26.05.16
Behaviour change for patient safety
Rebecca Lawton, professor of psychology at the University of Leeds, and an academic advisor to the Y&H AHSN Improvement Academy, talks to NHE’s David Stevenson about behaviour change and the impact it can have on patient safety.
“Many things we do in healthcare to improve safety, such as the introduction of new guidelines and technologies require NHS staff to change their behaviour. It is often assumed that this is easy – tell people what to do and they will do it.”
This is the ‘nutshell’ definition on the Improvement Academy’s website about behaviour change for patient safety, but it does add “this can be difficult to achieve”.
Highlighting this difficulty, Rebecca Lawton, professor of psychology at the University of Leeds, who is an academic advisor to the Improvement Academy, told NHE that not a great deal of effort tends to go into strategies to actually implement the changes in practice.
“When I’m speaking to my healthcare colleagues, I tend to refer them to the fact that everybody knows you shouldn’t smoke – smokers know that you shouldn’t smoke, there’s not much point in telling them anymore that they shouldn’t do that or what the risks are,” she said. “What we need to look at are the other factors that might affect their behaviour and work on addressing those determinants of behaviour.
“It is about looking at what your technology or guidance requires in terms of the resources or environmental changes in order to allow it to work. But it is also about focusing on the individual, but looking beyond knowledge.”
Prof Lawton added that this can involve focusing on the emotional reaction from staff to change, and whether they feel comfortable with the new way of working, or looking at social influences. For instance, supervisors or colleagues saying that ‘you don’t really need to do that’, which she adds happens more than you think.
While not advocating using behaviour change for every trivial matter – as the process, which is underpinned by tried and tested theories from psychology, comes with a cost – Prof Lawton did note that it can help deliver payback for trusts.
“We did a piece of work in the Yorkshire and Humber region, about three years ago, where the NPSA (National Patient Safety Agency) guidance was that people should stop using X-ray first line to check the position of nasogastric tubes, and instead should start using pH testing to check the tube was in the stomach,” she said.
She added that the team, working in three hospitals with a fourth acting as a control, adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change.
“In each of the hospitals a team of experts in that specialist area got together and we worked with them to use a set of tools, based on behaviour change theory, and they went through a process of understanding what people’s barriers were to change, and then developing interventions which specifically addressed those barriers,” said Prof Lawton.
“One of them, for example, was that social influence was a problem. Senior staff were saying to more junior staff: ‘just send for an X-ray, don’t worry about the pH testing stuff’. To address this, we had a training day showing people how to use pH testing correctly, but being modelled by senior members of staff. Another problem was the really simple issue that on some wards, pH testing paper simply wasn’t available.
“We identified the barriers, but the teams themselves devised the solutions. It was a very much bottom-up approach to implementation.”
Following the intervention implementation, the use of pH first line increased significantly across the hospitals and it was estimated that the cost savings in the first year were £2.56m across the region.
“It was a win-win really, we had greater safety but we also had cost savings for the trust,” said Prof Lawton, adding that when people are implementing change in the future they should, more generally, consider the implications and match barriers with appropriate interventions.
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