Discussion
This study evaluated the
implementation process of CCWs for patients with an increased risk of
falling and patients with dysphagia on the neurology ward of a
university hospital in the Netherlands. Results from this study indicate
most care professionals were informed of the intervention and understood
the received information. Overall, the care professionals reported being
satisfied with the CCWs and the way they were informed. In addition,
this study revealed that care professionals generally considered the
special needs of patients with a CCW. However, the care professionals
reported some deviations from protocol. First, patients with dysphagia
or an increased risk of falling did not always have a corresponding CCW.
Nurses seemed to sometimes forget to issue the CCWs during hectic
periods and patients sometimes removed the CCWs. Furthermore, it was not
verified on a daily basis whether all patients with a special patient
status were actually wearing their CCW. Finally, family members of
patients were not always informed on the intervention verbally or by
being handed the flyer.
Porter et al. [14] assessed the use of CCWs for indicating the
presence of allergies in a paediatric emergency department. The
researchers found that not all patients with allergies were wearing a
CCW. Of the 256 parent-child pairs that were included, there were 28
cases of true allergies according to a guideline-based assessment. Of
these 28 cases, only 16 were observed to wear a CCW. Similarly, our
findings indicate that in the present intervention not all patients with
an increased risk of falling or dysphagia were actually wearing a CCW.
Furthermore, our findings on the satisfaction of the CCWs among staff
and patients are consistent with the findings of Forster et al. [9].
In the study of Foster, 86% of the involved staff members reported that
the CCWs for indicating patients’ target oxygen saturation added at
least some benefit and 46% reported they helped significantly. Of the
staff members who were informed of the CCWs in our study, 55% and 67%
reported being (very) satisfied with respectively the green and yellow
wristband as an aid. Moreover, Forster and colleagues reported that the
patients that were surveyed in their study (n = 192) generally responded
positively. We were unable to directly assess the satisfaction of
patients with the CCWs in the present study. Still, in accordance with
the results of Forster and colleagues, the observations of the care
professionals in the present study suggest that patients generally were
content with the green and yellow wristband. Norris et al. [12]
describe several risks associated with the implementation of CCWs of
which some can be compared with our findings. Our findings substantiate
the claim of Norris and colleagues that the CCWs may not be seen by care
professionals. Indeed, the care professionals in our study noted that
CCWs were regularly covered by patients’ clothing. Norris and colleagues
also indicate that the colour coding of the wristbands may not be
understood by the care professionals. Yet, we found that the majority of
the care professionals were informed of the intervention. Moreover, the
surveyed care professionals who were informed of the intervention
generally appraised the received information on the green and yellow
wristband as clear. Therefore, our results indicate that the meaning of
the colour coding of the wristbands was clear for most care
professionals.
This study has several limitations. First, a risk in this type of
evaluation studies is that participants may feel inclined to give
socially desirable answers. To minimize this risk, we assured anonymity
to all study participants in the reporting of the study and conducted
the interviews in a private room. Second, our study design was
susceptible to recall bias as we relied on self-reported, retrospective
data. However, taking direct observations to assess the extent to which
the intervention was performed according to protocol was considered too
invasive. Third, the scope of this study was limited to evaluating the
implementation process of CCWs on only one ward. Hence, it remains
unclear to which extent our results are generalizable to other wards and
the hospital environment in general. However, it seems likely that the
issues related to the implementation of CCWs encountered in the present
study are not unique to neurology wards and are relevant to other
clinical settings as well. Strong aspects of this study are the use of a
multi-method approach and the incorporation of the framework by Saunders
et al. [15], which provides a systematic approach for studying
implementation processes.
Based on our results, we conclude that although the implementation of
CCWs seems feasible in daily practice, several challenges can arise when
implementing CCWs. We observed several deviations from protocol which
should be addressed when implementing CCWs in daily practice. The
following recommendations are made for addressing these challenges when
implementing CCWs. First, we recommend taking a rigorous and continuous
approach to informing the care professionals of the intervention.
Evidently, the colour coding can only provide cues to care professionals
that have been informed of the CCWs. As such, guidelines related to the
CCWs should be actively communicated to new staff members. Second, we
advise to embed the verification process of the CCWs in the daily
routines of care professionals. Finally, measures should be taken to
ensure that the CCWs are visible for staff members at all times. Wood
and Bagaine [13] found that especially the visibility of CCWs is of
importance in preventing adverse outcomes. Therefore, care professionals
should motivate patients to wear their CCWs in a visible way and notify
patients when their CCWs is covered up. More research is needed to
establish whether CCWs can help in improving health outcomes. The
present study highlights several challenges that arise when implementing
CCWs, of which some have been described in previous works. Future
research into the effectiveness of CCWs may yield more positive results
if these challenges are accounted for.