Results

Participants

All five selected project members agreed to participate in the interview. Among the five project members were four nurses and one quality manager. Two project members were interviewed in the same session at their request. Of the 40 care professionals that work on the neurology ward, 23 (57.5%) responded to the questionnaire. The majority of the respondents were nurses (table 2).
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Reach

Of the five project members who were interviewed, two reported that all targeted staff members were informed of the intervention. Two other project members reported that at least all nurses were informed, but that they were not sure whether all other care professionals were informed. The other project member indicated that staff members who exclusively work during weekends or vacation periods may not have been informed of the CCWs and their use. The results of the questionnaire revealed that 20 (87.0%) and 21 (91.3%) of the care professionals who participated in the survey reported to be informed of the use of respectively the green and yellow wristbands, respectively. Two of the nurses who participated in the survey reported not being informed of either wristbands and one of the speech therapists reported not being informed of the yellow wristband. The survey respondents were asked to rate their satisfaction with the manner in which they were informed of the CCWs. Of the survey respondents who were informed of the CCWs, 13 (65.0%) and 14 (66.6%) reported being (very) satisfied with how they were informed of respectively the green and yellow wristband. The survey respondents were asked to rate the extent to which they agreed with several statements related to the received information. The majority of the respondents reported that their colleagues were aware of the CCWs. Moreover, respondents generally appraised the information received on the CCWs as clear (table 3).
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Performance according to protocol

Results of the questionnaire showed that all 13 nurses who had reported that they had been informed of the CCWs always perform the water-swallowing test when admitting stroke patients. In addition, nine of these nurses reported that in almost all cases patients are issued a CCW after a fall incident and four reported that this happens in most cases. During the interviews, two of the five project members indicated encountering patients at the neurology ward who should have been wearing a CCW but who had not been issued one. According to these project members, nurses sometimes forget to issue the CCWs during hectic periods, such as nightshifts and large transfers of patients. In the questionnaire, the nurses who reported being aware of the CCWs were asked to which extent all patients who need a CCW, as indicated by their electronic health record, actually wear it. Nine of the 13 nurses who were informed of the CCWs reported that almost all patients who need a CCW wear one and four reported that most patients who need it wear one. These nurses were also asked how often they verify whether all patients who need a CCW wear it. Three nurses indicated patients are inspected for wearing a CCW every day, four indicated this is done almost every day, five indicated this is done a few times a week, and one indicated not knowing how often this is done.
All of the interviewed project members reported that the sign holders were placed in every patient room, as intended. The questionnaire revealed that five nurses always provide the flyers to the patients with a CCW and/or their family, six nurses provide them to the patients sometimes, and two nurses provide them seldom or never to the patients. The nurses were also asked to what extent they explain the use of the CCWs to patients and their families. The majority of the nurses (n = 11) reported always explaining the use of the CCWs to patients. One nurses reported explaining the use of the CCWs to the patients in some cases and another reported explaining it seldom or never. With regard to explaining the use of the CCWs to family members, seven nurses reported always doing so, four nurses reported doing so most of the times, one nurse reported doing so sometimes and another reported doing so seldom or never.
During the interviews, the four project members who are nurses reported being attentive to the special needs of patients with a CCW. Examples of preventive measures they took for patients wearing green wristbands included: employing motion sensors, putting on non-slip socks, putting the beds in low position, and putting the bed’s side rails up. With regard to the yellow wristband, the projected members mentioned a sign that is hung on the beds of patients with a yellow wristband, to remind staff and visitors to not provide food that poses a choking hazard. Project members also reported that the location of patients with a yellow wristband is mapped to aid the nutritionists in their work. In the questionnaire, respondents were asked to rate their level of agreement with several statements related to the performance according to protocol (table 3). The respondents generally reported being more careful when mobilizing patients with a green wristband and when offering food and drink to patients with a yellow wristband. However, respondents reported mixed attitudes towards whether they treat patients with a CCW differently.

Compliance

During the interviews, all five project members indicated that patients sometimes remove their CCWs during a state of deliriousness and that the CCWs are sometimes covered by patients’ clothing. In the questionnaire, the nurses were asked how often patients and family members refuse the CCWs. Of the 13 nurses that were informed of the CCWs, three reported the patients sometimes refuse the CCWs and 10 reported the patients refuse them seldom or never. One nurse reported that family members sometimes refuse the CCWs. The other nurses (n = 12) reported that family seldom or never refuse the CCWs. Respondents were asked how often they see patients (un- or intentionally) wear clothes over their CCWs. Of the respondents who were informed of at least one of the CCWs (n = 21), eight indicated seeing patients wear clothes over their CCWs often, five reported seeing this regularly, four reported seeing this sometimes, and four reported seeing this seldom or never or not having paid attention to it.

Opinion on the intervention

In the questionnaire, respondents were asked to express their opinion on the intervention by rating the extent to which they agreed with several statements (table 3). For both CCWs, approximately half of the respondents reported that they think that CCWs help to improve quality of care. Only a minority of the respondents reported that they think that patients find the CCWs bothersome. The respondents reported mixed attitudes towards whether the family of the patients find the CCWs useful. Respondents were asked to rate their satisfaction with the CCWs as an aid. Of the respondents who were informed of the CCWs, 11 (55.0%) and 14 (66.7%) reported being (very) satisfied with respectively the green and yellow wristband as an aid. All of the interviewed project members observed that patients and family members generally are content with the CCWs.
In the interviews and questionnaire, we asked how the intervention could be further improved. During the interviews, three project members suggested implementing a third colour code that represents both the green and yellow wristband to help make patients more comfortable. The two other interviewed project members offered no suggestions for improvement. The majority of the surveyed care professionals (n = 17, 74.0%) offered no suggestions for improvement. Two survey respondents wrote that they would like the physiotherapists be more involved in issuing the green wristbands. One survey respondent suggested organizing a meeting for all the neurology ward’s staff members to establish more clarity on the protocols of the intervention. Another respondent noted that the issue of patients covering their CCWs warrants more attention.

Context

During the interviews, the project members were asked how contextual factors could have affected the intervention. According to the project members, the implementation of the intervention was postponed because some staff members were concerned that labelling patients with CCWs would violate their privacy. In addition, the project members noted several factors that caused the implementation period to be busier than usual. First, during the implementation period, the hospital was also being accredited by the Netherlands Institute for Accreditation in Healthcare. Second, because of undergoing renovation, the neurology ward had to be temporarily move its activities to a different location in the hospital. Finally, two project members were absent for some time due to private reasons.