Title: Improving communication between patients and healthcare staff: Development and feasibility study of a behaviour change intervention
Funder: Department of Health and Social Care

Abstract: BackgroundIncreasing 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. AimsI 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. I will then carry out a feasibility study to see if a trial of the intervention's effectiveness is possible.I will answer four research questions: What methods of communication are effective for and acceptable to patients, and which effective methods do patients underuse and why? What format and content would be suitable for a behaviour change intervention to empower patients to communicate more effectively with staff? What would enhance the usability and acceptability of this intervention? Would it be feasible to carry out a definitive trial to evaluate the effectiveness and cost-effectiveness of this intervention?Plan of investigationI 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). Stage 1: Planning Qualitative synthesis: Use meta-ethnography to synthesise qualitative studies of communication in primary care, and explore what patients' find acceptable and helpful.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). Stage 2: Design Define key objectives for the intervention, using data from stage 1.Identify suitable ways and techniques to achieve these objectives, using established methods (Michie et al., 2014).Design the intervention. Stage 3: Development and evaluation of acceptability Think-aloud study: Observe 16 patients and 9 staff using the intervention.Modify the intervention in response to findings to make it more acceptable and useable. Stage 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 9 staff to explore the acceptability of study procedures. Potential benefitsPatients and staff will be consulted throughout the study, and patients will be directly involved in the design and development of the intervention (stages 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: AimTo empower older people, aged 65+, with multiple long-term conditions (multimorbidity) to improve their patient safety, by helping them communicate more effectively with healthcare staff (hereinafter referred to as staff).Specifically, I will: Identify what methods of communication help older people when talking to staff, and which of these methods are not often used and why. Design supportive materials to help older people with multimorbidity communicate effectively with staff. Find out how these supportive materials could be made easier and more appealing to use. Determine if it is possible to test whether the materials empower patients, improve communication with staff, increase satisfaction with care, and improve patient safety.BackgroundAn increasing number of people, including half of those aged 65+, have multimorbidity. Such people can: Be prescribed lots of medications. Receive conflicting advice from staff. Feel their needs and concerns are not being listened to or addressed. Feel overwhelmed by their healthcare. These factors mean that older people with multimorbidity are more likely to experience issues with their patient safety (e.g. delayed diagnoses, medication errors, and a lack of trust in staff). How such safety issues arise is currently being explored. Early findings suggest it is often because of gaps in communication between patients and staff.Most efforts to improve communication have focused on staff. However, there is growing recognition of the role of patients in safety. In a small number of studies, groups of older people have been taught to obtain and provide more information during healthcare appointments. However, no such study has been designed to help older people with multimorbidity (hereinafter referred to as patients), who could benefit most.I aim to address this gap by developing a set of supportive materials to: Empower patients. Improve communication with staff. Increase satisfaction with care. Improve patient safety.Design and methodsI will draw on existing theories and evidence, and follow the Person-Based Approach'; seeking the views of patients and staff to plan, design, develop, and test supportive materials: Stage 1: Planning Review existing evidence on what methods of communication help patients talk to staff. Observe video-recorded consultations between patients and staff to see which helpful methods are not often used. Interview 25 patients and staff about barriers to effective communication.Stage 2: Design Define objectives based on the most significant barriers to effective communication (identified in stage 1). Use the Behaviour Change Wheel' and Behaviour Change Technique Taxonomy' to identify how these objectives can be addressed. Use this information to design supportive materials, for example, a brief information and training document for patients, and an awareness exercise and posters for general practices.Stage 3: Development and evaluation Observe 25 patients and staff work through the supportive materials whilst thinking-aloud. Review findings to identify how the materials can be made easier and more appealing to use. Modify the materials, where appropriate.Stage 4: Use and test Recruit 4 general practices and 48 patients. Provide the supportive materials for use and testing. Collect information at the start of the study and two months later through questionnaires about participants' use of the materials and to measure the impact of these. Interview patients and staff about their experience of participating in this study. Use information from this study to determine if it is possible to do a larger study to definitively test the effectiveness of the materials.Patient and Public Involvement (PPI)I will involve patients in every stage of this research, from design and management to analysis and dissemination.PPI members of the research team and project advisory group will help ensure I stay focused on the needs and priorities of patients. Their input will help improve recruitment rates and patients' experience of participating (e.g. by ensuring materials are understandable and relevant).I will present findings to the PPI Multimorbidity Research Advisory Group and ask for help identifying: The most significant barriers to effective communication. Acceptable ways of addressing these barriers. Ways to make the supportive materials easier and more appealing to use. PPI members will receive fees and travel expenses in-line with INVOLVE guidelines (http://www.invo.org.uk/resource-centre/payment-and-recognition-for-public-involvement/). They will also be involved, acknowledged, and credited in dissemination activities. DisseminationI will engage with and disseminate findings to academics, staff and service managers, participants and involvement members, and patients by: Publishing articles in influential journals. Distributing plain English summaries of publications. Presenting at national and international conferences. Writing articles for Clinical Commissioning Group's newsletters. Attending Local Medical Committee meetings. Providing information through social media. Speaking at support groups. Running public engagement events.

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