Identify intervention options and content
After conducting the mapping exercise, we identified five intervention functions that are most suitable for facilitating the implementation of PDIS: education, training, enablement, persuasion, and environmental restructuring, as summarized in Additional file 3. An intervention function would be excluded if three or more aspects of APEASE were uncertain or if any one aspect was not met. Specifically, education focuses on enhancing the nurses’ understanding of PDIS background, responsibilities, and positive outcomes. Training is to enhance operation skills in manipulating the PDIS system and communicating medication risks. Enablement is characterized by increasing means, such as involving pharmacists as aids to increase nurses’ capabilities to make PDIS explanations and establishing a bidirectional feedback platform to increase opportunities for information circulation. Persuasion through opinion leaders to foster positive feelings. Lastly, restructuring the physical environment by modifications to the PDIS design. Four intervention functions were considered unsuitable in the current context either due to potential unwanted side effects on nurses or because three or more aspects of APEASE were uncertain. Subsequently, four policy categories were identified: communication/marketing, service provision, environmental/social planning, and guidelines, as summarized in Additional file 4. Marketing through utilizing mass media to educate staff by delivering comprehensive background information related to PDIS. Additionally, communication was employed by involving opinion leaders in advocating the benefits of PDIS. The provision of diverse training services and the integration of referral services by pharmacists to assist in explaining medication side effects should be considered. Furthermore, it is crucial to plan the organizational environment to foster a culture of continuous learning and to refine the PDIS system accordingly. Lastly, the establishment of implementation guidelines is recommended to standardize processes and ensure consistency in PDIS implementation. Following this, eleven BCTs were identified to enact each intervention function, which is summarized in Additional file 5. A multifaceted strategy package was developed and shown in Table 1 and Table 2. This strategy package had four components: flexible and sustainable training, communication and marketing, environment redesign, and implementation guidelines. Table 3 presents the key features of each of the strategy components with illustrative quotes from nurses.
Table 1
PDIS implementation strategy package to address barriers
No. | Barriers | TDF domains | COM-B components | Selected intervention function | Selected policy categories | Selected BCTs | Translation of BCTs into PDIS implementation strategy items |
1 | 1) PDIS drug database coverage is not enough; 2) Chinese version only is not enough; | Environmental context and resources | Physical opportunity | Environmental restructuring | Environmental/ social planning | Restructuring the physical environment | Review the current discharge drug list in the medical department and renew the PDIS drug coverage; Create an English version of the PDIS form |
2 | Information flow about the PDIS project is not smooth between front-line users and program management level | Environmental context and resources | Physical opportunity | Enablement | Environmental/ social planning | Restructuring the social environment | Establish a bidirectional platform to facilitate information exchange between nurses and the PDIS program committee |
3 | There is a time constraint when handling PDIS | Environmental context and resources | Physical opportunity | Enablement | Service provision | Social support (practical) | Establish a referral mechanism to direct inquiries to pharmacists at the dispensary to help explain medication side effects to patients or caregivers |
4 | PDIS is a not a priority when performing discharge education with multiple discharge materials on hand | Memory, attention, and decision process | Psychological capability | Education | Communication/ marketing | Feedback on outcomes of behavior | Provide written positive outcomes related to both nurses and patients of the PDIS program to educate and persuade to create more positive beliefs about the PDIS program |
Enablement | Service provision | Social support (practical) | Establish a referral mechanism to direct inquiries to pharmacists at the dispensary to help explain medication side effects to patients or caregivers |
Environmental/ social planning | Restructuring the physical environment | Incorporate the PDIS system into the Discharge Summary system |
5 | Training is not enough | Skills | Psychological capability | Training | Service provision | Demonstration of the behavior; Introduction on how to perform the behavior | Integrate PDIS training into the regular new staff orientation to demonstrate methods to execute PDIS on EHR and side effects explanations |
Restructuring the social environment | Set up a sharing group to encourage nurses to share their views and experience in terms of PDIS execution behaviors and techniques |
Psychological capability | Enablement | Environmental/ social planning | Restructuring the physical environment | Establish a training system to continuously enhance PDIS-related medication knowledge and other necessary skills, such as interpersonal communication, to help nurses deliver the PDIS program |
Abbreviation: PDIS, Post-Discharge Information Summary; TDF, Theoretical Domains Framework; COM-B, Capability, Opportunity, Motivation, Behavior Model; BCTs, Behavior Change Techniques. |
Table 2
PDIS implementation strategy package to enhance facilitators
No. | Facilitators | TDF domains | COM-B components | Selected intervention function | Selected policy categories | BCTs | Translation of BCTs into PDIS implementation strategy items |
1 | Having knowledge regarding PDIS background, content, and role | Knowledge | Psychological capability | Education | Communication/ marketing | Information about social and environmental consequences | Design brochures and make videos to introduce the PDIS program development background and objectives |
Guideline | Information about social and environmental consequences | Articulate job responsibilities and program content by formulating implementation guidelines |
2 | PDIS platform design is user-friendly | Environmental context and resources | Physical opportunity | Training | Service provision | Demonstration of the behavior; Introduction on how to perform the behavior | Integrate PDIS training into the regular new staff orientation to demonstrate methods to execute PDIS on EHR and side effects explanations |
Restructuring the social environment | Set up a sharing group to encourage nurses to share their views and experience in terms of PDIS execution behaviors and techniques |
3 | PDIS becomes routine | Memory, attention, and decision process | Psychological capability | Training | Service provision | Demonstration of the behavior; Introduction on how to perform the behavior | Integrate PDIS training into the regular new staff orientation to demonstrate methods to execute PDIS on EHR and side effects explanations |
4 | I think PDIS is useful for patients/ caregivers and/ or my work | Beliefs in consequences | Reflective motivation | Education; Persuasion | Communication/ marketing | Feedback on outcomes of behavior | Provide written positive outcomes related to both nurses and patients of the PDIS program to educate and persuade to create more positive beliefs about the PDIS program |
Persuasion | Communication/ marketing | Credible source | Invite leaders to convey the positive impact of the PDIS program and the importance of the role of nurses to induce positive emotions on role agreement Invite patients to give positive feedback to induce positive beliefs regarding PDIS values |
5 | I agree with my responsibility of PDIS | Social/ professional role and identity | Reflective motivation | Education; Persuasion | Communication/ marketing | Feedback on outcomes of behavior | Provide written positive outcome related to both nurses and patient of PDIS program to educate, persuade to create more positive beliefs about PDIS program |
Persuasion | Communication/ marketing | Credible source | Invite leaders to convey the positive impact of the PDIS program and the importance of the role of nurses to induce positive emotions on role agreement |
6 | I am confident that I am able to implement the PDIS | Beliefs in capabilities | Reflective motivation | Education; Persuasion | Communication/ marketing | Feedback on outcomes of behavior | Provide written positive outcome related to both nurses and patient of PDIS program to educate, persuade to create more positive beliefs about PDIS program |
Persuasion | Communication/ marketing | Credible source | Invite peers to share positive experiences about PDIS program to induce positive beliefs about the ability to execute PDIS |
7 | Distributing PDIS to every discharged case is mandatory | Goals | Reflective motivation | Education; Persuasion | Communication/ marketing | Feedback on outcomes of behavior | Provide written positive outcome related to both nurses and patient of PDIS program to educate, persuade to create more positive beliefs about PDIS program |
Persuasion | Communication/ marketing | Credible source | Invite leaders to convey the positive impact of the PDIS program and the importance of the role of nurses to induce positive emotions on role agreement |
8 | I am willing to implement PDIS in the future | Intentions | Reflective motivation | Education; Persuasion | Communication/ marketing | Feedback on outcomes of behavior | Provide written positive outcome related to both nurses and patient of PDIS program to educate, persuade to create more positive beliefs about PDIS program |
Persuasion | Communication/ marketing | Credible source | Invite leaders to convey the positive impact of the PDIS program and the importance of the role of nurses to induce positive emotions on role agreement. Invite patients to give positive feedback to induce positive beliefs regarding the consequences of PDIS program |
9 | I need constant practicing to implement PDIS | Skills | Psychological capability | Enablement | Environmental/ social planning | Restructuring the physical environment | Incorporate the PDIS system into the Discharge Summary system |
10 | I can handle this task with my professional knowledge | Skills | Psychological capability | Enablement | Service provision | Demonstration of the behavior; Introduction on how to perform the behavior | Integrate PDIS training into the regular new staff orientation to demonstrate methods to execute PDIS on EHR and side effects explanations |
Social support (practical) | Establish a referral mechanism to direct inquiries to pharmacists at the dispensary to help explain medication side effects to patients or caregivers |
Guideline | Problem solving; Action planning | Establish a hospital-wide review panel to regularly assess PDIS implementation and formulate action plans to address potential execution challenges |
Abbreviation: PDIS, Post-Discharge Information Summary; TDF, Theoretical Domains Framework; COM-B, Capability, Opportunity, Motivation, Behavior Model; BCTs, Behavior Change Techniques; EHR, Electronic Health Record. |
Table 3
Key features of the strategy package
Components | Key features | Example quotations from nurses |
Flexible and sustainable training services | Use hybrid formats | “I think new staff will need training. Other staff doesn’t need unless there are program updates.” “I think internal communication is better than official training because the daily work won’t be interrupted.” |
Mass media and opinion leader campaigns | Make benefits visible | “Maybe have to think about how to promote this program better. Because I rarely heard patients’ comments, I don't’ think this service is important or necessary. If we can see the benefits, we will have greater motivation.” |
| Frame the purpose | “I think it’s important to explain clearly the reasons behind it, the concept, why there is this new project, the future development, etc.” |
Technology and workflow redesign | Upgrade to be compatible with current workflow | “The drug database it out of date. Some medications were no longer prescribed and some new drugs are frequently prescribed now. About two-thirds of the medication are not covered. It’s important to regularly review and update the database” “From my perspective, I think the most important thing for discharge medication education is the what medication is changed, so it’s better for PDIS to include this part of information.” “As there are many ethnic minority patients coming in our hospital, currently there is only Chinese version. It’s hard for me to educate them without English version.” |
| Adopt a default design | “Is it possible to modify the system to combine the PDIS with other discharge documents with one print button? If so, the work will be more efficient.” |
| Provide a digital option | “Because of the Covid 19, we are comfortable with digital technologies. It would be more convenient if PDIS has a e-version, such as, incorporated into the patient portal.” |
| Multidisciplinary team approach | “I think we can work with pharmacists. Some wards have resident pharmacists. I think we need pharmacists to help with explaining medication side effect.” “I think we can print the form and pharmacists can help with the detailed explanation when patients go to pharmacy to get their medication.” |
| Build up a shared-decision approach | “I think there should be a mechanism involve front-line representatives from each cluster* participating in regular review of PDIS. Maybe set up a committee and send the feedback to the central government.” “I think it’s better to build up a platform to facilitate the collection of front-line users’ feedback in order to facilitate the refinement of the PDIS.” |
Corporate level audit & feedback | Concrete action plans | “It would be better to clarify what parts I have to explain, and something I need to pay attention to.” |
PDIS: Post Discharge Information Summary; |
*The public hospitals are divided into seven geographically diverse clusters in Hong Kong. |
Develop the logic model
The logic model was developed, illuminating the theory of change and theory of action underlying the strategy package (Fig. 2). In the subsequent section, each component of the strategy package will be explored, providing a detailed explanation of their potential to address implementation determinants and shed light on the underlying mechanisms leading to the expected implementation outcomes.
Flexible and sustainable training
The behavior diagnosis highlighted the importance of nurses' professional knowledge in effectively explaining PDIS medication side effects. Additionally, the lack of integration of PDIS into routine discharge practice presents a challenge for implementation. To address this, the strategy package includes the provision of training services to demonstrate the behaviors, aligning with commonly employed approaches for implementing evidence-based nursing (48–50). Previous studies recommend that training should encompass diverse formats to accommodate different learning styles and staff adaptability to new technologies (51, 52). Consequently, three levels of training were suggested. Firstly, new staff can receive PDIS training as part of their regular orientation, covering how to operate the PDIS system and explain medication side effects. Secondly, all nurses can engage in regular informal training through group sharing sessions, which have been shown to be highly effective for training purposes (53, 54). These sessions facilitate reflection, debriefing, and sharing techniques to address challenges. Thirdly, establishing a training system allowing continuous staff training is proposed to ensure their PDIS skills remain up-to-date. Integrating training opportunities within a practical structure has been proven to increase the likelihood of behavior change (55). Considering the time constraints frequently reported by nurses in clinical settings, a hybrid approach, which includes written materials, online learning, and face-to-face workshops, is suggested to provide a sustainable and convenient training method.
The first underlying mechanism can be elucidated through the concept of self-efficacy. When nurses possess the necessary skills, they tend to exhibit confidence and comfort in engaging with the PDIS process, thereby enhancing its acceptability and adoption. The second mechanism can be attributed to habit theory, wherein the successful integration of PDIS distribution and explanation into nurses’ routine practice becomes habitual. By automating this behavior through habit formation, cognitive capacity can be freed up amidst competing demands, potentially resulting in an increased uptake rate (36). Thirdly, the establishment of sharing groups and a training system can cultivate an organizational culture that embraces change, which serves as a pivotal factor in modifying practitioner behavior (37, 38) and has the potential to contribute to PDIS sustainability.
Mass media and opinion leader campaign
One of the implementation barriers is that nurses tend to prioritize alternative materials over PDIS when it comes to discharge education. However, several potential facilitators were identified, including positive beliefs about the benefits of PDIS for their work and patients, self-confidence in implementing PDIS, intention to implement, agreement on responsibilities, clear goals, and knowledge of the program background. To address these barriers and enhance facilitators, a range of communication and marketing strategies have been suggested. Notably, social norms interventions, which involve exposing healthcare workers to the values, beliefs, attitudes, or behaviors of reference individuals or groups, have shown effectiveness in multiple settings (56). This can be achieved by engaging opinion leaders, including patients and peers, to advocate for PDIS and foster positive beliefs in PDIS values and implementation capabilities. Credible sources have been proven effective in changing health providers’ clinical behavior (56). Combining reinforcement of new practice norms and peer group advocation is particularly effective as it establishes clear rules and encourages individuals to emulate their peers, according to a previous review (57). Therefore, inviting nursing leaders to reinforce PDIS implementation and emphasize the importance of nurses as responsible individuals to induce positive emotions in role agreement is suggested. In order to make information visible, disseminating written reports to showcase the positive outcomes of PDIS for both nurses and patients can serve as educational and persuasive tools, promoting more positive beliefs. Lastly, the development of brochures and videos that effectively communicate the background and objectives of PDIS can enhance nurses' knowledge and understanding.
Social identity and social comparison serve as the mechanism of these strategies (39, 40), wherein nurses evaluate their own abilities and compare themselves to their peers. This evaluation leads them to engage in behaviors that are congruent with the group norms and serve to maintain their social identity. Additionally, the theory of planned behavior (41) can explain prospective implementation outcomes as nurses are motivated to conform to the expectations of esteemed individuals, such as patients and leaders, in order to uphold their personal beliefs. The third mechanism is outcome expectations (10), whereby nurses perceive PDIS as beneficial for enhancing their workflow and improving patient outcomes to induce desired behaviors. These mechanisms have the potential to lead to a higher acceptability, adoption, appropriateness, and uptake rate.
Technology and workflow redesign
The behavior diagnosis has revealed that the current design of the PDIS system hinders the implementation process for nurses. There is a lack of transparent information exchange between the program committee and frontline implementers. Time constraints also frequently arise as a barrier to implementation, particularly when there are multiple tasks to be completed. To address these issues, it is recommended, based on previous research, that technology-based interventions should complement the current workload of health providers and consider the diverse settings in which they operate (10). Therefore, the PDIS system should be upgraded to better accommodate the needs of nurses, such as expanding the drug database and providing multiple language versions to facilitate their explanation. Furthermore, the use of default settings has been found to effectively change providers' behaviors in various contexts (58), particularly within electronic systems (59). Therefore, incorporating PDIS information as a default setting in the discharge summary can alleviate cognitive overload for nurses who need to refer to multiple information sources for printing discharge forms. To facilitate smooth information flow, it is suggested that a bidirectional platform be established that facilitates communication and information exchange between nurses and the program committee. It’s emphasized that nurses should actively engage with ICTs as managers and designers rather than having a passive relationship as mere users (60). Additionally, a prior review highlighted the multidisciplinary team approach is crucial to integrating new interventions into routine practice, fostering collaborations, and leveraging specialized skills (61). Therefore, establishing a referral mechanism to direct PDIS inquiries to the pharmacy, which can assist in explaining medication side effects to patients or caregivers, is recommended.
The first underlying mechanism aligns with the theory of diffusion of innovation (42), which suggests that improving the quality of PDIS design can positively influence perceived usefulness and subsequently impact the intention to use the technology. Secondly, drawing from the nudge theory in the field of behavioral economics (43), altering default choices to reduce the physical effort required to select among alternatives can facilitate uptake. Additionally, based on the theory of organizational readiness to change (44), end-user involvement is emphasized in effective implementation by increasing the change valence and realistically appraising the intervention fit. Lastly, social support serves as a mechanism characterized by creating a supportive environment to alleviate nurses' stress in explaining PDIS, thereby increasing the acceptability and uptake.
Regular corporate-level audit and feedback
The behavior diagnosis has brought attention to the variation in nurses’ implementation due to inadequate knowledge regarding PDIS responsibility and its target population, resulting in implementation barriers. Furthermore, nurses with ample experience in discharge education and procedures are better equipped with clear action plans to effectively implement PDIS. Taking into account previous research that has highlighted the advantages of audit and feedback (46), as well as the effectiveness of action plans in enhancing the impact of such feedback (45), it is recommended to develop implementation guidelines that not only standardize the PDIS implementation process to educate nurses regarding their roles and PDIS content but also outline concrete contingency plans to address potential implementation challenges, accompanied by regular corporate-wide evaluations to ensure consistent implementation.
Initiating guidelines serves as the mechanism to regulate behaviors and promote adherence to desired practices. Guiding and directing individuals to solve implementation problems can enhance nurses’ self-efficacy and further increase possible adoption. An additional mechanism centers around applying audit and feedback techniques to impose external pressure, such as performance measures, to exert nurses’ motivation to perform desired behaviors.