Implementing PERFECT-ER with Plan-Do-Study-Act on acute orthopaedic hospital wards: Building knowledge from an implementation study using Normalization Process Theory

PLOS ONE RESEARCH ARTICLE Implementing PERFECT-ER with Plan-DoStudy-Act on acute orthopaedic hospital wards: Building knowledge from an implementation study using Normalization Process Theory a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 Chris Fox1¤a, Simon P. Hammond1¤b, Tamara Backhouse2, Fiona Poland2, Justin Waring3, Bridget Penhale2, Jane L. Cross ID2* 1 Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, England, 2 School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, England, 3 Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, England ¤a Current address: University of Exeter College of Medicine and Health, St Luke’s Campus, Exeter, England ¤b Current address: School of Education and Lifelong Learning, University of East Anglia, Norwich, England * OPEN ACCESS Citation: Fox C, Hammond SP, Backhouse T, Poland F, Waring J, Penhale B, et al. (2023) Implementing PERFECT-ER with Plan-Do-StudyAct on acute orthopaedic hospital wards: Building knowledge from an implementation study using Normalization Process Theory. PLoS ONE 18(2): e0279651. https://doi.org/10.1371/journal. pone.0279651 Editor: Anandakumar Haldorai, Sri Eshwar College of Engineering, INDIA Received: July 17, 2022 Accepted: December 12, 2022 Published: February 24, 2023 Copyright: © 2023 Fox et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: In this paper we use NPT to understand how implementing, embedding, and integrating a complex intervention, designed to optimize care for patients experiencing CI and hip fracture, was carried out in three National Health Service (NHS) acute orthopedic wards over a twelve-month period conducted as part of the PERFECTED Abstract Background Delivering care to growing numbers of patients with increasingly ‘complex’ needs is currently compromised by a system designed to treat patients within organizational clinical specialties, making this difficult to reconfigure to fit care to needs. Problematic experiences of people with cognitive impairment(s) admitted to hospitals with a hip fracture, exemplify the complex challenges that result if their care is not tailored. This study explored whether a flexible, multicomponent intervention, adapting services to the needs of this patient group, could be implemented in acute hospital settings. Methods We used action research with case study design to introduce the intervention using a PlanDo-Study-Act (PDSA) model to three different hospital sites (cases) across England. The qualitative data for this paper was researcher-generated (notes from observations and teleconference meetings) and change agent-generated (action plans and weekly reflective reports of change agents’ activities). Normalization Process Theory (NPT) was used to analyze and explain the work of interacting actors in implementing and then normalizing (embedding) the intervention across contexts and times. Data analysis was abductive, generating inductive codes then identified with NPT constructs. Across the three cases, change agents had to work through numerous implementation challenges: needing to make sense of the intervention package, the PDSA model as implementation method, and their own role as change agents and to orientate these within their action context (coherence). They had to PLOS ONE | https://doi.org/10.1371/journal.pone.0279651 February 24, 2023 1 / 16 PLOS ONE programme funded by NIHR PGfAR (ref: DTC-RPPG-0311-12004). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Abbreviations: BPT, Best Practice Tariff; CI, Cognitive Impairment; CPD, Continuing Professional Development; HCA, Healthcare Assistant; NHFD, National Hip Fracture Database; NHS, National Health Service; NMC, Nursing and Midwifery Council; NPT, Normalization Process Theory; PDSA, Plan-Do-Study-Act; SIL, Service Improvement Lead; PL, Process Lead. Implementing PERFECT-ER with Plan-Do-Study-Act on acute orthopaedic hospital wards work to encourage colleagues to invest in these changes (cognitive participation) and find ways to implement the intervention by mobilising changes (collective action). Finally, they created strategies for clinical routines to continue to self-review, reconfiguring actions and future plans to enable the intervention to be sustained (reflexive monitoring). Conclusions Successful implementation of the (PERFECT-ER) intervention requires change agents to recognize and engage with local values, and then to enable its fit with practice and wider contextual goals. A context of constant change fragments normalization. Thus, sustaining practice change over time is fragile and requires change agents to continue a recursive twoway sense-making process. This enables implementation and normalization to re-energize and overcome barriers to change. Introduction Care systems are often designed to treat patients within discrete organizational clinical specialties, but this can compromise the delivery of healthcare as integrated and patient-centered, especially for older people with complex health conditions [1–3]. People experiencing cognitive impairment (CI) (including, but not exclusively, dementia and/or delirium) and hip fracture are a notable example, where their treatment creates a complex scenario of multiple simultaneous demands from hospital care [4, 5]. People experiencing CI who break their hip are cared for in environments designed to deliver excellent hip fracture care, but where they may be poorly managed due to a lack of expertise in managing CI. Care of these individuals calls for greater risk management because this group experiences more post-operative complications including delirium and mortality [3, 6–8]. As the demographic of patients change, uptake of relevant research findings into routine healthcare becomes even more vital. Developing and testing interventions for efficacy is important, but so is knowledge of appropriate robust, theory-based implementation to normalize changes [9]. Normalization Process Theory (NPT) is a middle-range conceptual framework that attends to work of implementing, embedding, and sustaining new modes of care into established routines and patterns of social organization [10, 11]. Researchers increasingly use NPT to examine how agents enact change, affected by individual, local, and national contexts, rather than how an intervention should be implemented in ideal circumstances [12–15]. However, an NPT approach can be used to examine chan (...truncated)