Department of Surgery and Cancer, Imperial College London, London, UK.
Centre for Behaviour Change, University College London, London, UK.
Lancet. 2023 Nov;402 Suppl 1:S67. doi: 10.1016/S0140-6736(23)02122-0.
Poor handovers between hospital and primary care threaten safe discharges, with elderly and frail patients most at risk of harm. Using Behavioural Science we explored influences and identified relevant behaviour change techniques (BCTs) to improve written handovers and safety during discharge.
We conducted two qualitative studies: (1) ethnographic observations (>80 h) collected by five researchers in five purposively sampled clinical areas of a London teaching hospital, investigating routine work and interactions of hospital staff involved in discharges; and (2) 12 semi-structured interviews with hospital staff involved in discharge exploring influences on preparations of written handovers. Written consent was sought from clinical leads for ethnographic observations and from interview participants. Ethnographic fieldnotes and interview transcripts were thematically analysed using inductive and deductive approaches, respectively. Study findings were triangulated to identify key influences, mapped onto the Theoretical Domains Framework (TDF). We identified appropriate BCTs to address observed influences within each TDF domain using the Theory and Techniques Tool. Health-care workers (n=15), patients (n=2) and carers (n=2) selected and designed an intervention to improve written handovers in two workshops. Hospital workshop participants were involved with preparing written discharge handovers. Public participants had either recently been discharged from hospital or cared for someone recently discharged, including patients from groups especially vulnerable during discharge.
Triangulation of study findings generated 11 key influences on preparations of written handovers within five TDF domains: knowledge (eg, lack of awareness of guidelines), skills (staff experience), social or professional role and identity (effective communication), environmental context and resources (working patterns), and social influences (lack of feedback). 14 BCTs were identified to address these influences, including behavioural rehearsal or practice, instruction on how to perform a behaviour, and social support (practical). Workshop participants selected and designed a multifaceted educational intervention to improve written handovers.
The quality of handover documentation prepared by hospital staff for primary care teams is affected by influences from multiple domains, requiring a multifaceted approach to improve handovers. Although only based on findings from one hospital, the designed intervention should be tested in clinical settings with key stakeholders, including primary care staff, to evaluate impact on quality of written handovers and patient safety.
National Institute for Health and Care Research (NIHR) Imperial Patient Safety Translational Research Centre.
医院和初级保健之间交接不善会威胁到安全出院，而最容易受到伤害的是老年和体弱患者。我们运用行为科学的方法来探讨影响因素，并确定相关的行为改变技术（BCT），以改进出院时的书面交接并提高安全性。
我们进行了两项定性研究：（1）由五名研究人员在伦敦一所教学医院的五个有针对性地抽样的临床科室进行的民族志观察（>80 小时），调查了参与出院的医院工作人员的日常工作和互动；（2）对参与出院准备工作的医院工作人员进行了 12 次半结构访谈，以探讨影响书面交接准备的因素。对民族志观察征求了临床负责人的书面同意，对访谈参与者征求了口头同意。民族志实地记录和访谈记录分别采用归纳法和演绎法进行主题分析。研究结果经过三角分析，以确定关键影响因素，并将其映射到理论领域框架（TDF）上。我们使用理论和技术工具，在每个 TDF 领域中确定了适当的 BCT，以解决观察到的影响。医护人员（n=15）、患者（n=2）和护理人员（n=2）在两次研讨会上选择并设计了一项改进书面交接的干预措施。医院研讨会的参与者参与了书面出院交接的准备工作。公众参与者要么最近刚从医院出院，要么照顾过最近出院的人，包括在出院期间特别脆弱的群体的患者。
研究结果的三角分析产生了五个 TDF 领域内书面交接准备的 11 个关键影响因素：知识（例如，缺乏对指南的认识）、技能（员工经验）、社会或专业角色和身份（有效沟通）、环境背景和资源（工作模式）以及社会影响（缺乏反馈）。确定了 14 个 BCT 来解决这些影响因素，包括行为排练或实践、关于如何执行行为的指导以及社会支持（实际支持）。研讨会参与者选择并设计了一项多方面的教育干预措施，以改进书面交接。
医院工作人员为初级保健团队准备的交接文件的质量受到来自多个领域的影响，因此需要采取多方面的方法来改进交接。尽管这只是基于一家医院的发现，但设计的干预措施应在具有关键利益相关者的临床环境中进行测试，包括初级保健工作人员，以评估其对书面交接质量和患者安全的影响。
英国国家卫生与保健优化研究所（NIHR）帝国患者安全转化研究中心。
