Methods
Intervention
A green wristband to indicate an increased risk of falling and a yellow
wristband to indicate the presence of dysphagia were implemented on the
neurology ward of the participating hospital in September 2016. The
implementation of the CCWs was guided by a project team of ten members,
consisting of nurses from the neurology ward and quality managers.
In total, 40 health care
professionals of the neurology ward were involved in conducting the
intervention and were supposed to take preventive measures based on the
CCWs. The care professionals included nurses (n = 31), physiotherapists
(n = 5), an occupational therapist, speech therapists (n = 2), and a
nutritionist. Physicians had a limited role in conducting the
intervention as they were not responsible for mobilizing and/or
monitoring food intake of patients. Therefore, physicians were not
included in this process evaluation. The care professionals were
informed of the intervention and their role in conducting the
intervention, through a newsletter and regular team meetings.
Of the care professionals involved, nurses have a primary role in
conducting the intervention as they are responsible for issuing the
CCWs. Nurses have to use a set of standardized questions to determine if
patients should be issued a green wristband, and have to administer a
water-swallowing test to determine if patients should be issued a yellow
wristband. In case of changes in the situation of a patient, nurses
should re-evaluate whether a CCW needs to be issued. Nurses should
verify daily whether all patients with a special patient status are
wearing a CCW. When a patient is issued a CCW, nurses need to inform
them and their family about the intervention verbally and by handing
them a flyer containing further information. In addition to the flyers,
further information for patients and family members was also included in
tabletop sign holders that were placed in every patient room. The sign
holders are three-sided and contain sheets detailing the use and purpose
of the CCWs. Instructions related to the issuing of the CCWs were
included in the regular training sessions of the nurses. All care
professionals involved in the intervention have to determine themselves
what preventive measures should be applied to meet the special needs of
patients wearing a CCW. The type of preventive measures that should be
applied are not prescribed by the project team but depend on the
assessment made by the care professionals.
Study design and setting
This process evaluation employed a multi-method approach, consisting of
a case study and a survey. Data collection took place on the neurology
ward of the MUMC+ between May and July 2017. The neurology ward can
accommodate up to 22 patients. Patients that are cared for in the
neurology ward are often cognitively impaired.
Case study
In the case study, data were gathered by means of semi-structured
interviews with members of the project team who guided the
implementation process (table 1). A purposive sampling technique was
used to recruit the five project members that were most involved in the
intervention for participation in the interview. A topic guide was
created to guide the interview process. The interviews were conducted
face-to-face in a private room in the hospital and were set to last
approximately 30 minutes. The interviews were digitally recorded with
verbal informed consent of the interviewee and transcribed using an
intelligent verbatim style [16]. Anonymity in the reporting of the
results was assured to the interviewees. The transcripts were coded
using open, axial and selective coding, as described by Boeije [17].
Subsequently, for each interview, a summary was made based on the coding
process and sent to the respective interviewee for a member check
[17]. The member check helps ensure that the results of the
interviews are correctly interpreted by the researcher.
Survey
For the survey, data were gathered by means of a self-administered
questionnaire among the care professionals (table 1). The questionnaires
were made available to the nurses in the staff room for a period of two
weeks. To increase the response, a reminder was sent to the nurses by
email and senior nurses were asked to notify the staff on the
questionnaire during staff meetings. The neurology ward’s
physiotherapists, speech therapists, and nutritionists received the
questionnaire in their pigeonhole.
The questionnaire consisted of
three sections: one for each wristband and one on the overall
implementation of the intervention. The questionnaire contained 38
questions of which 37 were close-ended and one was open-ended.
Among the close-ended questions
were five questions that measured the frequency at which the
intervention’s procedures were applied and 16 questions that assessed
attitudes towards the intervention, on a five-point Likert scale ranging
from 1 (strongly disagree) to 5 (strongly agree) or from 1 (very
dissatisfied) to 5 (very satisfied). The open-ended question was used to
collect views on how intervention could be improved. Data were processed
anonymously.
The answers to the close-ended questions were analysed by means of
descriptive techniques. The questions that related to the training
sessions, the issuing of the CCWs, and informing patients and their
family on the intervention, only applied to the nurses. For these
questions, only the answers of the nurses were analysed. The responses
to the open-ended question were categorized based on matching content.
Research ethics statement
Medical ethical approval was not necessary, as this study only included
care professionals.