Table 6 Behaviour change techniques, mode of delivery and use in HIRAID® implementation
Behaviour change techniques and mechanism of action (MOA) | Mode of delivery | Measure / Indicator | Degree of modification | Qualitative Evidence Nurse survey content analysis Instructor survey comments |
|---|---|---|---|---|
5.1 Information on health consequences Knowledge Belief about consequences | Information on evidence-based health consequences of using HIRAID® including, decreased adverse events in instructor and participant training - Participant workbook - Instructor manual - eLearning module - Face to face training (instructor/participant) | 100% sites had instructor 100% sites used training 91% nurses (n = 1255) did education | Minor Face to face instructor training became hybrid at small sites in Cluster 2 due to COVID pandemic and catastrophic flooding 12% of instructors modified face to face training to use paper version or modify a slide to localise context | Instructor survey: When time was limited I used the printed version of the presentation and did quick on the go education. This sometimes included starting and stopping the presentation to deal with ward requirements (Cluster 1) Nurse survey: Prompts and structure guides enables consistent, comprehensive assessment and appropriate prioritisation (n = 391) |
4.1 Instruction on how to perform behaviour Skills | Instruction in applying HIRAID® in all modes of training | 100% sites used training 98.6% of instructors explained what HIRAID® was 95% explained requirements 91% of all nurses did education | Nil | Instructor survey: I provided education to nurses I was working with on the floor during my clinical duties. I was not given any time off the floor to follow up on other staff's progress, access to the training materials, flip cards or pt's notes to perform audits (Cluster 2) After attending the in-service and going through the case scenario, most staff understand the constructs of HIRAID related to patient assessment (Cluster 1) |
6.1 Demonstration of the behaviour Skills Social /professional role and identity | - Face to face training (instructor/participant) - Interactive workshops -—Instructors use HIRAID® in clinical practice and routine ED education | As above and Instructors worked with novice nurses to complete patient assessment some/all the time (85%) | Nil | Instructor comments: Due to acuity and high workload. As the champions were still working on the floor with patient loads (due to poor staffing) we weren't always able to support colleagues as much as we would have liked to (Cluster 4) We gave it our best and continue to encourage people to use HIRAID in our ED (Cluster 1) |
8.1 Practice rehearsal Skills | - demonstrate HIRAID® in interactive, face to face workshops, ask participants to perform reassessment, and give the group feedback | 91% of all nurses did education Practice handover and escalation some/all the time 78% | Nil | Instructor comments: Some staff were on leave and some casual staff hard to capture (Cluster 1) I used the HIRAID documentation templates in my clinical documentation of assessment after triage (Cluster 4) |
8.3 Habit formation Skills | Adoption of the HIRAID® framework into broader ED education to increase nurse exposure to relevant application of skill and allows for ongoing training | In 100% orientation at all sites | Nil | It's become a habit (Cluster 2) |
7.1 Prompts/cues Environment context and resources | Integrate HIRAID® documentation templates into electronic medical record system to support and reduce cognitive load | All sites, 100% | Nil | Nurse survey: Structure and format of template enabled quality care and documentation (n = 83) Structure enables consistent, identification of potential problems and communication (n = 187) The templates make it so much easier to prompt and document (Cluster 3) |
12.2 Restructuring the social environment Environment context and resources | - recruit and train local clinical leaders in use of HIRAID® in instructor courses - Clinical supervision - protected time to complete HIRAID® education program - shift huddles using inclusive language provide feedback to staff on behaviour in using HIRAID® from shift/day before - regular stakeholder meetings to discuss implementation readiness and plans, and to troubleshoot problems | Champions at 100% sites 100% sites committed to protected time 77% used comms at staff huddle Steering committees at each cluster | Nil | Nursing survey comments I use because encouragement from HIRAID champion. Saved templates make documentation easy (Cluster 1) We were supported to attend training, although some people attended in their own time (Cluster 3) supportive 1: 1 on the spot training and guidance(Cluster 1) |
11.3 Conserving mental resources Environment context and resources | - Prompts in documentation templates - Flip cards to support recall framework steps | 100% have doc templates, 83% nurses using 77% said got a flip card, 83% of those said they used it to help HIRAID® recall | Nil | Nursing survey comments Provides structure in high turnover when feeling stressed (Cluster 3) It gives structure to the assessment and I find that I don't miss things. Very helpful to take a breath, think through the components of HIRAID, especially when we are busy. (Cluster 1) |
6.3 Information about others approval Social influences Optimism | - Email from hospital executives in support of HIRAID® - Ensure floor staff awareness of management support in meetings/huddles - Management, senior staff and influential peer staff support in video highlighting benefits of HIRAID® - Catch phrases to be used by Instructors to assist in reframing the behaviour with messaging to support/ encourage application in practice - Provide information on evidence and development of education program and implementation plan. For example, the implementation plan was developed using behaviour change theory - In interactive workshops, provide examples of poor documentation and how it has improved since using HIRAID® at other sites | 100% sites got memos from executive 77% comms at staff huddle 2 of 4 Clusters chose to do video 100% instructor courses did this | Moderate | thanks for providing such amazing changes to our processes and documentation (Cluster 4) I use because the Educators expect us to. (Cluster 3) |
3.2 Social support (practical) Social influences | - Support from educators to allow staff to take time to complete necessary assessment and documentation to increase familiarity and competency - Facilitation by HIRAID® team including site visits, and tracking of site education and issues - Daily walk-through ED by core research nurse/ HIRAID® Instructors to monitor, answer questions, assist, praise, feedback - Ongoing support from research team in education, implementation and stakeholder meetings | 100% sites had instructors 89.2% champions used HIRAID® CNC (research team) as a support. Only 6.7% used the teams / virtual drop in | Nil | Nursing survey comments We were given lots of education and support (Cluster 1) Instructors all did really well with the material they had. It was also good having a mix of senior nurses, and nurses who had less experience to allow them to provide education with support from others (Cluster 4) |
6.2 Social Comparison Optimism | - Demonstrate to staff how implementation has been achieved at other sites in training | 100% sites incorporated in training | Nil | |
5.3 Information about social and environmental consequences Knowledge Belief about consequences | - Provide information about HIRAID® impacts on emergency nursing care, e.g., improved documentation, and self-confidence in the education program | Evidence included in education | Nil | Nursing survey comments Wonderful instructors! Great too, for ED! Always great to review assessment skills. Thanks for all the research work (Cluster 2) It will support new nurses once they understand why we do it and how to do it properly (Cluster 3) I use them all the time I think it gives a great summary of the patient from the initial presentation right through to the assessment and plan (Cluster 1) |
1.4 Action planning Belief about consequences | - Implementation plan for each site, including who is making the changes, and timeframes and milestones, and progress measures | 100% sites | Nil | Managed by research team |
13.2 Framing / reframing Social /professional role and identity | - Ensure experienced staff understand that it does not necessarily change work practice but provides common terminology and approach to assessment in the ED (Education program) | The phrase “It is what we already do, just standardising it so we can teach new ED nurses and speak the same language” delivered in 100% instructor and provider courses | Nil | |
15.1 Verbal persuasion about capability Social /professional role and identity | - Instructors provided feedback at bedside, addressing areas for improvement and acknowledging where done well | 97% Instructors answered questions about HIRAID® some or all of the time 84% were able to work with new emergency nurses some or all of the time | Minor | The educator and champions followed up with staff to encourage use of the tool and support for questions” (Cluster 1) |
13.1 Identification of self as a role model Intentions | - Staff self-nominate as Instructors | 90% self nominated 10% appointed by manager | Nil | Upcoming leaders that were looking for a portfolio to build their CV (Cluster 3) HIRAID champions were role models in the department and were happy to support staff (Cluster 3) there were 2 instructors at our site. I don't feel that the other champion did 50% of the work. She turned up for training and ate the chocolates. (Cluster 1) |
9.1 Credible source Social Influences Optimism | - HIRAID® video includes ED nurse leaders from across the district and country as well as ED staff from clusters supporting HIRAID® | Video used in all Instructor courses and 93% of Provider courses Instructors were in leadership roles or emerging leaders | Minor | HIRAID champions were role models in the department (Cluster 3) it was wonderful to meet the leader of the project (Cluster 2) I got trained from ED's CNCs and CNEs to do HIRAID as part of my job!! (Cluster 3) |
2.2 Feedback on behaviour Reinforcement | - Local nurse leaders, managers and Instructors provide regular feedback to staff individually in coaching during patient care. Praise for a job well done and highlight areas to improve - Instructors provide feedback in practice, support application and documentation - Audit conducted 6/12 weeks during implementation—feedback aggregate on use per site | Documentation audits performed for 100% sites Feedback from managers and instructors regarding use of documentation templates 91% of audit results communicated to staff some or all the time | Nil | Nursing survey Use because mandatory (n = 12) i use HIRAID because we're told to, not because I want to (Cluster 2) if the staff aren't using it then they're subject to disciplinary action (Cluster 3) |
2.7 Feedback on outcomes of behaviour Reinforcement Beliefs about consequences | - Interactive feedback provided based on responses in interactive case studies in eLearning and interactive workshops | Education program Instructor support | Nil | Instructor survey: One on one feedback in a small site made this implementation fairly easy. Review of notes also made follow-up and corrections easy to do (SNSW) |
7.5 Remove aversive stimulus Reinforcement | - Remove old documentation templates | 100% sites | Nil | Managed by research team |
10.1 Material incentive Reinforcement Optimism | - Monitor uptake through HIRAID® templates, those consistently using and sites with the greatest proportion will have opportunity to receive prizes- varied by site based on local input | Prizes to first sites to complete 80% staff training Thankyou baskets of healthy food to all EDs from the HIRAID® team | Nil | Managed by research team |