Changing the way people behave is difficult. So, what made a nurse-led intervention in stroke care almost three times more effective than the current optimal strategy for behaviour change?
If improving outcomes for patients entails that you must change human behaviour, the existing behaviour change literature doesn’t offer many reasons for optimism.
A review of over 350 studies suggests that deploying local opinion leaders is likely to be your most effective strategy, nevertheless delivering a modest median effect size of 12%. Your next best option, peaking at a median of 6%, is education conducted through meetings or outreach. And at the lower end of the table, supplying printed educational materials, audit and feedback and computerised reminders can each tip the scales by about 4%.
Progress towards your objective will require a great deal of patience and tenacity – or as study results recently presented at the European Stroke Organisation Conference (ESOC 2021) suggest, you might call on the Angels Initiative to boost your efforts.
A behavioural change game changer
Between 2017 and 2020 an unprecedented project was implemented in 64 hospitals in 17 countries in Europe. The aim of the Quality in Acute Stroke Care project (QASC) was to replicate the positive impact of an Australia-based nurse-led intervention to reduce death and dependency after stroke, across Europe.
The original QASC trial led in 2011 by Professor Sandy Middleton of the ACU Nursing Research Institute in Australia and conducted at 19 stroke units in New South Wales, had shown a 15.7% reduction in death and disability at 90 days post stroke and reduced long- term mortality as a result of three simple protocols – to manager fever, sugar and swallowing – collectively known as FeSS.
By 2016 the FeSS protocol was already embedded in stroke services throughout New South Wales. And in the same year Professor Middleton received an email from Jan van der Merwe of the Angels Initiative that over the next four years would not only fundamentally change post-acute stroke care in Europe but shift perceptions of nurses’ role in stroke treatment.
A third, unanticipated outcome was that it would provide evidence regarding a new approach to behavioural change, as emerged from Professor Middleton’s presentation at ESOC 2021. The results of QASC Europe showed that implementation of the FeSS protocol had increased from 3.2% at baseline to 35% at the end of the study. In a study involving more than 7,000 patients, QASC Europe had delivered a behavioural change effect of greater than 30%. That is an astonishing 165% higher than the effect size previously believed possible, based on the literature. To account for this, one has to take a closer look at the project.
Shrinking the challenge
QASC Europe was among other things a study in collaboration. It was implemented with the support of the European Stroke Organisation, the Angels Initiative and the quality registry, RES-Q, where data from the study was recorded on a dedicated QASC page.
Hospitals to participate in the study were recruited and enrolled by Angels consultants – the facilitators and foot soldiers of the Angels’ behavioural change strategy who would also provide invaluable site support alongside local change agents nominated by each hospital.
Adept at reducing complexity, Angels consultants were on hand to help nursing teams shrink the challenges of identifying barriers and enablers, developing action plans, facilitating training, implementing the FeSS protocol as part of routine stroke care, and recording the data.
Fever, hyperglycaemia and dysphagia are all implicated in patient morbidity and mortality. Fever within the first 24 hours of hospitalisation is associated with doubling the likelihood of short-term mortality. Hyperglycaemic non-diabetic patients admitted to hospital with stroke are three times more likely to die than those with normal glucose levels, and failure to screen for dysphagia, which affects up to 78% of stroke patients, raises the risk of aspiration pneumonia contributing to severe disability and death.
The fever protocol requires temperature monitoring four times per day for three days and treatment with paracetemol for temperatures above 37.5 degrees. Glucose levels must be monitored on admission and four times per day for three days, with insulin administered if indicated. Finally, a swallow screen has to be performed within 24 hours and before oral intake, with speech pathologist referral for patients who fail the screen.
The desired primary outcome of QASC Europe was behaviour change translated into overall FeSS compliance.
It was “all of these Angels who really made this happen,” Professor Middleton told the audience during a presentation of the study results at a Power of Nurses symposium at ESOC. “They really supported the nurses to implement the FeSS protocol.”
The power of nurses
The study had another “unanticipated but delightful” outcome, Professor Middleton said. It established the power of nurses to influence practice at a local level, changed perceptions of stroke nurses’ role in hospitals, and boosted efforts to establish national stroke nursing interest groups.
“A really important legacy of this study was that it gave nurses a toolkit for improving care not only in post-acute stroke care but for any other care processes they want to change,” Professor Middleton said.
When it came to QASC- powered nurse leadership, Czech Republic lead the way. With 10 participating hospitals it had the highest hospital enrolment rate in the QASC Europe project. Angels consultant for the Czech Republic Robert Havalda, in his capacity as QASC champion, played a key role in supporting his fellow consultants throughout the project.
Working closely with the Czech Stroke Society and Prague-based head nurse Tereza Koláčná (an Angels Spirit of Excellence award recipient whose hospital was the first to complete QASC Europe implementation), Robert organised the country’s first Stroke Nurses Congress in 2019 and facilitated the establishment of an Angels Nurses Steering Committee in 2020.
Consultants in other countries are also mobilising nurse power, providing structured support to newly formed working groups and societies that facilitate knowledge sharing and communication, and, coinciding with the Year of Nurses and Midwives in 2020, making training available to stroke nurses.