Title: Empowering older people with multimorbidity to improve patient safety through better communication: development and feasibility study of a behaviour change intervention
Funder: Department of Health and Social Care

Abstract: Background Increasing numbers of people live with multimorbidity, including half of those aged 65+. These patients may be prescribed multiple medications, and have unmet needs and difficulties accessing and interacting with healthcare services (Goodwin et al., 2011; Hobbs et al., 2015). Such factors mean older people with multimorbidity are more likely to experience patient safety incidents. Initial findings from a longitudinal, qualitative study suggest many safety incidents arise because of gaps in communication between patients and healthcare staff (Daker-White et al., 2014). Communication issues can leave patients feeling dehumanised and disempowered, and threaten their safety (Coyle, 1999; Rhodes et al., 2016). Street et al. (2005) explored differences in how often patients express concerns and ask questions in consultations. These communication behaviours were found to be predominately patient-initiated, suggesting patient-orientated interventions could empower them to communicate more effectively, and improve safety. A systematic review identified three such interventions for older people (Wetzels et al., 2007). These had positive but inconclusive results, and there continues to be a lack of high-quality research in this area. Furthermore, no such intervention has been developed for older people with multimorbidity (hereinafter referred to as patients), who could benefit most. Aims We intend to address this gap by planning, designing, and developing a brief behaviour change intervention to empower patients to improve their patient safety by helping them communicate more effectively with staff. We will then carry out a feasibility study to see if a trial of the intervention s effectiveness is possible. We will answer four research questions: Question 1: What methods of communication are effective for and acceptable to patients, and which effective methods do patients underuse and why? Question 2: What format and content would be suitable for a behaviour change intervention to empower patients to communicate more effectively with staff? Question 3: What would enhance the usability and acceptability of this intervention? Question 4: Would it be feasible to carry out a definitive trial to evaluate the effectiveness and cost-effectiveness of this intervention? Plan of investigation We will follow a theory-, evidence-, and person-based approach to plan, design, develop, and trial an intervention that addresses patients needs (Yardley et al., 2015). Phase 1: Planning Qualitative research: Review pre-recorded primary care consultations, and interview 16 patients and 9 staff to explore what effective communication behaviours are underused and why. Analyse data in the context of a framework for understanding behaviour (Michie et al., 2013). Phase 2: Design Define key objectives for the intervention, using data from phase 1. Identify suitable techniques to meet these objectives, using established methods (Michie et al., 2014). Design the intervention. Phase 3: Development and evaluation of acceptability Think-aloud study: Observe 12 patients and 6 staff using the intervention. Modify the intervention in response to findings to make it more acceptable and useable. Phase 4: Implementation and trialling Feasibility study: Deliver the intervention to 4 general practices and 48 patients to determine whether it is feasible to recruit participants, collect and analyse data, and deliver the intervention in practice. Process evaluation: Interview 16 patients and 6 staff to explore the acceptability of study procedures. Potential benefits Patients and staff will be consulted throughout the study, and patients will be directly involved in the design and development of the intervention (phases 2 and 3). This will ensure the study is understandable and appealing, and the developed intervention is acceptable and useful. The proposed intervention has the potential to empower patients, improve communication with staff, increase satisfaction with care, and improve patient safety

Lay abstract: Although care in the NHS is generally very good, problems do occur, such as missed diagnoses or medication errors. In these situations, patients sometimes suffer harm. Trying to avoid harm from healthcare is called patient safety . People who have multimorbidity (two or more long-term conditions) often receive more healthcare than others. Thus, they may be more likely to experience risks to their patient safety. Older people are more likely to have multimorbidity, and be more vulnerable to harm. We have researched how risks to patient safety arise for older people with multimorbidity. Risks arise for a range of reasons, including poor communication. We shared our findings with a group of carers and older people with multimorbidity. They considered good communication to be the most important issue for patient safety. Good communication can be difficult for older people with multimorbidity, especially those who: Have many, complicated health problems. Have mental health as well as physical health problems. Are prescribed multiple, regular medicines. Find it difficult to manage their treatments or day-to-day activities. Need help from different staff in different parts of the NHS. Evidence suggests it is possible to empower patients to communicate better with healthcare staff. Doing this could improve patients satisfaction with their care, and improve their patient safety. However, older people with multimorbidity do not receive help to do this. Working closely with patients, we will design materials to support them when talking to healthcare staff. We will ensure the materials are easy to use and meet patients needs. We will then do a small study to help us work out whether we could to do a big enough study to test the materials to see if they help older patients with multimorbidity communicate better, feel more empowered, be more satisfied with their care, and be safer

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE