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      Using normalisation process theory to evaluate the implementation of a complex intervention to embed the surgical safety checklist

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          Abstract

          Background

          The surgical Safety Checklist (SSC) was introduced in 2008 to improve teamwork and reduce the mortality and morbidity associated with surgery. Although mandated in many health care institutions around the world, challenges in implementation of the SSC continue.

          To use Normalisation Process Theory (NPT) to help understand ho w/why implementation of a complex intervention coined Pass The Baton (PTB) could help explain what facets of the Surgical Safety Checklist use led to its’ integration in practice, while others were not.

          Methods

          A longitudinal multi-method study using survey and interviews was undertaken. Implementation of PTB involved; change champions, audit and feedback, education and prompts. Following implementation, surgical teams were surveyed using the NOrmalization MeAsure Development (NoMAD) and subsequently interviewed to explore the impact of PTB on their use of the checklist at 6 and 12 months respectively. Respondents’ self-reported perceptions of implementation of PTB was explained using the four NPT constructs; coherence, cognitive participation, collective action, and reflexive monitoring. Survey data were analysed using descriptive statistics. Interview data were coded inductively and content analysed using a framework derived from NPT.

          Results

          The NoMAD survey response rate was 59/150 (39.3%). Many (45/59, 77.6%) survey respondents saw the value in PTB, while 50/59 (86.2%) would continue to use it; 45/59 (77.6%) believed that PTB could easily be integrated into existing workflows, and 48/59 (82.8%) thought that feedback could improve PTB in the future.

          A total of 8 interviews were completed with 26 surgical team members. Nurses and physicians held mixed views towards coherence while buy-in and participation relied on individuals’ investment in the implementation process and the ability to modify PTB. Participants generally recognised the benefit and value of using PTB in the ongoing implementation the checklist.

          Conclusions

          Workarounds and flexible co-construction in implementation designed to improve team communications in surgery may facilitate their normalisation in practice.

          Electronic supplementary material

          The online version of this article (10.1186/s12913-018-2973-5) contains supplementary material, which is available to authorized users.

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          Most cited references16

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          Individual determinants of research utilization by nurses: a systematic review update

          Janet Squires, Carole Estabrooks, Petter Gustavsson … (2011)
          Background Interventions that have a better than random chance of increasing nurses' use of research are important to the delivery of quality patient care. However, few reports exist of successful research utilization in nursing interventions. Systematic identification and evaluation of individual characteristics associated with and predicting research utilization may inform the development of research utilization interventions. Objective To update the evidence published in a previous systematic review on individual characteristics influencing research utilization by nurses. Methods As part of a larger systematic review on research utilization instruments, 12 online bibliographic databases were searched. Hand searching of specialized journals and an ancestry search was also conducted. Randomized controlled trials, clinical trials, and observational study designs examining the association between individual characteristics and nurses' use of research were eligible for inclusion. Studies were limited to those published in the English, Danish, Swedish, and Norwegian languages. A vote counting approach to data synthesis was taken. Results A total of 42,770 titles were identified, of which 501 were retrieved. Of these 501 articles, 45 satisfied our inclusion criteria. Articles assessed research utilization in general (n = 39) or kinds of research utilization (n = 6) using self-report survey measures. Individual nurse characteristics were classified according to six categories: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, and socio-demographic/socio-economic characteristics. A seventh category, critical thinking, emerged in studies examining kinds of research utilization. Positive relationships, at statistically significant levels, for general research utilization were found in four categories: beliefs and attitudes, information seeking, education, and professional characteristics. The only characteristic assessed in a sufficient number of studies and with consistent findings for the kinds of research utilization was attitude towards research; this characteristic had a positive association with instrumental and overall research utilization. Conclusions This review reinforced conclusions in the previous review with respect to positive relationships between general research utilization and: beliefs and attitudes, and current role. Furthermore, attending conferences/in-services, having a graduate degree in nursing, working in a specialty area, and job satisfaction were also identified as individual characteristics important to research utilization. While these findings hold promise as potential targets of future research utilization interventions, there were methodological problems inherent in many of the studies that necessitate their findings be replicated in further research using more robust study designs and multivariate assessment methods.
          Article 0 comments Cited 298 times – based on 0 reviews     Review now
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            Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements.

            G Johansson, P Odenrick, Johan Larsson … (2013)
            Previous research suggests that the World Health Organization Surgical Safety Checklist time-out reduces communication failures and medical complications and supports development of better safety attitudes. Previous research also indicates that different values can affect the implementation of interventions. To investigate the actual usage of the checklist in practice and to catalogue deviations for the purpose of identifying improvements. Twenty-four surgical procedures were video recorded. The time-out was analysed quantitatively assessing compliance with a predefined observational protocol based on the checklist and qualitatively to describe reasons for non-compliance. The operating unit of a Swedish county hospital. Compliance with checklist items and the participation of different personnel groups. Activities were conducted during the time-out. Highest compliance was associated with patient ID, type of procedure and antibiotics; the worst with site of incision, theatre nurse team reviews and imaging information. Team member introductions occurred in half of the operations. Surgeons and the anaesthesia team dominated the time-out. The checklist is not always applied as intended. The components that facilitate communication are often neglected. The time-out does not appear to be conducted as a team effort. It is plausible that the personnel's conception of risk and the perceived importance of different checklist items are factors that influence checklist usage. To improve compliance and involve the whole team, the concept of risk and the perceived relevance of checklist items for all team members should be addressed.
            Article 0 comments Cited 36 times – based on 0 reviews     Review now
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              Improving teamwork climate in operating theatres: the shift from multiprofessionalismto interprofessionalism.

              Adrian Hobbs, James Boyden, J Allard … (2006)
              A multi-faceted, longitudinal and prospective collaborative inquiry was initiated in December 2002 with one half of the cohort of operating theatre personnel in a large, acute UK hospital serving a mainly rural population. The same intervention was introduced in January 2004 to the other half of the cohort. The project aims to improve patient safety through a structured educational intervention focussed upon changing teamwork practices. This article reports one critical element of the larger project - changing teamwork climate as a necessary precursor to establishing an interprofessional teamwork culture. The aggregate of individual, unidirectional attitude changes across a large cohort constitutes a change in climate. This shift challenges the conventional culture of multiprofessionalism, where uniprofessional identification (the "silo" mentality) is traditionally strong.
              Article 0 comments Cited 33 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Brigid M. Gillespie:
                ORCID: http://orcid.org/0000-0003-3186-5691
                b.gillespie@griffith.edu.au
                Emma Harbeck: e.harbeck@griffith.edu.au
                Joanne Lavin: Joanne.Lavin@health.qld.gov.au
                Therese Gardiner: Therese.Gardiner@health.qld.gov.au
                Teresa K. Withers: tkay911@gmail.com
                Andrea P. Marshall: a.marshall@griffith.edu.au
                Journal
                Journal ID (nlm-ta): BMC Health Serv Res
                Journal ID (iso-abbrev): BMC Health Serv Res
                Title: BMC Health Services Research
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1472-6963
                Publication date (Electronic): 9 March 2018
                Publication date PMC-release: 9 March 2018
                Publication date Collection: 2018
                Volume: 18
                Electronic Location Identifier: 170
                Affiliations
                [1 ]ISNI 0000 0004 0437 5432, GRID grid.1022.1, School of Nursing & Midwifery, , Griffith University, ; Gold Coast, QLD Australia
                [2 ]ISNI 0000 0004 0625 9072, GRID grid.413154.6, Gold Coast Hospital and Health Service, ; Gold Coast, QLD Australia
                [3 ]ISNI 0000 0004 0437 5432, GRID grid.1022.1, National Centre of Research Excellence in Nursing, Menzies Health Institute of Queensland, , Griffith University, ; Gold Coast, QLD Australia
                [4 ]Surgical and Procedural Services, Gold Coast Hospital and Health Service, Gold Coast, QLD Australia
                [5 ]Nursing & Midwifery Education & Research Unit, Gold Coast Hospital and Health Service, Gold Coast, QLD Australia
                Author information
                http://orcid.org/0000-0003-3186-5691
                Article
                Publisher ID: 2973
                DOI: 10.1186/s12913-018-2973-5
                PMC ID: 5845378
                PubMed ID: 29523148
                SO-VID: dc3a2451-ed7c-4249-948e-b0bacd296b2c
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 9 October 2017
                Date accepted : 27 February 2018
                Funding
                Funded by: National Health & Medical Research Council (NHMRC) [Australia] Translation into Practice (TRIP) Fellowship
                Award ID: APP1068707
                Funded by: Australian College of Perioperative Nurses (ACORN) Research Grant
                Award ID: NA
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Health & Social care
                Keywords: surgical safety checklist,implementation,evaluation,tailoring,sustainment,nomad tool,pass the baton,operating room
                Data availability:
                ScienceOpen disciplines: Health & Social care
                Keywords: surgical safety checklist, implementation, evaluation, tailoring, sustainment, nomad tool, pass the baton, operating room

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