Identifying facilitators and barriers to develop implementation strategy for an ED to Ward handover tool using behaviour change theory (EDWHAT)

Abstract

Background

Effective clinical handover is fundamental to clinical practice and recognised as a global quality and safety priority. Problems with clinical handover from the emergency department (ED) to inpatient ward across four hospitals in the Illawarra Shoalhaven Local Health District (ISLHD) were identified in a number of reportable clinical incidents. To address this, an ED to inpatient ward electronic clinical handover tool was developed and implemented. However, site uptake of the tool varied from 45 to 90%.

Aim

To determine the facilitators and barriers of the ED to Ward Handover Tool (EDWHAT) implementation and design strategy to improve local compliance and inform wider implementation.

Methods

An exploratory convergent mixed-method approach was used. Data were collected via a 13-item electronic survey informed by the Theoretical Domains Framework (TDF) distributed to eligible nurses across the health district. Descriptive statistics for quantitative data and thematic analysis for qualitative data were conducted. The data were then integrated and mapped to the TDF and the Behaviour Change Wheel to identify specific behaviour change techniques to support implementation.

Results

There were 300 respondents. The majority of nurses knew where to locate the tool (91.26%), but 45.79% felt that it was not adequate to ensure safe handover. The most frequently reported factors that hindered nurses from using the tool were inability to access a phone near a computer (44.32%) (environmental domain), being told to transfer the patient before being able to complete the form (39.93%) (reinforcement) and the other nurse receiving (or giving) the handover not using the form (38.83%) (social influence). An implementation checklist to identify barriers and solutions to future uptake was developed.

Conclusion

To improve uptake, the functionality, content, and flow of the handover tool must be revised, alongside environmental restructuring. Nurses would benefit from an awareness of each speciality’s needs to develop a shared mental model and monitoring, and enforcement of tool use should become part of a routine audit.

Contributions to the literature

• This original research work presents the facilitators and barriers of the ED to Ward Handover Tool (EDWHAT) implementation and design strategy to improve local compliance and inform wider implementation.

• Behaviour change theory is applied to the emergency and acute care environment to find real-world practical solutions to improving clinical handover—a quality improvement priority.

Background

Effective clinical handover is fundamental to clinical practice and is recognised as a local [1], national [2], and global [3] quality and safety priority. Ineffective clinical handover increases the risk of patient-related errors as a result of poor communication and the lack of appropriate and timely transfer of critical information at the time of reporting. This creates inefficiencies in clinical practice leading to suboptimal patient care [2]. This is especially problematic at transitions of care, such as transfer from the ED to the ward, when communication errors are more likely and there is an increased risk of information being miscommunicated or lost. Ineffective communication at clinical handover is also associated with clinicians spending extensive time attempting to retrieve relevant and correct information [4]. This can result in inappropriate care, and the possibility of misuse or poor use of resources [5]. There remain multiple barriers to effective handover including a lack of systematic structure, including incomplete handovers, excessive reliance on memory without reference to written documentation and poor quality of written medical records [6]. These barriers are particularly prevalent in the complex and hectic emergency department (ED) context where more than 2.5 million ED to ward clinical handovers occur in Australian hospitals each year [7], and the work pattern is unpredictable making delivery of safe patient handover challenging [8]. Responses to this have included recommendations to standardise the structure of handover communication [9] and include the patient and their carers in the handover [2]. An effective standardised and structured clinical handover process enhances the reliability of information transfer by decreasing the reliance on memory and maintaining a focus on important aspects of care [10]. All relevant participants know the minimum information that needs to be communicated when handovers take place, the purpose of the handover, the structured format to aid communication, and how responsibility and accountability are transferred. Further, critical information is more likely to be accurately transferred and acted on. Standardised and structured clinical handover results in greater levels of patient satisfaction [11], better understanding of diagnosis and treatment [12], and reduced errors [6, 13].

The clinical handover from the ED to inpatient ward across four hospitals in the Illawarra Shoalhaven Local Health District (ISLHD) was identified by incident management system reports to be inadequate. The clinical handover practice was not meeting key criteria of the local Ministry of Health policy Clinical Handover [1], particularly the requirement of a standardised process as different groups of clinicians were requiring different information resulting in varying quality of the information provided. This coincided with a number of reportable clinical incidents, and subsequent recommendations to improve the standard of ED to ward clinical handover practices.

To address this policy—practice gap, an ED to inpatient ward clinical handover tool (EDWHAT), was developed to comply with the Ministry of Health Clinical Handover policy and for the use in the digital platform used by the ISLHD (Fig. 1). EDWHAT was developed by an ED and ward nurse educator and nurse manager. The tool was reviewed by a small group of senior nurses and then implemented at all four hospital sites by local nurse educators using face to face education. A formal strategy was not developed. A local audit following the implementation of EDWHAT demonstrated that uptake of the tool was mixed between sites and wards. Compliance at the different sites ranged from 45 to 90% (mean 70.1%). The proposed research will determine the facilitators and barriers to the use of this newly implemented clinical handover tool by nursing staff at the study sites. Behaviour change theory will then be used to develop interventions to improve the target behaviour, that is, the use of the clinical handover tool.

Fig. 1

The ED to Ward electronic handover tool

Methods

This exploratory convergent mixed-method study [14] was designed using French et al.’s four-step implementation process model [15]; (a) clarifying who needs to do what differently (nursing staff), (b) identifying barriers and enablers (electronic survey of nursing staff, informed by the Theoretical Domains Framework), (c) selecting fit-for-purpose intervention strategies and components (mapping survey results using the behaviour change wheel) and (d) evaluating implementation interventions (comparing the original implementation with the findings of this study). The study process is outlined in Fig. 2. The study was conducted in a Local Health District (LHD) which has four geographically and casemix diverse EDs (rural, regional, metropolitan). The STROBE Statement was used as a checklist for reporting guidelines for cross-sectional studies and is provided as Additional file 1. Research conducted as part of this study adhered to the National Statement on the Conduct of Human Research by the Australian National Health and Medical Research Council and was approved by the University of Wollongong (UOW) and ISLHD Health and Medical Human Research Ethics Committee (LNR/18/WGONG/148).

Fig. 2

Convergent mixed methods study informed by behaviour change theory

Phase 1: staff survey

Instrument

The electronic survey was administered via REDCap (Research Data Capture), a secure Web-based application for data management and survey tool. The survey commenced with participant characteristics such as age, place of work (ward or ED) and level of experience. This was followed by 11 questions focussed on known barriers and enablers to uptake of new tools in the clinical environment generally [2] and specific to the study site [16, 17] that were then mapped to the domains of the Theoretical Domains Framework (TDF). The TDF is a synthesis of behavioural change theories presented as a framework to explore the science of intervention implementation in health care [18]. The TDF was selected to inform the survey to enable targeted questions related to practice within the clinical environment, classification of enablers and barriers using a broad range behavioural influences, as the investigators had previously successfully used the TDF to identify and design interventions in the ED/acute care context [16, 17, 19]. Each of the key influences on behaviour are listed in Table 1. The information gathered from the survey assisted in identifying the main factors influencing behaviour change in the clinical setting. Most questions had a 5-point Likert response, with the opportunity for free text/comment. The survey can be found in Additional file 2.

Table 1 The 14 behavioural influences of the Theoretical Domains Framework [20]

Participant recruitment and procedure

Eligible participants were registered or enrolled nurses, who as part of their role would be involved in the giving or receiving of handover on patients being transferred from an ISLHD ED to a participating inpatient unit within the ISLHD. Maternity and mental health units were excluded as at the time of the study, they did not use the handover tool. There were approximately 3000 nurses across ISLHD eligible to complete the survey.

The study was conducted over a 5-month period from November 2018 to March 2019. The data collection period was extended due to delays in distribution and the Christmas holiday period. Participants were emailed the survey link and a participant information sheet to their NSW Health staff email address via their managers. Time to complete the survey was allocated during education and other downtimes. Reminders were sent fortnightly.

Data analysis

Quantitative survey data were analysed using descriptive statistics. Preliminary analyses were run to check for missing data. Responses were presented as proportional data. Sub-analyses were conducted to identify specific barriers or facilitators by site, and/or by ward or ED location. Qualitative data from the free-text responses were analysed using inductive thematic analysis using Braun and Clark’s 6-step process [21]. The responses were read through several times to get a sense of the data and allocated into thematic areas [22]. The meaning units were developed by condensing the text. Meaning units were classified into themes and sub-themes. This process was completed by two authors (KR and KC).

Phase 2: identification of facilitators and barriers and data integration

Quantitative items were considered facilitators if they were positively worded with greater or equal to 70% agreement with a statement. Items were considered barriers if they were positively worded with less than 70% agreement with a statement [23, 24]. Qualitative themes were considered facilitators or barriers based on the literature, and/or positively or negatively worded statement. The quantitative and qualitative results were then mapped to each of the TDF domains by two authors (KR and KC). Each item was reviewed to identify potential facilitators and barriers to implementation in each domain. If it was unclear if an item (survey response or theme) was a facilitator or barrier for the implementation, then the consensus was sought from a senior member of the study team with experience in the use of the TDF (BM). For any items that crossed multiple domains, for ease of presentation, we selected the domain we felt most represented the item. However, if the secondary domain was not identified in any other items, we allocated that domain to prevent the omission of any relevant domains. Sub-analyses (cross-tabulation) of enablers and barriers were conducted to determine if there were any findings specific to the type of nurse (ED or ward) or hospital site.

Phase 3: development of implementation strategies

The facilitators and barriers from the survey were then mapped to intervention functions and behaviour change techniques guided by the Behaviour Change Wheel [25]. Firstly, the authors mapped the TDF domains identified in phase 2 to intervention functions. Intervention functions are “broad categories by means of which an intervention can change behaviour”. Each intervention function was assessed to see if they were Affordable, Practical, Effective, Acceptable, had Side-effects and were safe and Equitable (APEASE criteria) [25], and prioritised [26]. Stakeholders (front line nurses, nurse managers, nurse educators) were involved in the assessment of intervention functions during a series of meetings where the initial concept was tabled at various departmental meetings to garner support for the intervention. Secondly, the authors chose behaviour change techniques (BCTs) from the Behaviour Change Technique Taxonomy (BCTTv1) based on the intervention functions. A BCT is a component of an intervention that will alter behaviour [25]. The taxonomy includes 93 techniques for behaviour change linked to the Behaviour Change Wheel. Each intervention function is associated with a list of BCTs that are relevant to that intervention function, which can be assessed for relevancy to the local context. For example, if the barriers and facilitators differed between the ward and emergency nurses, the intervention function and supporting BCTs were refined to that context. Each BCT was also assessed using the APEASE criteria for inclusion alongside the intervention functions. The resulting BCTs were collated and used as suggested techniques to support the selected modes of delivery specific to the context of the sites (wards vs EDs, or particular sites). The TDF domains were grouped using COM-B then developed to a logic map.

Results

Participant characteristics

Of the 300 nurses (approximate10% response rate from the whole of ISLHD) involved in the study, 80.41% were between 20 and 50 years of age, with just over one third (33.89%) between six and 15 years of experience. The responses were proportionally representative of the size of each site. Just over half of respondents were ward nurses (56.7%) (Table 2).

Table 2 Characteristics of nursing respondents

Reasons for not using the EDWHAT

The most common reasons for not using EDWHAT were uniform across nurse type and hospital site. However, within each reason, there was some variance. For example, the most frequently cited reason for not using the tool was the inability to locate a computer near a phone (44%, n = 121, but more so in the ward 47%, n = 65), being told to transfer the patient before being able to complete the form (particularly in ED 52.10%, n = 62), the other nurse receiving (or giving) the handover not using the form (38.83%, n = 106) and not having time (34%, n = 94) (Fig. 3). More than half of nurses from the two sites with the poorest uptake felt the tool did not support timely (60%, n = 75; 55%, n = 50) or easy handover (54%, n = 68 and 54%, n = 49). These two sites also had the largest proportions of nurses that reported being told to transfer the patient before being able to complete the form (33%, n = 42 and 55%, n = 50). The site who had the highest uptake also had the highest proportion of nurses reporting the tool was important (76%, n = 38).

Fig. 3

Factors that hinder nurses from using the EDWHAT by nurse type

Quantitative results presented within the corresponding behavioural domains

Knowledge

Knowing where to locate the tool proved a facilitator to using the tool, with 91.26% (n = 261) of staff across all nursing types knowing where to locate the tool. All of the nurses in the ED knew where to locate the tool, whereas a small portion of ward nurses did not (16%, n = 24).

Skills

The majority of nurses (78.25%, n = 223) indicated they had a good understanding of how to use the tool. Some ward nurses however had little (23.13%, n = 34) or no (8.16%, n = 12) understanding of how to fill out the tool, which was considered a barrier.

Environment

Environmental influences were a substantial barrier. The most frequently reported factor that hindered nurses from using the tool was the inability to access a phone near a computer (44.32%, n = 121).

Beliefs about capabilities

The majority of respondents reported they felt confident using the tool (77.39%, n = 219). However, more ward nurses reported not feeling confident with using the tool (33.10%, n = 48) compared to ED nurses (9.92%, n = 12). Overall, 68.27% (n = 185) of nurses agreed that the tool was easy to use. Within the ED setting, ease of use was a facilitator (78.99%, n = 94), whereas this was a barrier for ward nurses (60.74%, n = 82) and nurses who work in both contexts (52.94%, n = 9).

Beliefs about consequences

Beliefs about consequences were one of the largest barriers to use of the tool, as just over half of the respondents considering the tool important (59.30%), in particular those aged over 51 years. The age group with the largest proportion reporting that the tool was not important was the 31–40-year group (46.27%). There was a little difference between ED and ward nurses regarding the importance (59.86% and 57.85%) or how long nurses had been working. The information communicated within the tool was also a substantial barrier as nearly half of respondents felt it was inadequate to ensure safe handover (45.79%, n = 125). The majority of nurses considered the tool did not promote timely handover (54.91%, n = 151) or make the handover process easier (50.91%, n = 140). These beliefs trends are the same between nurses who work on the wards, in the ED, and who do both.

Memory

Overall, finding the tool easy to remember to use was a facilitator (83.15%, n = 232). However, this trend differed between nurse types, with this being a barrier for ward nurses (51.05%, n = 73) in contrast to ED nurses (81.51%, n = 97). The greatest factor for remembering to use the tool is having time to prepare for the handover (52%), which is similar between nurse types. In contrast, the factor contributing the least to remembering to use the tool is being reminded by a manager (6%) (Fig. 4).

Fig. 4

Factors that make it easier to remember to use the EDWHAT by ward vs ED

Qualitative results

There were 399 free-text comments, resulting in 31 themes representing 22 barriers and nine facilitators (Table 3). These mapped to eight of the 14 TDF domains (Table 3). The most barriers were related to the environment in which the tool is required to be used, the content and usability of the form, and beliefs about the benefits (or lack thereof), particularly in relation to social influence. The most problematic behavioural influence was the environment with four sub-themes. Firstly, the functionality of the form within the electronic medical record system. This highlighted the technical difficulties of having the information in a “form” template within the electronic medical record, which means it cannot be minimised or open and shut, without losing information, to view other areas of the patient chart. Encapsulated by these respondents;

Table 3 The 32 themes identified that facilitate or hinder the use of the EDWHAT in the ISLHD

“Issue is that once in the tool you cannot revisit your notes which is a problem because you miss vital information” (ED nurse 16)

“Access to the form should be instant as ED/ward are very busy. Access to the handover form depends on computer availability, staff login time and form loading time, for a busy ward and at ED the wait is too long. Also some ED Nurses are happy to wait for form to be accessed, some ensure you hear their displeasure with sighs or statements of being too busy to wait.” (Ward nurse 301)

“…The form is hard to access, through 3 menu’s…” (Ward nurse 222)

Secondly, there were a number of responses related to the lack of phones and computers which impacted on staff ability to use the form to handover. For example,

“The only reason to not fill the form out is access to computers/ telephones” (ED nurse 204)

and;

“there have been times where all the computers have been used and there is no other option than to write on a piece of paper….buy more computers” (Ward nurse 78)

The third sub-theme identified concerns related to the structure of the form. The form has limited free-text sections, some auto-populated information, with the majority of information being tick boxes. A number of comments are related to the content of the form itself; however, this was often contradictory. For example, these respondents stated;

“I believe that the section where you tick that their obs are btf is important to ensure safe transfer as well as outstanding actions to ensure there is a record of what still needs to be done for the patient” (ED nurse 17)

“It is easy to use however it is useless as it does not provide enough information and the other staff member becomes complacent and just wants to tick boxes” (ED nurse 158)

And in contrast;

“sometimes important information is lost or importance negated by the volume of information asked for and given. often questions are mechanically asked with nil active listening involved…” (ED nurse 24)

“…Some nurses will ask all the questions in the tool and then they go to hang up, and you have to promt them and say ' do you wan tto know what i have done since they have been here now?’” (ED nurse 249)

The other frequently reported domains were beliefs about consequences and social roles and influences. Within these domains, staff reported feeling that the tool was useful in helping important patient safety information gets handed over and improving the patient continuity of care and the patient experience;

“The tool is useful in ensuring a holistic handover is covered” (ED nurse 204)

However, responses also highlighted a number of beliefs held by the nurse sending the patient (ED) and the nurse receiving the patient (ward) about the handover. These beliefs seem to indicate conflict which may have been present prior to the introduction of the form. This may indicate differences in the working environments of emergency departments and wards who have different functions and responsibilities. Responses from ward staff suggest a lack of knowledge about the patient by ED staff;

“most of the time handover was wrong and wasting time filling the form” (Ward nurse 280)

and;

“…The ED nurses most of the time do not know enough information about the patients to be able to complete all the questions, as they are taking over from another nurse who cared for that patient previously or it is another nurse bringing the patient to the ward. A telephone handover from the nurse who is caring for the patient, so I can access my computer and they can access their computer to complete the form and then the ward nurse collects the patient or the ED nurse brings the pateint down would be MORE EFFECTIVE.” (Ward nurse 222)

Conversely, the ED nurse respondents felt the ward staff are focused on tasks and not the patient condition;

“Often ward nurses want to skip the brief handover (2 minutes). I would usually provide that tells them why the patient presented, what we've done and the plan. They only want to hear the answers to the questions prompted by the form” (ED nurse 97)

Within these themes, time pressure was raised as a strong influence on the ability to adequately handover,

“Being told to hurry a handover does not respect the value of handover” (Ward nurse 10)

and;

“I don't have any objection to using the handover form. However I have found time constraints sometimes prevent me using it. Also at times we are directed to transfer the patient prior to having handover” (Ward nurse 81)

“The information is only as good as what is handed over from ED. It can vary from thorough, to vague, to someone who doesn't know the patient. An experienced clinician knows the questions to ask, a novice clinician may take all information on face value” (Ward nurse 36)

Phase 3: development of implementation strategies

The TDF domains identified in phase 2 were mapped to the nine corresponding intervention functions (Table 4). Each intervention function [27] and selected BCT [28] was assessed using the APEASE criteria. Seven of the nine intervention functions and 18 BCTs were considered appropriate for use in future implementation, and the commentary from key stakeholders regarding each intervention function is listed in Table 4.

Table 4 TDF domains identified to contain facilitators and barriers mapped to nine intervention functions and BCTs with APEASE

The agreed-upon BCTs were collated and were used to develop implementation strategies (modes of delivery) specific to the context of the sites (wards vs EDs, or particular sites). These were then developed into a logic map (Fig. 5). The logic map demonstrates the mapping process and selection of BCTs to inform the strategy to improve uptake of the EDWHAT. Filled boxes or partially filled boxes in the recommendation column represent interventions/BCTs that were completed or partially completed in the original implementation. An implementation checklist for future use was developed based on the behavioural influences most prominent in the survey responses and themes, the intervention functions selected through the APEASE process and gaps highlighted by the logic map (Fig. 6).

Fig. 5

Logic map demonstrating the mapping process and selection of BCTs to inform the strategy to improve uptake of the ED to Ward Handover Tool. *Filled boxes or partially filled boxes in the recommendations column represent BCTs that were completed or partially completed in the original implementation

Fig. 6

Implementation checklist

Discussion

This study demonstrated the numerous barriers and facilitators to uptake of a new intervention designed to improve ED to Ward Handover across a local health district, in particular, the influence of the working environment, social influence and beliefs about consequences.

Implementation of new interventions needs planning and strategy that address the complexity of healthcare systems and individual practitioners [29] and strong organisational support [30]. There are multiple models available on which to develop and plan an implementation strategy [31], the most well known in health is perhaps the Promoting Action on Research Implementation in Health Services Framework or PARIHS Framework [32]; however, human behaviour, which is central to the sustainable success of any change, must also be incorporated. Using a systematic four-step approach as the principal framework to inform intervention development process such as that proposed by French et al. [15] is ideal and is known to be effective in the acute care context [19]. Colquhoun et al.’s [33] systematic review of papers focussing on methods for designing interventions to change health care professionals’ behaviour reported that designing an intervention for individual-level change includes identifying barriers, selecting intervention components, using theory and engaging end-users. Developing interventions systematically based on evidence and theory enhances implementation success and sustainable worthwhile effect. Further, clear presentation of the methods of theory use progresses theory development by helping to understand why interventions have failed or succeeded [34].

All intervention functions, with the exception of environmental restructuring and financial incentives, were assessed as affordable and practical within existing roles and orientation processes. Environmental restructuring was ranked as one of the most important interventions required, and while some investment will be required, the majority can be achieved with existing IT and senior nursing staff roles. Additional computers are not an onerous budget item and a priority. When operationalising the reinforcement and persuasive interventions, particular care must be taken to ensure an equitable approach to all staff to ensure no staff feel “singled out” and the intervention is not misconstrued as too authoritarian. A transformational leadership approach is preferred [35]. The success of the interventions would also be enhanced by nursing staff from different areas having a shared mental model, that is, a common understanding of the task (handover process) and the clinical and logistical needs to conduct handover for their colleague [36]. It would also ensure that nursing staff from different areas of the hospital are familiar with one another’s roles and responsibilities, could anticipate each other’s needs and be flexible [37].

In relation to education as a method to influence change, the excessive educational focus may lead to neglect in other domains and in isolation is unlikely to be effective in increasing uptake of the EDWHAT [38]. This is reinforced by the fact that education was the main intervention in initial implementation that had suboptimal uptake. The study process also highlights the importance of using a structured, evidence-informed process to diagnose implementation problems and solutions that are likely acceptable and practical to the organisation to enable success. This is demonstrated in the logic map (Fig. 5). The initial implementation of the EDWHAT partially considered only three aspects of human behaviour (knowledge, skills and beliefs about capability). The poor uptake of the tool is a clear indication that for interventions to success in the clinical environment, influences on human behaviour must be addressed. A re-implementation strategy is now under consideration by the organisation; however, it must be adequately resourced and take into consideration the findings of this study for optimal implementation. It will be necessary to evaluate the re-implementation of the tool in the future.

Limitations

There were some limitations to this study. Firstly, the survey response rate was much lower than expected (10%) despite allowing time during work hours to complete the survey, although data saturation was reached. The overall estimate of staff obtained from departmental managers included part-time, casual and visiting staff, as well as those on maternity, annual and long service leave which may have exaggerated the actual numbers of staff available to participate. Staff from all departments and levels of seniority completed the survey, resulting in a representative sample.

The theoretical frameworks provided a systematic method for the identification of facilitators and barriers; however, our experience was of crossover between domains. These were resolved with a discussion between the authors. The authors agreed to categorise barriers or facilitators in one domain over another to aide in the integration and interpretation of the results while appreciating the potential interaction between TDF domains.

Conclusions

To improve uptake, the functionality, content, and flow of the handover tool must be revised, alongside environmental restructuring. Modelling and enabling of effective handover by nursing management is also required. Nurses need increased awareness of each other’s needs to develop a shared mental model, and monitoring and enforcement of tool use should become part of a routine audit.