Roberts Neil, Lorencatto Fabiana, Manson Joanna, Brundage Susan I, Jansen Jan O
Departments of Critical Care and Anaesthesia, Royal Cornwall Hospital, Truro, Cornwall, UK.
Division of Health Services Research and Management, School of Health Sciences, City University London, London, UK.
Scand J Trauma Resusc Emerg Med. 2016 Mar 12;24:30. doi: 10.1186/s13049-016-0226-3.
Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations.
The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base.
1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes.
This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries.
作为创伤系统的一部分，大型创伤中心（MTC）可提高创伤患者的生存率和功能预后。由当前的教学医院发展此类中心可能会在工作人员中产生不同的观念，这些观念可能成为障碍或促进因素。事先识别这些因素可能会使服务发展过程更有效率。人们已经强调了应用理论来系统识别急诊医学中改变临床实践的障碍和促进因素的重要性。本研究系统地探讨了基于理论的障碍和促进因素，以推动一家三级医院转型为MTC。我们的目标是展示一种可复制的方法，以识别可解决的目标，从而实现从一个为提供特定类型临床护理而发展起来的组织成功转型为一个具有不同需求、要求和期望的临床系统。
理论领域框架（TDF）是一种旨在引出和分析影响行为的观念的工具。在苏格兰一家即将成为MTC的大型三级医院，围绕TDF进行了半结构式访谈，目的抽样选取了主要利益相关者，包括创伤护理相关专科的临床医生和护士、临床管理人员及行政人员。通过定性分析确定观念陈述，并根据普遍性、不一致性和证据基础评估其重要性。
记录了1728条话语并编码为91条观念陈述。58条被归类为重要的障碍/促进因素。对资源需求存在重大担忧，只有在这些需求得到满足的情况下才会持乐观态度。急诊科内分散注意力的优先事项众多。需要更好的沟通。工作人员积极性很高，应让他们参与技能发展和绩效改进流程。
本研究提出了一种系统且可复制的方法，用于识别基于理论的复杂服务发展障碍和促进因素。它识别出多个障碍/促进因素，可为制定实施干预措施以促进MTC的发展提供依据。这种方法可用于应对发展中国家和发达国家在发展专科中心或在急诊护理中实施临床实践变革方面的类似挑战。
