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DEveloping a Complex Intervention for DEteriorating Patients using Theoretical Modelling (DECIDE study)

Smith, D.J. (2022). DEveloping a Complex Intervention for DEteriorating Patients using Theoretical Modelling (DECIDE study). (Unpublished Doctoral thesis, City, University of London)


Patients who deteriorate without recognition and/or response are at risk of unplanned admission to intensive care, cardiac arrest, death (termed Serious Adverse Events (SAEs)). To mitigate SAEs, track-and-trigger tools are used internationally to prompt healthcare practitioners (typically nursing staff) to recognise physiological changes that signal deterioration, and to contact a practitioner with expertise in acute/critical illness. In the United Kingdom and parts of Europe, the National Early Warning Score (NEWS) (track-and-trigger tool) was developed and disseminated widely to standardise practice. Despite evidence track-and-trigger tools (like NEWS) improve patient outcomes, their translation into clinical practice is inconsistent. This is partly attributed to nursing staff failing to change their behaviour.

To develop a theory-based, preliminary, behaviour change intervention, to enhance enablers and overcome barriers to Registered Nurses (RNs) and Healthcare Assistants (HCAs) enacting expected behaviours in recognising and responding to signs of patient deterioration.

A mixed methods design with three phases: 1. Focused ethnography on two clinical floors in an acute hospital to compare directly observed behaviours (of RNs and HCAs) with those specified in policy. From directed content analysis of field notes, target behaviours were identified, specified, and shortlisted; 2. Brief (not audio-recorded but recorded in field notes) interviews were conducted soon after direct observation of relevant behaviour. Some brief interview participants were recruited for an audio-recorded, semi-structured, interview informed by a Theoretical Domains Framework (TDF) topic guide. Interview data were analysed deductively (the 14 TDF domains were coding categories) and inductively to identify determinants (i.e. barriers and enablers) of target behaviours. TDF domains representing important determinants were identified using published criteria and linked to Behaviour Change Techniques (BCTs) from expert consensus literature; 3. BCTs were shortlisted by the research team and presented to clinical stakeholders alongside example applications (i.e. concrete strategies for operationalising BCTs). Using Nominal Group Technique, stakeholders ranked BCTs and their potential applications for acceptability and feasibility. Ranking data were used to inform the content of the preliminary intervention.

During 300 hours of fieldwork, 499 items of data (i.e. an episode of observation or a set of vital signs from chart review) were recorded; 289 (58%) associated with expected (i.e. policy-specified) behaviour; 210 (42%) associated with unexpected behaviour (i.e. alternative behaviour or no behaviour). Ten behaviours were identified as potential behaviours for change; shortlisted to seven target behaviours. Brief interviews were conducted with 39 RNs and 50 HCAs, and semi-structured interviews with 16 RNs and 16 HCAs. Quotes from interviews were linked to nine (for brief interviews) and 14 (for semi-structured interviews) TDF domains. Nine TDF domains were identified as being of high importance: Knowledge, Social Professional Role and Identity, Beliefs about Consequences, Reinforcement, Intentions, Goals, Memory, Attention and Decision Processes, Environmental Context and Resources, Social Influences. These domains were linked to 50 BCTs; shortlisted to 14. Ranking data from two nominal groups held with 19 stakeholders were used to shortlist further, resulting in a preliminary intervention that includes an educational package and 12 BCTs that will be delivered through workshops and on acute wards, using 18 applications.

This research makes a unique contribution to the international body of evidence, as it is the first study where a theoretical framework of behaviour change has been used to model an intervention to improve responses to deteriorating patients by RNs and HCAs. The intervention is preliminary, as it is anticipated that it will be refined during a subsequent feasibility study (a programme of work planned for after this PhD).

Publication Type: Thesis (Doctoral)
Subjects: R Medicine > RT Nursing
Departments: School of Health & Psychological Sciences
School of Health & Psychological Sciences > School of Health & Psychological Sciences Doctoral Theses
Doctoral Theses
[thumbnail of Smith DJ thesis volume 1 .pdf]
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[thumbnail of Smith DJ Thesis volume 2.pdf]
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