Dr Judith Dyson, Senior Lecturer, Implementation Science Achieving Behaviour Change Workshop Working Together for Improvement: Behaviour change in the NHS Quality Improvement Conference 12 July 2018 Dr Judith Dyson, Senior Lecturer, Implementation Science

Best practice? 40% do not receive care according to guidelines (Eccles et al., 2005), e.g. SR Hand Hygiene 38.7% (WHO, 2009 . .and various subsequent similar estimates. . . ) Keeping up with the evidence. . . necessary for general medicine physicians to read 19 articles per day 365 days a year. . . the actual time reported - less than an hour per week (Sackett et al., 2007) NICE . . . effects on practice have been limited

We have gone to a lot of trouble to find out how to change/influence practice 30+ SRs about strategies to enhance the implementation of best practice – “no magic bullets” Some strategies work sometimes for some people in some environments. . . . . no one strategy is universally effective

And concluded . . We need to assess individual determinants to best practice (barriers and levers/facilitators and everything in between) We need to tailor our strategies according to these We need a theoretical approach to assessment and the intervention I will demonstrate why and how First, where does this approach (psychology/behaviour change theory) sit?

An intro’ to . . W. Edward Deming 1900-1993 Improvement is (profound knowledge – four elements) 1. Appreciation of a system - the processes involved . . . e.g. flow (Prince2, Sigma black belt, Lean) 2. Knowledge of variation – common or special cause . . . . . an example

Prof Mohammed A Mohammed

W. Edward Deming 1900-1993 Improvement is (profound knowledge four elements): 1. Appreciation of a system; the processes involved 2. Knowledge of variation: the range and cases . . . 3. Epistemology – the theory of knowledge: the concepts . . and the limits of what can be known. . . an example . . . through the ages

W. Edward Deming 1900-1993 Improvement is: 1. Appreciation of a system; the processes involved 2. Knowledge of variation: the range and cases . . . 3. Epistemology – the theory of knowledge: the concepts . .and the limits of what can be known. . . 4. Knowledge of psychology: human nature and behaviour . .

We (health) are catching up with Deming

Exercise One - in four groups – 5 mins Barriers to your own health behaviour (e.g. exercise, diet, stop smoking) Barriers to our patients/service users taking their medicines (e.g. emollient) Barriers to our practice behaviours (e.g. hand hygiene) How does our organisation support us in providing optimal care (if it helps think about what they do after a serious untoward inicident/never event)

Why is Psychology Useful? Assessing, tailoring, Interventions Our health behaviour (cake, wine, exercise) Patients concordance behaviour Our implementation behaviour Strategy Lazy, enjoyment/lack of enjoyment, motivation, stress, can’t be bothered, forget, my mates do it. . . . . . . . Don’t understand benefits, think they know better, don’t know how. Time, staffing levels, resources, forget, the consultant tells me to. . . . . . Email, guidelines, training. . . . they tell us. Interventions underpinned with BCTs are more effective than those that are not (Webb et al 2010, Taylor et al 2014)

Using Theory We have demonstrated how interventions need to address barriers (tailoring) We have demonstrated why we need to use theory to assess barriers And why need theory to underpin our interventions as they are more effective But HOW?

Theory to assess barriers – problems

Beliefs about capabilities Domain Meaning Knowledge Does the person know they should be doing behaviour X? Do they understand the evidence? Skills Does the person know how to do the behaviour (X)? How easy or difficult does the person find behaviour? Beliefs about capabilities How easy is it for the person to do X? Have they previously encountered problems? How confident are they that they can overcome difficulties? Motivation and goals How much do they want to do X? How much do they feel the need to do X? Are there incentives to do X? Are there competing priorities? Environment To what extent do physical or resource factors hinder X? Are there any competing tasks or time constraints? Beliefs about consequences What do they think will happen if they do X? What are the costs/consequences of doing X? Does the evidence suggest that doing X is a good thing? Emotion Does doing X evoke an emotional response? To what extent do emotional factors help or hinder X? How does emotion affect X? Social influences To what extent do social influences help or hinder X? Will the person observe others doing X? Role/identity How much is doing X part of the person’s identity? How much doing X important to the person? Memory/attention Can the person remember to do behaviour X? Do they usually do X? Action planning Does the person put plans in place to ensure they do the behaviour?

Exercise 2 – shout out Where do your barriers fit?

BCTs are not all tricky. .. and some are mapped to determinants 2=knowledge, 3=skills, 1 soc inf, White = agreed use

The process - three quick wins Forming implementation teams Identifying/defining the target behaviour(s) Identifying local barriers to performing the target behaviour Co-developing evidence based strategies to address local barriers (BCT and pragmatic) Implementing interventions Evaluation

Exercise 3 – shout out Win 1. Identifying the behaviour Exercise 3 – shout out Win 1. Identifying the behaviour? (the foundation of success) Example - Reducing antibiotic prescribing for unconfirmed UTIs Inappropriate dip stick testing (e.g. catheter, e.g. no UTI symptoms) Antibiotic prescribing without MSU Antibiotic prescribing not in line with policy (e.g. Cefalexin 2nd line due to C diff being Rx 1st line) Not all positive dipstick results followed up by MSU Prescriptions for antibiotics 3 days or less. . . . .

Win 2 -Identifying barriers Sending an MSU after positive dipstick

Win 3 - Co designing tailored (theoretically underpinned) interventions

Some examples of brilliant, simple, tailored and theoretically underpinned interventions (and the barriers they address) Talking cones (prompt - memory/automatic behaviours) MRSA (YMCA) on hospital radio (info and prompt - awareness/memory) A certificate and a day extra annual leave (incentives/rewards - motivation) “sister”. . . . . . (peer pressure/encouragement/support - social influences) Motorway service stations (peer pressure/encouragement/support -- social influences) The accidental intervention. . . The woman in the opposite bed 2=knowledge, 3=skills, 1 soc inf, White = agreed use

Questions? 2=knowledge, 3=skills, 1 soc inf, White = agreed use

Sincere thanks for listening Sincere thanks for listening. For references, help changing practitioner behaviour or because you feel like it . . . J.Dyson@hull.ac.uk @JudithDyson1 http://www.improvementacademy.org/patient-safety/behaviour-change-for-patient-safety.html