Drew Sarah, Judge Andrew, May Carl, Farmer Andrew, Cooper Cyrus, Javaid M Kassim, Gooberman-Hill Rachael
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK.
MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD, UK.
Implement Sci. 2015 Apr 23;10:57. doi: 10.1186/s13012-015-0243-z.
National and international guidance emphasizes the need for hospitals to have effective secondary fracture prevention services, to reduce the risk of future fractures in hip fracture patients. Variation exists in how hospitals organize these services, and there remain significant gaps in care. No research has systematically explored reasons for this to understand how to successfully implement these services. The objective of this study was to use extended Normalization Process Theory to understand how secondary fracture prevention services can be successfully implemented.
Forty-three semi-structured interviews were conducted with healthcare professionals involved in delivering secondary fracture prevention within 11 hospitals that receive patients with acute hip fracture in one region in England. These included orthogeriatricians, fracture prevention nurses and service managers. Extended Normalization Process Theory was used to inform study design and analysis.
Extended Normalization Process Theory specifies four constructs relating to collective action in service implementation: capacity, potential, capability and contribution. The capacity of healthcare professionals to co-operate and co-ordinate their actions was achieved using dedicated fracture prevention co-ordinators to organize important processes of care. However, participants described effective communication with GPs as challenging. Individual potential and commitment to operationalize services was generally high. Shared commitments were promoted through multi-disciplinary team working, facilitated by fracture prevention co-ordinators. Healthcare professionals had capacity to deliver multiple components of services when co-ordinators 'freed up' time. As key agents in its intervention, fracture prevention coordinators were therefore indispensable to effective implementation. Aside from difficulty of co-ordination with primary care, the intervention was highly workable and easily integrated into practice. Nevertheless, implementation was threatened by under-staffed and under-resourced services, lack of capacity to administer scans and poor patient access. To ensure ongoing service delivery, the contributions of healthcare professionals were shaped by planning, in multi-disciplinary team meetings, the use of clinical databases to identify patients and define the composition of clinical work and monitoring to improve clinical practice.
Findings identify and describe elements needed to implement secondary fracture prevention services successfully. The study highlights the value of Normalization Process Theory to achieve comprehensive understanding of healthcare professionals' experiences in enacting a complex intervention.
国内和国际指南都强调医院需要提供有效的二次骨折预防服务，以降低髋部骨折患者未来发生骨折的风险。医院组织这些服务的方式存在差异，护理方面仍存在重大差距。尚无研究系统地探究其原因，以了解如何成功实施这些服务。本研究的目的是运用扩展的规范化过程理论，来理解二次骨折预防服务如何能够成功实施。
对参与英格兰一个地区11家接收急性髋部骨折患者医院的二次骨折预防服务的医疗保健专业人员进行了43次半结构化访谈。这些人员包括老年骨科医生、骨折预防护士和服务经理。扩展的规范化过程理论为研究设计和分析提供了指导。
扩展的规范化过程理论明确了与服务实施中的集体行动相关的四个要素：能力、潜力、能力和贡献。通过设立专门的骨折预防协调员来组织重要的护理流程，实现了医疗保健专业人员合作与协调行动的能力。然而，参与者表示与全科医生进行有效沟通具有挑战性。个人实施服务的潜力和积极性普遍较高。骨折预防协调员促进了多学科团队合作，从而推动了共同的承诺。当协调员“腾出”时间时，医疗保健专业人员有能力提供服务的多个组成部分。因此，作为干预措施中的关键因素，骨折预防协调员对于有效实施至关重要。除了与初级保健协调困难外，该干预措施具有很高的可行性，并且易于融入实践。尽管如此，人员配备不足和资源匮乏、缺乏进行扫描的能力以及患者就诊不便，都对实施构成了威胁。为确保服务的持续提供，在多学科团队会议中通过规划、利用临床数据库识别患者并确定临床工作的组成以及进行监测以改善临床实践，塑造了医疗保健专业人员的贡献。
研究结果确定并描述了成功实施二次骨折预防服务所需的要素。该研究强调了规范化过程理论对于全面理解医疗保健专业人员在实施复杂干预措施过程中的经验的价值。
