Here we present our theory-driven approach to co-designing the Let’s Talk complex intervention toolkit. Our findings are organised under the three stages (and eight constituent steps) of the BCW guide, as shown in Figure 1.
Stage 1: Understanding the behaviours
Step 1: Define the problem in behavioural terms
Through previous research (5), our integrative review (31) and initial discussions with our PPI, advisory groups and the clinical service lead, modern matron and divisional medical director at the NHS organisation, the behavioural problem was defined as the absence of high quality nurse-patient therapeutic engagement on acute mental health wards i.e. not using the Principles of Engagement identified in our review.
Step 2: Select target behaviour(s)
In keeping with the EBCD methodology, it was important to understand how service users and staff typically experienced engagement prior to the identification of relevant areas for behavioural change. Through observations and semi-structured interviews, the research team identified 28 touchpoints. Some examples of touchpoints were 1) I was left on my own and ignored; 2) my care was robotic and 3) As a nursing team we need to create better bonds with service users (full results in preparation to be published elsewhere).
To ensure credibility, the touchpoints were discussed during two facilitated feedback workshops – one for service users and one for clinicians. In an emotional mapping exercise, participants were encouraged to identify improvement priorities based on their touchpoints and assign associated behaviours (see Additional file 2 for breakdown of touchpoints into improvement priorities and associated behaviours). Participants then ranked their improvement priorities in a dot voting exercise and chose four priorities to take forward to the joint workshop. The service user and clinician priorities are shown in Table 1.
Table 1 – Service user and clinician priorities for change
At the joint workshop, facilitated discussion encouraged participants to consider the potential impact, likelihood of change, spill over effect and ease of measurement of all the improvement priorities and associated behaviours. An affinity grouping exercise was conducted and through this, four shared improvement priorities were identified and agreed:
- Improve communication with withdrawn people
- Nurses to help service users help themselves
- Increasing nurses’ confidence when interacting with service users
- Improve team relations and ward culture.
Step 3: Specify target behaviour(s)
EBCD focuses on identifying participants’ improvement priorities as a way of bringing about change that is meaningful to service users and clinicians (35). We used the BCW to examine each of the four joint improvement priorities. At the joint workshop, the co-design team formed into smaller groups with equal numbers of service users and clinicians. Each group completed a written exercise where they examined the joint priorities and associated behaviours in terms of who needs to perform the behaviour, what the person needs to do differently to achieve change and when, where, and with whom they will do it (Table 2) (See Additional file 3 for example of written exercise).
Table 2 – Specification of behaviours for joint improvement priorities
Step 4: Identify what needs to change
From our review and semi-structured interviews with service users, carers and clinicians, the research team identified 26 barriers to engagement and mapped them to the COM-B/TDF domains. The barriers were discussed with participants at the feedback workshops to ensure credibility. At the joint workshop participants matched the barriers to their four joint improvement priorities. The barriers related to each COM-B component are discussed below, with the corresponding TDF domains presented in parentheses.
Capability
Participants agreed that nurses often had limited knowledge and inadequate training in therapeutic engagement techniques (skills and knowledge):
“Although I’ve been doing this for almost five years it’s like sometimes with certain patients you just don’t know what to say…I wish there could be some training to understand that stuff.” – RMN6
Nurses also felt that the very nature of having a mental health problem could make it difficult to engage, and while service users agreed that their mental illness and medication effects could negatively impact engagement (memory/attention/decision process), they were able to describe helpful engagement techniques that nurses could employ, even with the most acutely unwell people. This further highlighted the need to improve nurses’ engagement skills:
“Sometimes you have a lot more patients who are unwell or sometimes they’re less unwell, so engagement fluctuates week on week from that point of view” – RMN2
Opportunity
It was felt that there needed to be a cultural shift on the ward and within the organisation so that nurse-patient engagement activities were supported and valued in the same way as other tasks such as hourly observations or administrative duties (social influences):
“It was a numbers game, everyone’s taking handover, another one’s doing checks, some are on break…in an ideal world allocate friendly HCAs just to sit with patients.” – SU7
There was unanimous agreement that lack of resources negatively impacted on nurses’ ability to engage therapeutically:
“The problem for me lies on the number of staff, that is not enough…” – C1.
This created an untherapeutic ward environment where “professionals would run around like mad rabbits not giving any attention to the patients.” – SU2 (environmental contexts and resources).
Motivation
Nurses felt that they could not always trust all members of their team to carry out the job in the right way. This created a feeling of helplessness for some nurses, which deterred them from engaging therapeutically (beliefs about capabilities):
“I became very aware that when there is an incident, I’m left on my own…I stopped trusting the team…I couldn’t rely, therefore I needed to take a step back from the patients.” – HCA2
Service users were also deterred from approaching nurses for engagement because they felt nurses often did not understand their problems or would punish them if they asked for therapeutic engagement too often (beliefs about consequences):
“I kept myself to myself because even when I asked for simplest of things I was made to wait for ages so I would get frustrated, but if I showed frustration no doubt that would be on my notes and I would get set back.” – SU4
As well as issues of trust, the ward staff felt as though their team were transient, with many longstanding nurses leaving to work elsewhere. This led to a lack of shared responsibility. Therapeutic engagement could easily “fall through the cracks – HCA1” and when poor quality engagement was witnessed, it was rarely followed up by a senior member of the team. This made some nurses feel they could not be bothered to engage:
“I mean to put it blunt; I know it sounds really bad…I can’t be bothered.” – RMN5
There was also a blurring of professional roles, where although nurses knew they should engage, they left it to other professionals such as the occupational therapist or activities coordinator:
“I can completely understand why nurses want separate roles because they would say you don’t do our job so why should we do yours, but I do take people out on escorts and I do blur the boundaries there.” – PT1.
When asked to give examples of nurse-patient engagement, many service users spoke about engagement with professionals other than nurses. This shows both the lack of engagement from nurses and the difficulty service users have in delineating between the nursing role and the role of other health professionals (social/professional identity).
There was a general sense from nurses that therapeutic engagement “didn’t always help people” – RMN8 (optimism). This led some nurses to feel anxious about engaging therapeutically, particularly when they felt they did not have the required skills. When this was coupled with feelings of frustration at the perceived lack of managerial support, nurses reported feeling drained, burnt out and demotivated (emotions):
“One of the biggest problems is the management style which on paper, yes, it seems to be doing everything right, but in practice they have a very poor relationship with their staff and that does impact on performance…I just feel like no one cares about you, so why give up your time?” – RMN3
Stage 2: Identify intervention options
Step 5: Identify intervention functions
PPI and advisory group meetings highlighted that some of the terminology used to describe intervention functions would not be suitable to use with our participants. Words such as “coercion” can have negative connotations to mental health service users. Instead, practical examples that captured the essence of each intervention function were provided to participants at the joint co-design workshop. In a written exercise they were encouraged to use these examples to think about intervention functions that could address their four joint improvement priorities. Where possible we modelled these examples on illustrations from interviews with service users and staff. Where this was not possible, we developed examples from the BCW book (32) (Table 3).
Table 3 – Practical examples of behaviour change wheel functions given to co-design team
Participants identified five intervention functions that were relevant to bringing about the desired change. These were 1) training; 2) education; 3) enablement; 4) coercion and 5) persuasion. Through discussions with senior management, the research team also identified restriction as a relevant function. The links between the COM-B/TDF domains and the intervention functions are shown in Table 4.
Step 6: Identify policy categories
The BCW includes policy categories which may help to support the delivery of an intervention. At the outset, changing policy was not a primary aim of this study; the research team did not engage in this step with participants. However, through discussion with senior management the research team identified communication/marketing, guidelines and social planning as potentially relevant to facilitating our intervention on other wards in the future.
Stage 3: Identifying intervention content and implementation options
Step 7 & 8: Identify behaviour change techniques and mode of delivery
Rather than provide participants with a long list of BCTs, the written exercise at the joint workshop encouraged them to design intervention strategies they thought relevant to each of the four priorities and its influencing factors. The research team retrospectively assigned BCTs to the participants’ examples and selected further BCTs and intervention strategies not identified during the joint workshop. These were the basis for the development of the first intervention prototype.
The prototype was further refined through an iterative process of email exchanges, telephone calls, a PPI meeting, seven small co-design team meetings and finally presentation of the work at an organisation wide acute care forum. As per the BCW guide (32) the APEASE criteria (affordability, practicability, effectiveness/cost effectiveness, acceptability, side effects/safety and equity) were used in an adapted form (see Additional file 4) to stimulate discussion and ideas. These criteria ultimately informed the choice of intervention strategies for each improvement priority.
Fourteen BCTs were considered relevant to the Let’s Talk intervention toolkit. Table 4 shows the link between each phase of the behaviour change intervention design process, the 14 BCTs and the intervention strategies and modes of delivery which resulted from the co-design process.
The Let’s Talk toolkit consisted of four main components, linked to the co-design team’s four joint improvement priorities:
- A 30-minute training film for nurses, delivered by service users and carers to be shown to nurses at the start of the intervention. Service users and carers discuss good and bad engagement techniques and personal accounts of their experiences of engagement whilst an inpatient, structured by our model of engagement.
- An illustrated workbook called My Conversation Companion which includes guided exercises that nurses and service users can do together to help structure therapeutic conversations.
- Signs attached to the outside of service users’ bedroom doors to enable them to indicate, with a sliding panel, whether they would like engagement time or not. The signs are linked to the hourly nursing observation record, where each hour nurses will be required to record if a service user has requested engagement and if that request has been fulfilled. “Missed engagement” will be handed over at each nursing shift with the expectation that it is fulfilled that day. Observation records will be audited each month and feedback given to the nursing team. Additionally, an illustrated sign on the inside of service users’ doors will encourage service users to use the signs if they want to engage.
- Changes to nurses’ daily routines, for example during handover, time will be made to check-in with the nursing team and offer additional support to any team member that needs it that day. Additionally, quarterly facilitated workshops will bring clinicians and service users together to discuss, reflect and improve practice.
Through discussions with the chief nurse, assistant director of nursing and divisional medical director and presentation of the work at an acute care forum it was agreed that the Let’s Talk intervention would support the relaunched implementation of PET within the organisation. Discussion with participants revealed that they supported this and considered some form of PET essential to support nurses to use Let’s Talk in practice. See Additional file 5a and 5b for the toolkit.
Table 4 – The co-design-behaviour change process and components of the resulting Let’s Talk intervention toolkit