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.