Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement “Sepsis Six”

Abstract

BackgroundSepsis has a mortality rate of 40 %, which can be halved if the evidence-based “Sepsis Six” care bundle is implemented within 1 h. UK audit shows low implementation rates. Interventions to improve this have had minimal effects. Quality improvement programmes could be further developed by using theoretical frameworks (Theoretical Domains Framework (TDF)) to modify existing interventions by identifying influences on clinical behaviour and selecting appropriate content. The aim of this study was to illustrate using this process to modify an intervention designed using plan-do-study-act (P-D-S-A) cycles that had achieved partial success in improving Sepsis Six implementation in one hospital.MethodsFactors influencing implementation were investigated using the TDF to analyse interviews with 34 health professionals. The nursing team who developed and facilitated the intervention used the data to select modifications using the Behaviour Change Technique (BCT) Taxonomy (v1) and the APEASE criteria: affordability, practicability, effectiveness, acceptability, safety and equity.ResultsFive themes were identified as influencing implementation and guided intervention modification. These were:(1) “knowing what to do and why” (TDF domains knowledge, social/professional role and identity); (2) “risks and benefits” (beliefs about consequences), e.g. fear of harming patients through fluid overload acting as a barrier to implementation versus belief in the bundle’s effectiveness acting as a lever to implementation; (3) “working together” (social influences, social/professional role and identity), e.g. team collaboration acting as a lever versus doctor/nurse conflict acting as a barrier; (4) “empowerment and support” (beliefs about capabilities, social/professional role and identity, behavioural regulation, social influences), e.g. involving staff in intervention development acting as a lever versus lack of confidence to challenge colleagues’ decisions not to implement acting as a barrier; (5) “staffing levels” (environmental context and resources), e.g. shortages of doctors at night preventing implementation.The modified intervention included six new BCTs and consisted of two additional components (Sepsis Six training for the Hospital at Night Co-ordinator; a partnership agreement endorsing engagement of all clinical staff and permitting collegial challenge) and modifications to two existing components (staff education sessions; documents and materials).ConclusionsThis work demonstrates the feasibility of the TDF and BCT Taxonomy (v1) for developing an existing quality improvement intervention. The tools are compatible with the pragmatic P-D-S-A cycle approach generally used in quality improvement work.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0376-8) contains supplementary material, which is available to authorized users.

What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis

“…The use of available BCT × TDF domain mapping tools in a systematic review context represents a methodologically innovative aspect of this work and provides an example of how these recently developed tools may be further applied in secondary analyses of existing interventions. This systematic approach also demonstrates how these frameworks may be applied to identify limitations of, and missed opportunities in, the design of existing interventions, 221 and thus offers clear implications for future intervention refinement, design and research. In turn, this systematic approach has clear implications for future intervention design, refinement and research.…”

Factors influencing application of behavioural science evidence by public health decision-makers and practitioners, and implications for practice

“…The current research utilises the Theoretical Domains Framework (TDF) ( Francis et al, 2012 ; Cane et al, 2012 ) which unites theoretical constructs from multiple behaviour change theories. The TDF classifies 14 domains including ‘Knowledge’, ‘Skills’, ‘Beliefs about capabilities’ and ‘Emotion’, known to influence behaviour and offer potential targets for change ( Steinmo et al, 2016 ). The TDF has been used to study a range of health professionals behaviours ( Fuller et al, 2014 ; Patey et al, 2012 ; Curran et al, 2013 ; French et al, 2012 ; Bussières et al, 2012 ) and offers ‘an inclusive, rather than selective, approach to exploratory research in the field of implementation’ ( Francis et al, 2012: 6 ).…”

Developing interventions to improve health: a systematic mapping review of international practice between 2015 and 2016

“…When the intervention aimed to increase implementation of an existing intervention, the target population was not those directly affected by the health issue. For example, Steinmo et al [46] set out to improve the implementation of the 'Sepsis Six' care bundle [47] because the target for use of the Sepsis Six bundle had not been reached within a UK hospital. In this instance, they viewed the target population as those in a position to implement 'Sepsis Six' rather than patients receiving the bundle.…”

“…Developers working with high levels of stakeholder involvement identified a concern that the developed intervention might have limited transferability beyond the setting or group that contributed to its development. For example, Steinmo et al [46] observed that their collaborative approach was an important strength and a significant lever to the success of the intervention because it allowed the intervention to be shaped to the specific context; however, it was also a limitation because they could not draw conclusions about feasibility in other hospitals.…”

“…Others identified behavioural targets through consultation with stakeholders (e.g. Steinmo et al [46]), from qualitative research with the target population (e.g. Mummah et al [59]), or from a combination of all of these (e.g.…”