Bosch Marije, Tavender Emma J, Brennan Sue E, Knott Jonathan, Gruen Russell L, Green Sally E
Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia.
National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia.
PLoS One. 2016 Feb 4;11(2):e0148091. doi: 10.1371/journal.pone.0148091. eCollection 2016.
The Neurotrauma Evidence Translation (NET) Trial aims to design and evaluate the effectiveness of a targeted theory-and evidence-informed intervention to increase the uptake of evidence-based recommended practices for the management of patients who present to an emergency department (ED) with mild head injuries. When designing interventions to bring about change in organisational settings such as the ED, it is important to understand the impact of the context to ensure successful implementation of practice change. Few studies explicitly use organisational theory to study which factors are likely to be most important to address when planning change processes in the ED. Yet, this setting may have a unique set of organisational pressures that need to be taken into account when implementing new clinical practices. This paper aims to provide an in depth analysis of the organisational context in which ED management of mild head injuries and implementation of new practices occurs, drawing upon organisational level theory.
Semi-structured interviews were conducted with ED staff in Australia. The interviews explored the organisational context in relation to change and organisational factors influencing the management of patients presenting with mild head injuries. Two researchers coded the interview transcripts using thematic content analysis. The "model of diffusion in service organisations" was used to guide analyses and organisation of the results.
Nine directors, 20 doctors and 13 nurses of 13 hospitals were interviewed. With regard to characteristics of the innovation (i.e. the recommended practices) the most important factor was whether they were perceived as being in line with values and needs. Tension for change (the degree to which stakeholders perceive the current situation as intolerable or needing change) was relatively low for managing acute mild head injury symptoms, and mixed for managing longer-term symptoms (higher change commitment, but relatively low change efficacy). Regarding implementation processes, the importance of (visible) senior leadership for all professions involved was identified as a critical factor. An unpredictable and hectic environment brings challenges in creating an environment in which team-based and organisational learning can thrive (system antecedents for innovation). In addition, the position of the ED as the entry-point of the hospital points to the relevance of securing buy-in from other units.
We identified several organisational factors relevant to realising change in ED management of patients who present with mild head injuries. These factors will inform the intervention design and process evaluation in a trial evaluating the effectiveness of our implementation intervention.
神经创伤证据转化（NET）试验旨在设计并评估一种有针对性的、基于理论和证据的干预措施的有效性，以提高对轻度头部受伤并前往急诊科（ED）就诊患者的循证推荐治疗方法的采用率。在设计旨在促使急诊科等组织环境发生变化的干预措施时，了解环境的影响对于确保实践变革的成功实施至关重要。很少有研究明确运用组织理论来研究在规划急诊科变革过程时哪些因素可能最为重要。然而，在实施新的临床实践时，这个环境可能存在一系列独特的组织压力需要加以考虑。本文旨在运用组织层面理论，深入分析轻度头部受伤患者在急诊科的管理以及新实践实施所处的组织环境。
对澳大利亚急诊科工作人员进行了半结构化访谈。访谈探讨了与变革相关的组织环境以及影响轻度头部受伤患者管理的组织因素。两名研究人员采用主题内容分析法对访谈记录进行编码。运用“服务组织中的扩散模型”来指导结果的分析和组织。
对13家医院的9名主任、20名医生和13名护士进行了访谈。关于创新（即推荐治疗方法）的特征，最重要的因素是它们是否被认为符合价值观和需求。对于急性轻度头部受伤症状的管理，变革压力（利益相关者认为当前状况不可容忍或需要改变的程度）相对较低，而对于长期症状的管理则好坏参半（变革承诺较高，但变革效能相对较低）。关于实施过程，确定（可见的）高层领导对所有相关专业人员的重要性是一个关键因素。不可预测且忙碌的环境给营造一个团队学习和组织学习能够蓬勃发展的环境带来了挑战（创新的系统前提）。此外，急诊科作为医院入口的地位表明获得其他科室认可的相关性。
我们确定了与实现轻度头部受伤患者急诊科管理变革相关的几个组织因素。这些因素将为评估我们实施干预措施有效性的试验中的干预设计和过程评估提供参考。
