Implementation of a complex intervention to improve care for patients whose situations are clinically uncertain in...

Area of Science:

• Healthcare implementation science
• Process evaluation methodology
• Clinical practice improvement

Background:

• The AMBER care bundle aims to improve care for patients with clinical uncertainty.
• Successful integration of new care bundles into acute hospital settings is complex.
• Normalisation Process Theory (NPT) provides a framework for understanding and managing implementation.

Purpose of the Study:

• To evaluate the normalization of the AMBER care bundle in acute hospital practice using NPT.
• To identify barriers and facilitators to its successful implementation.
• To suggest modifications for optimizing the bundle's integration.

Main Methods:

• A multi-method process evaluation was embedded within a feasibility cluster randomised controlled trial.
• Data collection included focus groups, interviews, observations, and clinical note reviews.
• Thematic analysis guided by NPT components was used, with data triangulation.

Main Results:

• Health professionals recognized the AMBER care bundle's value (coherence).
• Challenges were observed in operationalizing eligibility criteria and engaging staff (cognitive participation, collective action).
• A 'champion' was crucial for integration, and variable staff skills impacted difficult conversations; reflexive monitoring was not routine.

Conclusions:

• Successful normalization of the AMBER care bundle requires addressing implementation challenges within the broader hospital context.
• NPT is valuable for identifying practical strategies to normalize complex interventions in acute care.
• Modifications are needed to optimize the AMBER care bundle's integration and sustainability.