Planning for Change: Co-Designing Implementation Strategies to Improve the Use of Sensory Approaches in an Acute Psychiatric Unit

Figures & data

Figure 1. Models used for project planning and development of tailored implementation strategy. Adapted from: Porcheret et al. (2014). Adapted with permission under Creative Commons licence: http://creativecommons.org/publicdomain/zero/1.0/.

Figure 2. The behaviour change wheel aligned to the theoretical domain framework. Note: Adapted from: Atkins et al. (2020). Reprinted with permission under Creative Commons licence: http://creativecommons.org/licenses/by/4.0/.

Table 1. Theoretical Domain Framework (TDF) domains mapped to COM-B (capability, opportunity, motivation-behaviour) model and behaviour change wheel intervention functions.

COM-B System	TDF Domain	Relevance of Domain	Intervention Functions
Psychological Capability	Knowledge	How, why, and when to use sensory interventions.	Education: Increasing knowledge or under­standing Training: Imparting skills Modelling: Providing an example for people to aspire to or imitate Enablement: Increasing means/reducing barriers to increase capability or opportunity Environmental restructuring: Changing the physical or social context
	Skills (cognitive & interpersonal skills)	Proficiency in demonstrating use of sensory interventions and completing sensory assessment and plans with consumers.
	Memory, attention, & decision making	Remember to use sensory interventions with patients.Being able to decide when it is appropriate to use sensory approaches.
Physical Capability	Environmental context and resources Skills	Are sensory equipment tools readily accessible in the work area? Do staff have the skills to operate the sensory equipment?	Environmental restructuring Enablement Training
Social Opportunity	Social influences	The opportunity to observe senior staff to use sensory interventions. Support from senior staff to use sensory interventions as a way of managing distress and agitation.	Environmental restructuring Modelling Enablement
Physical Opportunity	Environmental context and resources	Provision and maintenance of sensory resources and materials.Resource of time- having the time to complete sensory interventions with consumers.	Environmental restructuring Enablement
Reflective Motivation	Professional/social role and identity	Relevant as there were differing views on whose role it was to provide sensory interventions.	Persuasion: Using communication to induce positive or negative feelings or stimulate action Education Training Modelling
	Beliefs about capabilities	Confidence in abilities to perform sensory approaches with consumers.
	Beliefs about consequences	Belief that the use of sensory interventions will lead to positive outcomes for consumers.
Automatic Motivation	Reinforcement	Reinforce use of sensory interventions through routines and habits.	Training Environmental restructuring Modelling Enablement

Adapted from: Fahim et al. (2020). Modified and reprinted with permission under Creative Commons licence: https://creativecommons.org/publicdomain/zero/1.0/.

Table 2. Behaviour change interventions mapped to behaviour change wheel (BCW) intervention functions and local barriers.

Behaviour Change Interventions	Details of Interventions to Be Implemented.	BCW Intervention Functions	Barriers That Will Be Addressed	Rationale/Evidence
1. Provision and maintenance of sensory equipment and resources	Refurnish the sensory room with new furniture (rocking chair, bean bag) and sensory equipment (light projector, stereo, aromatherapy diffuser). Provide sensory trolley in nursing station (instead of sensory boxes under the desk) and purchase additional weighted modalities. Establish an ongoing process for maintenance and restocking of sensory equipment.	Environmental restructuring Enablement	Lack of sensory materials and resources Lack of maintenance of sensory equipment	Rationale: Participants’ feedback highlighted lack of access to sensory equipment and poor maintenance of sensory boxes. Recommended: 1) new furniture and equipment for sensory room; 2) use sensory trolley in nursing station instead of sensory boxes under the desk. Evidence: Easy access and maintenance of sensory approaches identified as an enabler to use (Machingura & Lloyd, 2017; Wright et al., 2020)
2. Education and training	Planned education and training include: full day introductory workshops and a new advanced sensory workshops every 2 months Inservices (30-minute sessions), 1–2 a month for ward staff. Additional inservices (1-h sessions) for medical staff and peer support workers throughout the project. Weighted modality in-service (30-minute session) in mandatory training workshops. Staff were encouraged to complete online Sensory Approaches e-module.	Education Persuasion Training	Lack of knowledge Lack of skills Lack of confidence	Rationale: Participants recommended more training and education to improve staff knowledge, skills, and confidence. Evidence: Education in sensory approaches had been found to increase their use (Martin & Suane, 2012).
3. Workplace modelling and demonstration	The researcher, ward occupational therapists, occupational therapy students, and trained nursing staff modelled and demonstrated the use of sensory approaches on the ward over 12 months. Staff were given an explanation and demonstration of how sensory equipment can be used with patients. Staff observed how to conduct a sensory assessment with a consumer.	Enablement Modelling Training	Lack of skills Lack of social support and modelling	Rationale: Participants recommended modelling of sensory approaches would improve use. Evidence: Modelling and demonstration of sensory approaches has been recommended to improve their use (Blackburn et al., 2016; Machingura & Lloyd, 2017; Yakov et al., 2018)
4. Audit and feedback	This involved providing feedback on frequency of use of the sensory room and kits, weighted modalities to the steering committee and ward coalition members.	Enablement Environmental restructuring	Lack of feedback on outcomes of behaviour	Rationale: Feedback of the use of sensory approaches in the ward was limited. Evidence: Audit and feedback can the increase the use of clinical interventions (Lifvergren et al., 2008)
5. Prompts and reminders	Prompts and reminders will be included in the orientation procedures, outside and inside the medication room, in the sensory room and in PICU.^1 Strategies such as orientation checklists, educational posters and factsheets, and instructional manuals.	Environmental restructuring Enablement	Limited time High workload Competing demands High acuity Lack of prompts and reminders	Rationale: Lack of prompts and reminders to use sensory approaches in the ward. Evidence: The use of prompts and reminders have been recommended to increase use of sensory approaches (Sutton & Nicholson, 2011; Wright et al., 2020)
6. Development of workplace coalition group	Workplace coalition to be developed over the length of the project. The researcher will recruit and cultivate relationships with ward staff to work towards improving the implementation of sensory approaches. (Powell et al., 2015). The researcher met with ward staff individually and in groups to discuss their efforts to use sensory approaches, current challenges, and their ideas to improve their use. The researcher spent initially 3 days per week on the unit, and this reduced as the project continued to 1–2 days per week.	Enablement Environmental restructuring	Lack of workplace modelling and support for sensory approaches.	Rationale: Participants described a lack of support from their peers for the use of sensory approaches and the need for more modelling. Evidence: Workplace coalitions provide support for implementation within a local work unit by engaging stakeholders in the change process (Lifvergren et al., 2008). Support from peers enables use of sensory approaches (Dawson et al., 2022; Wright et al., 2020)
7. Facilitation	The researcher acted as the driver/ motivator for change. The researcher acted as a coach to demonstrate sensory approaches on the ward and to encourage and support nursing staff to develop confidence in using their use. The researcher facilitated change by problem solving barriers and coordinating the purchase of equipment.	Persuasion Enablement	Lack of leadership to drive change	Rationale: Participant feedback described need for person to drive change. Evidence: Previous research has identified the need for a leader for implementation of sensory approaches to be successful (Sutton & Nicholson, 2011; Wright et al., 2020). Facilitation can improve the use of evidence-based interventions (Harvey & Kitson, 2015)

1 Psychiatric intensive care unit

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