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Abstract
Objectives We aimed to improve the nutritional care of preterm infants by developing a complex (multifaceted) intervention intended to translate current evidence into practice. We used the sociological framework of Normalization Process Theory (NPT), to guide implementation in order to embed the new practices into routine care.
Design A prospective interventional study with a before and after methodology.
Participants Infants <30 weeks gestation or <1500 g at birth.
Setting Tertiary neonatal intensive care unit.
Interventions The intervention was introduced in phases: phase A (control period, January–August 2011); phase B (partial implementation; improved parenteral and enteral nutrition solutions, nutrition team, education, August–December 2011); phase C (full implementation; guidelines, screening tool, ‘nurse champions’, January–December 2012); phase D (postimplementation; January–June 2013). Bimonthly audits and staff NPT questionnaires were used to measure guideline compliance and ‘normalisation’, respectively. NPT Scores were used to guide implementation in real time. Data on nutrient intakes and growth were collected continuously.
Results There were 52, 36, 75 and 35 infants in phases A, B, C and D, respectively. Mean guideline compliance exceeded 75% throughout the intervention period, peaking at 85%. Guideline compliance and NPT scores both increased over time, (r=0.92 and 0.15, p<0.03 for both), with a significant linear association between the two (r=0.21, p<0.01). There were significant improvements in daily protein intake and weight gain between birth and discharge in phases B and Ccompared with phase A (p<0.01 for all), which were sustained into phase D.
Conclusions NPT and audit results suggest that the intervention was rapidly incorporated into practice, with high guideline compliance and accompanying improvements in protein intake and weight gain. NPT appears to offer an effective way of implementing new practices such that they lead to sustained changes in care. Complex interventions based on current evidence can improve both practice and clinical outcomes.
- change management
- neonatology
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Footnotes
Dr Dimitrov died on 15th January 2017, after the manuscript had been finalised but before submission to the journal.
Contributors MJJ contributed to the design of the study, carried out data analysis and interpreted all data. He was responsible for drafting the article and revising it critically for important intellectual content. He is guarantor. AAL, FP, HWC contributed to the conception and design of the study and interpretation of data. They revised the article critically for important intellectual content. BDD supervised the statistical analysis and developed the statistical model used for longitudinal data analysis. He contributed to the interpretation of data and revised the article critically for important intellectual content. CP and CRM contributed to the design of the study, the use of NPT in the study and interpretation of data. They revised the article critically for important intellectual content.
Funding Work leading to this paper was funded by the National Institute for Health Research (NIHR) Biomedical Research Centre, Southampton. MJJ’s contribution was partly supported by an NIHR Doctoral Research Fellowship DRF-2012-05-272, and CRM’s contribution was partly supported by NIHR CLAHRC Wessex and partly by ESRC Grant ES-062-23-3274. We gratefully acknowledge the financial support from these agencies. Funders had no role in the design of the study and collection, analysis and interpretation of the data or in writing the manuscript, and the paper does not necessarily represent their views.
Competing interests CRM is an original author of Normalization Process Theory; all other authors declare no conflicts of interest.
Patient consent Detail has been removed from these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.
Ethics approval The study was approved by an NHS Research Ethics Committee, (‘Oxford ‘B’’ Reference 11/sc/0365).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data sets generated and/or analysed during the current study are not publicly available due to further pending publications and current approvals, but may be available from the corresponding author on reasonable request. An implementation toolkit and a validated instrument to measure implementation processes using Normalisation Process Theory are available at www.normalizationprocess.org.