Discussion

This study evaluated the implementation process of CCWs for patients with an increased risk of falling and patients with dysphagia on the neurology ward of a university hospital in the Netherlands. Results from this study indicate most care professionals were informed of the intervention and understood the received information. Overall, the care professionals reported being satisfied with the CCWs and the way they were informed. In addition, this study revealed that care professionals generally considered the special needs of patients with a CCW. However, the care professionals reported some deviations from protocol. First, patients with dysphagia or an increased risk of falling did not always have a corresponding CCW. Nurses seemed to sometimes forget to issue the CCWs during hectic periods and patients sometimes removed the CCWs. Furthermore, it was not verified on a daily basis whether all patients with a special patient status were actually wearing their CCW. Finally, family members of patients were not always informed on the intervention verbally or by being handed the flyer.
Porter et al. [14] assessed the use of CCWs for indicating the presence of allergies in a paediatric emergency department. The researchers found that not all patients with allergies were wearing a CCW. Of the 256 parent-child pairs that were included, there were 28 cases of true allergies according to a guideline-based assessment. Of these 28 cases, only 16 were observed to wear a CCW. Similarly, our findings indicate that in the present intervention not all patients with an increased risk of falling or dysphagia were actually wearing a CCW. Furthermore, our findings on the satisfaction of the CCWs among staff and patients are consistent with the findings of Forster et al. [9]. In the study of Foster, 86% of the involved staff members reported that the CCWs for indicating patients’ target oxygen saturation added at least some benefit and 46% reported they helped significantly. Of the staff members who were informed of the CCWs in our study, 55% and 67% reported being (very) satisfied with respectively the green and yellow wristband as an aid. Moreover, Forster and colleagues reported that the patients that were surveyed in their study (n = 192) generally responded positively. We were unable to directly assess the satisfaction of patients with the CCWs in the present study. Still, in accordance with the results of Forster and colleagues, the observations of the care professionals in the present study suggest that patients generally were content with the green and yellow wristband. Norris et al. [12] describe several risks associated with the implementation of CCWs of which some can be compared with our findings. Our findings substantiate the claim of Norris and colleagues that the CCWs may not be seen by care professionals. Indeed, the care professionals in our study noted that CCWs were regularly covered by patients’ clothing. Norris and colleagues also indicate that the colour coding of the wristbands may not be understood by the care professionals. Yet, we found that the majority of the care professionals were informed of the intervention. Moreover, the surveyed care professionals who were informed of the intervention generally appraised the received information on the green and yellow wristband as clear. Therefore, our results indicate that the meaning of the colour coding of the wristbands was clear for most care professionals.
This study has several limitations. First, a risk in this type of evaluation studies is that participants may feel inclined to give socially desirable answers. To minimize this risk, we assured anonymity to all study participants in the reporting of the study and conducted the interviews in a private room. Second, our study design was susceptible to recall bias as we relied on self-reported, retrospective data. However, taking direct observations to assess the extent to which the intervention was performed according to protocol was considered too invasive. Third, the scope of this study was limited to evaluating the implementation process of CCWs on only one ward. Hence, it remains unclear to which extent our results are generalizable to other wards and the hospital environment in general. However, it seems likely that the issues related to the implementation of CCWs encountered in the present study are not unique to neurology wards and are relevant to other clinical settings as well. Strong aspects of this study are the use of a multi-method approach and the incorporation of the framework by Saunders et al. [15], which provides a systematic approach for studying implementation processes.
Based on our results, we conclude that although the implementation of CCWs seems feasible in daily practice, several challenges can arise when implementing CCWs. We observed several deviations from protocol which should be addressed when implementing CCWs in daily practice. The following recommendations are made for addressing these challenges when implementing CCWs. First, we recommend taking a rigorous and continuous approach to informing the care professionals of the intervention. Evidently, the colour coding can only provide cues to care professionals that have been informed of the CCWs. As such, guidelines related to the CCWs should be actively communicated to new staff members. Second, we advise to embed the verification process of the CCWs in the daily routines of care professionals. Finally, measures should be taken to ensure that the CCWs are visible for staff members at all times. Wood and Bagaine [13] found that especially the visibility of CCWs is of importance in preventing adverse outcomes. Therefore, care professionals should motivate patients to wear their CCWs in a visible way and notify patients when their CCWs is covered up. More research is needed to establish whether CCWs can help in improving health outcomes. The present study highlights several challenges that arise when implementing CCWs, of which some have been described in previous works. Future research into the effectiveness of CCWs may yield more positive results if these challenges are accounted for.