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Applying normalization process theory and process mapping to understand implementation of a co-management program for older hip fracture patients in China: a qualitative study

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Abstract

Summary

This qualitative study identified the barriers to the implementation of a multidisciplinary co-management program for older hip fracture patients and provided evidence for future intervention improvement and scale-up.

Introduction

Multidisciplinary co-management has been recommended as an effective intervention for hip fracture management in older people. This study is a process evaluation of a multidisciplinary co-management program in an orthopaedic hospital in Beijing, China, to better understand the barriers to implementation.

Methods

Data collection involved semi-structured interviews with key implementers of the co-management intervention (surgeon, geriatrician, physician, nurse, physiotherapist and anaesthetist) and observations of patients’ journey to map the care processes were conducted in Beijing Jishuitan Hospital. Data were transcribed, qualitatively coded and analysed using normalization process theory to understand the intervention process from four constructs: coherence, cognitive participation, collective action and reflexive monitoring.

Results

Ten stakeholder interviews were conducted. Despite multidisciplinary co-management intervention was meaningful and valued by participants, barriers to its implementation were identified. These included unmatched investment and benefit (cognitive participation), challenges of facing increased workload (collective action), deficient training and supervision system (collective action), limited accommodating capacity of hospital (collective action) and difficulties in accessing information about the effect of the intervention (reflexive monitoring).

Conclusions

Multiple barriers to the effective implementation of the multidisciplinary co-management program in China were identified. The process evaluation highlights key aspects in less willingness to fully invest in the program, inappropriate workload allocation and lack of training and supervision which need to be addressed before scaling up.

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Funding

Professor Rebecca Ivers is financially supported by a National Health and Medical Research Council Senior Research Fellowship (grant number APP1136430).

Author information

Author notes

  1. Xinbao Wu and Rebecca Ivers contributed equally to this work.

Authors and Affiliations

  1. School of Public Health, The University of Sydney, Sydney, Australia

    Ke Peng & Rebecca Ivers

  2. The George Institute for Global Health, UNSW Sydney, Sydney, Australia

    Ke Peng, Hueiming Liu, Yishu Liu, Maoyi Tian & Rebecca Ivers

  3. School of Public Health and Community Medicine, UNSW, Sydney, Australia

    Jing Zhang

  4. The George Institute for Global Health at Peking University Health Science Center, Beijing, China

    Jing Zhang, Yishu Liu, Maoyi Tian & Rebecca Ivers

  5. Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China

    Minghui Yang & Xinbao Wu

  6. Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China

    Hongling Chu

Authors
  1. Ke Peng
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  2. Hueiming Liu
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  4. Minghui Yang
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  8. Xinbao Wu
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  9. Rebecca Ivers
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Corresponding author

Correspondence to Xinbao Wu.

Ethics declarations

Ethics approval was obtained from Peking University Health Science Centre ethics committee and JSTH ethics committee. All interviewees gave written consent to participate in the study.

Conflicts of interest

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Appendix. Semi-structured interview

Appendix. Semi-structured interview

Normalization:

  1. 1.

    Can you tell me what is the intervention for hip fracture clinical management? (Ask for a comprehensive description)

  2. 2.

    What is the purpose of this intervention and who is the beneficiary? (No need to ask if it has been included in Q1)

  3. 3.

    What is your role in this intervention and have you ever talked it with your colleagues? Do you and your colleagues think it is worthy?

  4. 4.

    Was there a training for the intervention?

  5. 5.

    Are your colleagues doing well in terms of the intervention?

  6. 6.

    What is your view on the intervention, and will it affect your original job?

  7. 7.

    Do you have a sense that the intervention has been a standard process for you? (No need to ask if it has been included in Q6)

  8. 8.

    If there is a need to continue performing this intervention, what do you think?

  9. 9.

    Do you think you have been adapted to the new intervention? (No need to ask if it has been included in Q6)

Potential issue:

(Managers)

(Clinical doctors)

  1. 10.

    The proportion of patients received surgery within 48 hours from ward arrival had a dramatical increase since the intervention was performed. After intervention embedded, the overall proportion was increased, there were inevitably some fluctuations. From June 2015 to Feb 2017, the peak of the proportion (62%) occurred in June 2015 when the intervention was performed, but it kept declining until Feb 2016 (28%). Then it declined again after rising to 58%, the decrease stopped in Oct 2016 (38%). In first several months of 2017, the proportion kept around 60%.

  1. a.

    There were 2 turning points for the proportion of patients received surgery within 48 hours from ward arrival. One was in Dec 2015, another was in Oct 2016. Please think back and what do you think why this happened?

  2. b.

    Why the proportion could keep around 60% in 2017?

  1. 11.

    The proportion of patients transferred from ED to Ort/Geri ward within 4 hours decreased after intervention was performed. The proportion increased slightly but stably before the intervention was performed, the opposite trend occurred afterwards. There were several turning points, one occurred in Feb 2016, one was in Aug 2016. During Oct 2016 to Feb 2017, the number as well as the proportion of patients transferred from ED to Ort/Geri ward within 4 hours were relatively higher after the intervention was carried out, the number were from 40 to 46 nearly in the prior time then nearly doubled after the intervention took place.

  1. a.

    Why there were several turning points?

  2. b.

    Why the number of patients transferred from ED to Ort/Geri ward within 4 hours from Oct 2016 to Feb 2017 was higher. (nearly equal to pre-intervention mostly 40-50)

  3. c.

    Why the overall proportion decreased?

(Orthopedic)

  1. 12.

    The proportion of patients received osteoporosis assessment showed an increase after intervention was performed, but during June 2016 and Oct 2016, the proportion was low. We noticed that the total number of hip fracture patients during these months were higher than which in the first several months after intervention performed. The number of patients was more than 100 during this time.

  1. a.

    Why the proportion went down then rise later?

  2. b.

    How did the team adjust to it?

  3. c.

    How did you perform the assessment?

(Geriatrician)

  1. 13.

    How was the geriatric assessment performed? Do you have an SOP for that?

(Nurses)

  1. 14.

    How was the pressure ulcers prevention performed? Can you tell me the detail?

  2. 15.

    How was the fall risk assessment performed? Can you tell me the detail?

Participating observation will be adopted to identify how the intervention is executed.

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Peng, K., Liu, H., Zhang, J. et al. Applying normalization process theory and process mapping to understand implementation of a co-management program for older hip fracture patients in China: a qualitative study. Arch Osteoporos 15, 92 (2020). https://doi.org/10.1007/s11657-020-00760-1

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