Original ResearchUsing the Behaviour Change Wheel to identify interventions to facilitate the transfer of information on medication changes on electronic discharge summaries
Introduction
In the United Kingdom (UK), the discharge summary provides the primary means of communication between hospital services and primary care in the National Health Service (NHS).1 The document details a patient's hospital stay and recommended follow up actions for the patient's general practitioner (GP). The majority are written by foundation year (FY) junior doctors.2 FY1 and 2 junior doctors are one to two years post graduation from medical school, similar to a junior resident in the USA.
Various studies advocate the need to include details of medication changes on discharge summaries3, 4 such as medications stopped, started and dose changes. GPs have also highlighted the importance of receiving such information on medication changes.5, 6, 7 A lack of information on medication changes could lead GPs to believe a medication has been discontinued when it has not been or for a GP to inadvertently restart a medication that was intended to be stopped. Inclusion of the information also helps to promote continuity of care.3, 8, 9 In addition to the patient safety risks, there is the potential for wasted staff time while attempts are made to establish if a change was intentioned.10
Professional bodies in the UK have issued guidance advocating the need to transfer information on medication changes.8, 11, 12 Despite this, there is evidence that this is not happening at the point of discharge – an issue which is not confined to the UK.13, 14, 15 Studies suggest from 29% to 72% of discharge summaries do not contain any information on medication changes.10, 16, 17, 18 These results occurred in spite of the introduction of processes such as medicines reconciliation and the use of electronic discharge summaries. Medicines reconciliation is the process of creating the most accurate list possible of all medications a patient is taking and comparing that list against the prescribers admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patients at all transition points.19 Many hospitals in the UK conduct medicines reconciliation on admission and some may record this as part of the electronic patient record (EPR). It has been suggested the use of electronic templates which contain a section for medication changes, might improve the likelihood of adherence to recommended national standards.10 Both electronic templates and the medicines reconciliation process aimed to improve the transfer of information around medicines.1, 10, 20
Writing a discharge summary using an EPR can be thought of as an example of a behavior. If aspects of that behavior can be changed, this could improve the completion of such electronic discharge summaries to include information on medication changes. Various behavior change theories exist and the Behaviour Change Wheel (BCW) is a synthesis of 19 frameworks of behavior change and can be applied to any behavior in any setting.21 At its core is a model of behavior known as COM-B – Capability, Opportunity, Motivation and Behavior. These components can be further divided into physical and psychological capability, physical and social opportunity and automatic and reflective motivation. The model recognizes that behavior is part of an interacting system involving all these components. Changing behavior will involve changing one or more of the components. Surrounding these components, the BCW incorporates nine intervention functions aimed at targeting one or more of these components that requires changing. The nine interventions include modeling, environmental restructuring, and restrictions which impact on capability whilst education, persuasion and incentivization impact on opportunity. Finally, coercion, training and enablement impact on motivation. If the components to be targeted can be identified, interventions can be tailored to change behavior and potentially ensure that all electronic discharge summaries contain information on medication changes and thus contribute to maintaining patient safety.22 A detailed examination of such behavior can determine the current barriers and facilitators to the inclusion of information on medication changes on electronic discharge summaries. Little research has been conducted which has explored barriers and facilitators in relation to the completion of discharge summaries.10, 23, 24 Those studies that have examined barriers and facilitators in relation to transfer of information of medication changes have focused on the medicines reconciliation process rather than the process of completing discharge summaries.25, 26, 27, 28, 29, 30
This study aimed to identify and design interventions tailored to target specific elements of behavior within the COM-B model. Study objectives were to identify the barriers and facilitators to junior doctors completing information on medication changes on electronic discharge summaries including why these occurred. The identified barriers and facilitators were then mapped to components of behavior as described in the COM-B model contained within the BCW. This study focused on the use of intervention functions and did not consider policy interventions. The focus was to establish interventions that individual hospitals could implement to enforce change and an exploration of policy interventions were outside the scope of this study.
Section snippets
Study design and participants
A qualitative design allowed the researcher to interpret and understand motives, explore social interactions and the meaning of events.31, 32 Semi structured interviews captured in depth, individual views and experiences of junior doctors in a confidential and non-threatening environment.33 The views and perspectives of junior doctors were sought as this staff group completes the majority of discharge summaries2 and little is reported in the literature about their perspectives. The study
Results
The interviews provided ‘thick’ descriptive data, and saturation was achieved.43 Nine main categories were identified that encompassed the barriers and facilitators identified in this study, Table 1. The identified barriers and facilitators were then mapped with the main components of the COM-B model to identify which components of behavior each aspect impacted upon, Table 1. The identified barriers often mapped to several components of the COM-B model. For example, barriers within the
Discussion
The aim of this study was achieved by using the BCW to help design tailored interventions to target components of behavior, influence change and improve the transfer of information on medication changes, Table 2. Other studies have similarly recommended a range of interventions to help improve the transition of care at discharge.44, 45, 46, 47, 48, 49 Many of these studies related to the medicines reconciliation process. Nonetheless, there are parallels between the recommended interventions in
Conclusion
In this study, using the BCW as a theoretical lens enabled identification of interventions that targeted specific components of behavior requiring change. Such tailoring is important for trust managers and policymakers, as it strengthens the evidence base for interventions in an NHS where resources are scarce. Persons developing interventions need to be cognizant of all possible strategies and all the events/interventions already occurring in the facility. It is the combined affect of all these
Acknowledgments
Thanks go to Lindsay Harper, Chedia Hoolickin, Dr Anu Trehan, Claire Davies, Gillian Crawshaw and Jane Lane for their assistance in this research. Thanks, also, to all the willing volunteer junior doctors who took part in this research.
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2019, Research in Social and Administrative PharmacyCitation Excerpt :The COM-B model has been employed in healthcare settings both to understand behaviour and to design interventions. For example, the COM-B model was used to explore facilitators of and barriers to medication adherence,31 to identify interventions that facilitate the transfer of information on medication discharge summaries,32 to understand behaviours when using a stop smoking services,33 to change behaviour of women with gestational diabetes,34 and to increase hearing aid use.35 The aim of this study was to use the COM-B model to explore the behaviours that could have caused PEs made by senior doctors in a speciality paediatric inpatient ward.
Conflict of interest/funding: The researcher was awarded an HEE/NIHR studentship to complete this piece of research as part of a Masters in Clinical Research.