systems have adapted, including the cessation of routine surgery and the re-deployment of staff to critical care settings. Prompt interventions such as endotracheal (ET) intubation, are deemed essential in patients with Acute Respiratory Distress Syndrome. Intubation requires a coordinated approach and effective teamwork, as it is a high-risk procedure not least because it is an aerosol-generating intervention with increased infection risk. As a result, teams responsible for performing ET intubation are required to wear Personal Protective Equipment (PPE), which in turn hinders communication and situational awareness, and can hamper team work.

Method

This review considers the effects of wearing PPE on performance and situational awareness in a healthcare environment. Drawing on literature from the fire service and military, the review will explore approaches to improving communication and situational awareness for teams who, at times, are unfamiliar with one another. The review will consider human factors and, identify approaches that assist teams, including teams that are unfamiliar with one another, to adapt to new ways of working while performing high-risk procedures.

Conclusion

Literature indicates that standardisation, pre-brief and training are important elements of developing improved situational awareness and team working in individuals whose senses may be affected by PPE. In addition, checklists provide a useful way of standardising procedures and can form the basis of a structured pre-brief. Checklists exist for both intubation and patient proning, which, alongside simulation-based team training, provide a useful method of preparing an often unfamiliar workforce for their roles during an epidemic or pandemic. The multi-phase nature of most pandemics provides an opportunity to review processes and implement such procedures, and to develop staff using team-based training during the post-peak period.

Interdisciplinary clinical debriefing in the emergency department: an observational study of learning topics and outcomes

Background

Defined as a ‘guided reflective learning conversation’, ‘debriefing’ is most often undertaken in small groups following healthcare simulation training. Clinical debriefing (CD) following experiences in the working environment has the potential to enhance learning and improve performance.

Methods

Prior to the study, a literature review was completed resulting in a standardised approach to CD that was used for training faculty. A pilot study of CD (n = 10) was then performed to derive a list of discussion topics and optimise the faculty training. The resulting debriefing approach was based on the “S.T.O.P.” structure (Summarise the case; Things that went well; Opportunities for improvement; Points of action). A debriefing aid, with suggested scripting, was provided. A subsequent observational study assessed CD within 1-h of clinical events. ‘Significantly distressing’ or ‘violent’ events were excluded. Data was collected on participant characteristics, discussion topics, and team recommendations. Study forms were non-identifiable. Subsequent analysis was performed by two investigators using content analysis of the debriefing forms (n = 71). Discussion topics (learning points) were coded using a modified version of the Promoting Excellence and Reflective Learning in Simulation (PEARLS) framework. One month after completion of the study, ED management staff were surveyed for reports of “harm” as the result of CD.

Results

During the study period, 71 CDs were recorded with a total of 506 participants. Mean debriefing length was 10.93 min (SD 5.6). Mean attendance was 7.13 (SD 3.3) participants. CD topics discussed were divided into ‘plus’ (well-done) and ‘delta’ (need to improve) groupings. 232 plus domains were recorded of which 195 (84.1%) aligned with the PEARLS debriefing framework, suggesting simulation debriefing skills may be translatable to a clinical setting. Topics discussed outside the PEARLS framework included family issues, patient outcome and environmental factors. CD reports led to preventative interventions for equipment problems and to changes in existing protocols. There were no recorded incidents of participant harm resulting from CD.

Conclusions

Topics discussed in CD predominantly aligned to those commonly observed in simulation-based medical education. Collective recommendations from CD can be used as evidence for improving existing protocols and models of care.

Theory-driven development of a medication adherence intervention delivered by eHealth and transplant team in allogeneic stem cell transplantation: the SMILe implementation science project

BACKGROUND

Medication adherence to immunosuppressants in allogeneic stem cell transplantation (alloSCT) is essential to achieve favorable clinical outcomes (e.g. control of Graft-versus-Host Disease). Over 600 apps supporting medication adherence exist, yet they lack successful implementation and sustainable use likely because of lack of end-user involvement and theoretical underpinnings in their development and insufficient attention to implementation methods to support their use in real-life settings. Medication adherence has three phases: initiation, implementation and persistence. We report the theory-driven development of an intervention module to support medication adherence (implementation and persistence phase) in alloSCT outpatients as a first step for future digitization and implementation in clinical setting within the SMILe project (Development, implementation and testing of an integrated care model in allogeneic SteM cell transplantatIon faciLitated by eHealth).

METHODS

We applied Michie's Behavior Change Wheel (BCW) and the Capability-Opportunity-Motivation and Behavior (COM-B) model using three suggested stages followed by one stage added by our team regarding preparation for digitization of the intervention: (I) Defining the problem in behavioral terms; (II) Identifying intervention options; (III) Identifying content and implementation options; (IV) SMILe Care Model Prototype Development. Scientific evidence, data from a contextual analysis and patients'/caregivers' and clinical experts' inputs were compiled to work through these steps.

RESULTS

(I) Correct immunosuppressant taking and timing were defined as target behaviors. The intervention's focus was determined within the COM-B dimensions Capability (lack of knowledge, lack of routine), Opportunity (lack of cues, interruptions in daily routine) and Motivation (lack of problem solving, trivialization). (II) Five intervention functions were chosen, i.e. education, training, modelling, persuasion and enablement. (III) Twenty-four behavior change techniques were selected, e.g., goal setting, action planning and problem solving. (IV) Finally, seventeen user stories were developed to guide the SMILeApp's software development process.

CONCLUSION

Our example on the theory-driven development of an intervention module in alloSCT delivered by eHealth and transplant team using a rigorous 3 + 1-stage approach based on BCW, COM-B and agile software development techniques, can be used as methodological guidance for other eHealth intervention developers. Our approach has the potential to enhance successful implementation and sustained use of eHealth solutions in real-life settings.

Interprofessional simulation training in difficult airway management: a narrative review

The aim of this narrative literature review was to explore the impact of interprofessional simulation-based team training on difficult airway management. The Fourth National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society identified recurrent deficits in practice that included delayed recognition of critical events, inadequate provision of appropriately trained staff and poor collaboration and communication strategies between teams. Computerised databases were assessed to enable data collection, and a narrative literature review and synthesis of eight quantitative studies were performed. Four core themes were identified: debriefing, measures of assessment and evaluation, non-technical skills and patient safety, and patient outcomes. There are many benefits to be gained from interprofessional simulation training as a method of teaching high-risk and infrequent clinical airway emergencies. The practised response to emergency algorithms is crucial and plays a vital role in the reduction of errors and adverse patient outcomes.