Table 4 Overview of bronchiolitis interventions developed including rationale

1.Clinical leads

Rationale: Provide consistent credible, influential and trustworthy leadership.

Increase knowledge and skills through education, influence and persuasion.

Clinical leads ensure interdisciplinary and interdepartmental coverage.

Clinical leads (one nursing and one medical in both ED and inpatient paediatric units) for each hospital to both lead the study and train staff for duration of implementation period (May to November 2017).

‘Ideal characteristics’ of clinical leads discussed with hospitals.

EPOC review on local opinion leaders.

Power and influence within clinician groups rather than across.

Clinician groups have their own systems to disseminate / implement changes.

Leadership needs to be observable to keep momentum and give topic importance.

Clinical leads for duration of study ensure consistency of education, role modelling, reinforcement of evidence-based practice and positivism.

Given the intensity needed and to ensure maximum staff coverage, needed more than one clinical lead per area.

Encourage communication and relationship building between ED and inpatient paediatric units: Bronchiolitis is a condition which spans the hospital journey, therefore collaboration between areas is important.

Guide hospitals with their selection of appropriate clinical leads.

2.Stakeholder Meeting

Rationale: Create site buy-in.

Provide feedback on current bronchiolitis management.

Knowledge of own practice variation is likely to drive change.

Increase knowledge of intervention process.

Identify and address any potential barriers.

Duration: 1 h

Meeting with local stakeholders / clinical leads / clinical directors (nursing and medical).

Provide information on study, expectations, attributes and importance of clinical leads.

Provide opportunity to create buy-in at an organisational level and for senior leadership to express support.

Start conversation with stakeholders (ED and inpatient paediatric units).

Hospital organisational factors.

Ensure all clinicians are aware of expectations of study involvement with aim to minimise chance of hospital or clinical leads dropping out over the duration of study.

Opportunity for hospital clinicians to be together and create team cohesiveness from outset.

Create buy-in from senior people involved in the implementation of the recommendations (organise top down, multi-disciplinary leadership).

Present endorsed Australasian Bronchiolitis Guideline and discuss the 5 key guideline recommendations and evidence supporting these.

Discuss international and local variation in bronchiolitis management.

The evidence-based Australian Bronchiolitis Guideline.

Discuss Australasian Bronchiolitis Guideline and recommendations, and international and local variation in practice.

Strong evidence is pre-requisite for effecting change.

Provide evidence-based recommendations using persuasive language.

Review and discuss results of own hospital audit (20 ED and 20 inpatient bronchiolitis infants) and compliance to primary outcome (no CXR, salbutamol, glucocorticoids, antibiotics and adrenaline in first 24 h of presentation).

Identify areas for improvement.

EPOC review on audit and feedback.

Other documentation/information.

Qualitative interview findings.

Acknowledging change is needed creates buy-in.

Ensure the ‘key-people’ are aligned in their thinking.

Create buy-in from clinical leads / stakeholders that change in practice is required with identification of the areas requiring most attention.

Preliminary discussion of any anticipated local barriers and how to solve those.

Hospital organisational factors.

Intervention needs to fit in with local practices.

Begin discussions between areas on how study and clinical leads will work in their hospital.

Recognising and addressing any potential barriers at the beginning is more likely to optimise the hospital’s commitment and completion of the study.

3.Train the Trainer Workshop

Rationale: Improve knowledge.

Change beliefs.

Optimise professional interdisciplinary and interdepartmental relationships.

Motivate clinical leads as drivers of change.

One day event (8 h) – delivered in Melbourne.

All four clinical leads invited to attend.

Setting: off-site workshop venue.

Delivered by senior research team clinicians / clinical opinion leaders.

EPOC review on local opinion leaders and continuing education meetings and workshops.

Hospital organisational factors.

Clinical leads need to:

- Have the clinical and leadership knowledge and skills in order to provide the local education / training / undertake requirements of study.

- Understand the importance of their role.

- Receive all interventions and resources required for local training.

- Understand what is expected from them in terms of intervention delivery.

- Have opportunity for time with other clinical leads from their hospital to plan intervention delivery and roles for the study.

Set the scene: Australasian Bronchiolitis guideline, international / local variation in practice.

Information on implementation science and implementation research.

Other documentation / information.

Set the scene / implementation capacity building.

Gain buy-in on robust nature of how and why interventions have been developed and are to be delivered.

Findings from qualitative study on barriers and facilitators to bronchiolitis management and intervention development.

Rationale for intervention package.

How to deliver intervention package.

All study requirements.

Planning time for clinical leads.

EPOC review on local opinion leaders.

Qualitative interview findings.

Intervention development.

Having knowledge of the process of intervention development will optimise buy-in.

Clinical leads understanding of intended delivery method will ensure delivery of intervention with key messages relayed to their staff.

4.Educational intervention delivery (PowerPoint)

Rationale: Improve knowledge.

Increase skills.

Change beliefs.

Feedback on performance.

Address barriers and enablers to evidence-based management.

Reinforce importance of evidence-based management and consequences of not following recommendations.

Positive reinforcement.

Education delivered by nursing and medical clinical leads to clinicians using PowerPoint presentation supplied (10–30 min).

Additional slides provided giving more detail on evidence.

Aim to train at least 80% of staff within one month and on-going training throughout implementation period.

Bronchiolitis intervention package (detailed below).

Role model to clinical leads what and how to teach their staff.

Teach all participants together (nursing and medical).

EPOC review on local opinion leaders.

Hospital organisational factors.

Qualitative interview findings.

Designed with key messages and behaviour change techniques as detailed below.

Role model delivery – emphasising persuasive and key messages.

Management is both team-based, occurs across and between specialty teams as well as between medical and nursing.

Potential staff availability issue, therefore clinical leads ideally to function as a team.

Training materials addressing:

1. CXR

Evidence re not performing CXR.

Persuasive communication from credible sources / clinical leads.

Reinforcement messages to follow guideline.

Information on consequences of doing CXR.

Role modelling of discussion with families about bronchiolitis and supportive care.

Australasian Bronchiolitis guideline readily available.

Fact sheets with more detailed evidence regarding CXR.

Prompts.

Posters.

Audit and feedback.

Qualitative interviews.

TDF domains addressed:

1. Beliefs about consequences

2. Knowledge

3. Social influences

4. Skills

Qualitative interviews.

Hospital organisational factors.

TDF domain addressed:

1. Environmental context and resources

2. Salbutamol

Evidence re not using salbutamol.

Persuasive communication from credible sources / clinical leads.

Reinforcement messages to follow guideline.

Information on consequences of giving salbutamol.

Role modelling of discussion with families about bronchiolitis and supportive care.

Australasian Bronchiolitis guideline readily available.

Fact sheets with more detailed evidence regarding salbutamol.

Prompts.

Posters.

Audit and feedback.

Qualitative interviews.

TDF domains addressed:

1.Beliefs about consequences

2. Knowledge

3. Social professional role and identity

4. Social influences

3. Antibiotics

Evidence re not using antibiotics.

Persuasive communication from credible sources / clinical leads.

Reinforcement messages to follow guideline.

Information on consequences of giving antibiotics.

Antibiotic stewardship.

Role modelling of discussion with families about bronchiolitis and supportive care.

Australasian Bronchiolitis guideline readily available.

Fact sheets with more detailed evidence regarding antibiotics.

Prompts.

Posters.

Audit and feedback.

Qualitative interviews.

TDF domains addressed:

1.Beliefs about consequences

2. Social influences

3. Knowledge

4. Glucocorticoids

Evidence re not using glucocorticoids.

Persuasive communication from credible sources / clinical leads.

Reinforcement messages to follow guideline.

Role modelling of discussion with families about bronchiolitis and supportive care.

Australasian Bronchiolitis guideline readily available.

Prompts.

Posters.

Audit and feedback.

Qualitative interviews.

TDF domains addressed:

1.Beliefs about consequences

2. Knowledge

3. Social influences

4. Beliefs about capabilities

5.Additional educational tools and materials

Rationale: Improve knowledge.

Increase skill and confidence.

Provide encouragement and support.

Clinician training video – role modelling how to talk with families about bronchiolitis (delivered by clinical leads to clinicians).

Qualitative interviews.

TDF domains addressed:

1. Knowledge

2. Skills

3. Social influences

Fact sheets (delivered by clinical leads to clinicians).

Qualitative interviews.

EPOC review on printed educational materials.

TDF domains addressed:

1. Knowledge

2. Social influences

3. Social professional role and identity

4. Beliefs about consequences

Promotional materials – posters (placed in departments by clinical leads for clinicians and parents/caregivers).

Hospital organisational factors.

1. Knowledge

2. Environmental context and resources

Parent/caregiver bronchiolitis information sheet (delivered by clinical leads to clinicians for use with parents/caregivers).

Qualitative interviews.

Hospital organisational factors.

TDF domain addressed:

1. Knowledge

2. Social influences

6.Audit and feedback

Rationale: Provide real-time feedback on targeted behaviours.

Motivate by benchmarking.

Promote goal / target specific action planning to optimise on-going improvement.

Increase knowledge.

Change beliefs.

Monthly audit and feedback cycles (7 months).

Reports provided tabulated and graphical displays of hospitals performance compared to previous audits.

Benchmark against top site.

Disseminated regularly by clinical leads to clinicians using written, verbal methods of feedback.

EPOC review on audit and feedback.

Sites provide monthly data.

TDF domain addressed:

1. Knowledge

2. Social professional role and identity

Action planning in response to audit results (by clinical leads to clinicians).

Sites provide monthly data.

Action planning may improve practice – written and verbal.

Clinical leads can target one behaviour at a time; use case review of non-compliant infant to discuss recommendations.