The document discusses strategies for achieving behavior change in patient safety, emphasizing the importance of assessing individual barriers and tailoring interventions based on theoretical frameworks. It outlines how psychological theories can enhance the effectiveness of behavior change techniques, as well as provides examples of barriers and suggested strategies from focus group results. Theoretical frameworks, such as the Theoretical Domains Framework, guide the development and implementation of interventions aimed at improving compliance with patient safety measures.

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Achieving Behaviour Change for Patient safety
Dr Judith Dyson
Academic Improvement Fellow

2. Quality Improvement

3. Background

4. Lets first consider behaviour
•Health behaviour
•Patients concordance
•Implementation
What determines our behaviour?
What strategies do we generally employ to change?

5. 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)

6. 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)

7. But tricky

8. 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

9. 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)

10. 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

11. 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

12. 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

13. 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

14. 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)

15. Putting it into practice
•The improvement academy
•Behaviour change workshops
•The toolkit
•My role within the academy

16. Workshops

17. Where to find the toolkit
The 6 steps
Me
Worked
examples
www.improvementacademy.org

18. My role
•“It’s all about urine”
•Electronic monitoring of HH
•Safer dispensing
•Medicines on care transfer
•Sepsis bundle
•Restructuring of teams
•Falling

19. “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 . . . . . . . . .

20. Steps 1 and 2

21. 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. . . . .

22. Understanding Barriers

24. Validity and Reliability

25. What do you think the barriers are?
•Sending an MSU after a dipstick when nursing assistants discover leucocytes and nitrates?

27. Next steps

28. Devising interventions

29. Defined and with examples

30. Behaviour change techniques for specific barriers

31. Implement. . . .Evaluate

33. Evaluate
•Table (behaviour change)
•Run chart (behaviour change)
•Barriers before and after
•Impact on outcomes (e.g. MRSA, falls)

34. Is this approach helpful? Weaknesses?
•It is for us 
•?difficult to navigate and understand
•Formal evaluation
•There is more info’ . . . . balance
•Keeping things current

35. 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

36. Thank you
Any questions? Feel free to contact me: Judith Dyson J.Dyson@hull.ac.uk
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