Hampton Sarah, Murray Jenni, Lawton Rebecca, Sheard Laura
Health Sciences, University of York, York, UK
Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK.
BMJ Qual Saf. 2025 Jan 28;34(2):92-99. doi: 10.1136/bmjqs-2024-017268.
'Hybrid' interventions in which some intervention components are fixed across sites and others are flexible (locally created) are thought to allow for adaptation to the local context while maintaining fidelity. However, there is little evidence regarding the challenges and facilitators of implementing hybrid interventions. This paper reports on a process evaluation of a patient safety hybrid intervention called Your Care Needs You (YCNY). YCNY was tested in the Partners at Care Transitions (PACT) randomised controlled trial and aimed to enhance older patients and their families' involvement in their care in order to achieve safer transitions from hospital to home.
The process evaluation took place across eight intervention wards taking part in the PACT trial. 23 interviews and 37 informal conversations were conducted with National Health Service (NHS) staff. Patients (n=19) were interviewed twice, once in hospital and once after discharge. Interviews with staff and patients concerned the delivery and experiences of YCNY. Ethnographic observations (n=81 hours) of relevant activities (eg, multidisciplinary team meetings, handovers, etc) were undertaken.
The main finding relates to how staff understood and engaged with YCNY, which then had a major influence on its implementation. While staff broadly valued the aims of YCNY, staff from seven out of the eight wards taking part in the process evaluation enacted YCNY in a mostly task-based manner. YCNY implementation often became a hurried activity which concentrated on delivering fixed intervention components rather than a catalyst for culture change around patient involvement. Factors such as understaffing, constraints on staff time and the COVID-19 pandemic contributed towards a 'taskification' of intervention delivery, which meant staff often did not have capacity to creatively devise flexible intervention components. However, one ward with a sense of distributed ownership of YCNY had considerable success implementing flexible components.
Hybrid interventions may allow aspects of an intervention to be adapted to the local context. However, the current constrained and pressured environment of the NHS left staff with little ability to creatively engage with devising flexible intervention components, despite recognising the need for and being motivated to deliver the intervention.
“混合”干预是指一些干预组件在各地点是固定的，而其他组件是灵活的（在当地创建），人们认为这种干预在保持保真度的同时能够适应当地情况。然而，关于实施混合干预的挑战和促进因素的证据很少。本文报告了一项名为“您的护理需要您”（YCNY）的患者安全混合干预的过程评估。YCNY在“护理过渡伙伴关系”（PACT）随机对照试验中进行了测试，旨在增强老年患者及其家庭对其护理的参与度，以实现从医院到家庭的更安全过渡。
过程评估在参与PACT试验的8个干预病房中进行。对国民保健服务（NHS）工作人员进行了23次访谈和37次非正式交谈。对19名患者进行了两次访谈，一次在医院，一次在出院后。与工作人员和患者的访谈涉及YCNY的实施和体验。对相关活动（如多学科团队会议、交接班等）进行了81小时的人种学观察。
主要发现涉及工作人员如何理解和参与YCNY，这进而对其实施产生了重大影响。虽然工作人员普遍重视YCNY的目标，但参与过程评估的8个病房中有7个病房的工作人员大多以基于任务的方式实施YCNY。YCNY的实施往往变成一项匆忙的活动，集中于提供固定的干预组件，而不是围绕患者参与进行文化变革的催化剂。人员不足、工作人员时间受限以及新冠疫情等因素导致干预实施出现“任务化”，这意味着工作人员往往没有能力创造性地设计灵活的干预组件。然而，一个对YCNY有分布式所有权意识的病房在实施灵活组件方面取得了相当大的成功。
混合干预可能使干预的某些方面能够适应当地情况。然而，国民保健服务当前受限且压力大的环境使工作人员尽管认识到实施干预的必要性并有积极性，但几乎没有能力创造性地参与设计灵活的干预组件。
