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Compliance with hand hygiene is an effective way of reducing the incidence of healthcare acquired infections (HCAI). At one London National Health Service (NHS) Trust, improving hand hygiene compliance (HHC) was a patient safety priority in response to non-compliance and ongoing occurrences of HCAI. The objective of this study was to co-design a behavioural science informed intervention to improve HHC. To obtain a baseline level of HHC and understand associated behaviours, 18 hours of observation were undertaken on three inpatient wards. These focused upon Moment 1 and 5 of the World Health Organisation’s moments for hand hygiene. The intervention was co-designed with clinical staff and took the form of “visual primes”. Three different stickers designed to create a motivational “nudge” were placed at key points where HHC had been observed to fail. Following implementation, a further 18 hours of observation took place. A Chi-squared statistical analysis compared proportions of HHC pre- and post-intervention. Our intervention led to an 11% increase in HHC across the three study wards for both Moments ( X 2 (1, N = 1,285) = 13.711, p = <0.001) in the six weeks following the intervention. The intervention had a more marked effect on Moment 1, (with an increase of 15%, X 2 (1, N = 667) = 17.091, p = <0.001 when compared to the change in compliance with Moment 5 (11%, X 2 (1, N = 652) = 7.449, p = 0.06). This study demonstrated that utilising behavioural science in the co-design and placement of visual motivational nudges can significantly improve compliance with hand hygiene practices. We highlight the benefit of co-design when designing interventions–both in terms of engagement with and efficacy of the intervention.

Inflammatory demyelinating lesions of the central nervous system are a common feature of both neuromyelitis optica and multiple sclerosis. Despite this similarity, it is evident clinically that the accumulation of disability in patients with neuromyelitis optica is relapse related and that a progressive phase is very uncommon. This poses the question whether there is any pathological evidence of disease activity or neurodegeneration in neuromyelitis optica between relapses. To investigate this we conducted a longitudinal advanced MRI study of the brain and spinal cord in neuromyelitis optica patients, comparing to patients with multiple sclerosis and controls. We found both cross-sectional and longitudinal evidence of diffusely distributed neurodegenerative surrogates in the multiple sclerosis group (including thalamic atrophy, cervical cord atrophy and progressive widespread diffusion and myelin water imaging abnormalities in the normal appearing white matter) but not in those with neuromyelitis optica, where localised abnormalities in the optic radiations of those with severe visual impairment were noted. In addition, between relapses, there were no new silent brain lesions in the neuromyelitis optica group. These findings indicate that global central nervous system neurodegeneration is not a feature of neuromyelitis optica. The work also questions the theory that neurodegeneration in multiple sclerosis is a chronic sequela to prior inflammatory and demyelinating pathology, as this has not been found to be the case in neuromyelitis optica where the lesions are often more destructive.

Burnout in doctors is reported in many countries. Following a randomised controlled trial of a novel 10-month fortnightly text message intervention to reduce burnout in trainee anaesthetists, an interview study was conducted. The intervention's format and content were developed based on findings from a preceding literature review and interview study with trainee anaesthetists, and messages incorporated 11 evidenced themes including gratitude and self-efficacy from the wellbeing and behavioural science literatures. Objectives of the interviews were to explore experiences of the intervention, understand perceived mechanisms of impact (or lack thereof), and identify improvements. In the trial's endline survey (ISRCTN11418903), all 74 participants in the treatment group (those who received the text messages) were invited to interview and sampled purposively. Semi-structured interviews (audio-recorded and transcribed) were conducted following verbal consent (the participant information sheet and consent questions were sent by email before the interview). Data were managed using the Framework Approach and analysed thematically. The Imperial Joint Research Compliance Office approved this study on July 13, 2020 in an amendment to an original application to the Imperial College Research Ethics Committee (reference number 19IC5205, approval Aug 14, 2019). The pool of 23 potential participants (who registered interest) was resampled five times (eg, when the research team did not receive a response to the initial recruitment or subsequent reminder emails) until no volunteers remained. Nine interviews (three women, six men) were conducted, with diversity captured across training location, year, and change in burnout over the trial. Reported engagement (reading or acting on messages) varied. Factors affecting engagement were work pressures, mood, and COVID-19 (due to wearing personal protective equipment and wellbeing information overload). Interviewees described the content as useful, varied and interesting, among other positive descriptors. Critique referenced the intervention's impersonal nature, and that some content was generic or basic. Interviewees enjoyed the low-intensity, passive nature of the intervention. Text message was viewed as a novel, unsaturated (not heavily used) delivery mechanism (better than email). Messages provoking meaningfulness, professional value, and community were highlighted as higher impact, along with those fostering perceptions of shared experience and encouraging communication between colleagues. Suggestions for no perceived impact included personal factors (eg, high existing resilience and support) and the intervention's impersonal nature. Interviewees suggested content to add and remove, and ways of personalising format and content. Interviewees generally found the intervention acceptable and recommended it. Although the trial only observed an effect in a subsample, the intervention may benefit from re-evaluation following adaptation based on interviewees' recommendations. National Institute for Health Research.

Barcode medication administration (BCMA) technology can improve patient safety by using scanning technology to ensure the right drug and dose are given to the right patient. Implementation can be challenging, requiring adoption of different workflows by nursing staff. In one London National Health Service trust scanning rates were lower than desired at around 0–20% of doses per ward. Our objective was to encourage patient safety behaviours in the form of medication scanning through implementation of a feedback intervention. This was informed by behavioural science, codesigned with nurses and informed by known barriers to use. Five wards were selected to trial the intervention over an 18-week period beginning August 2021. The remaining 14 hospital wards acted as controls. Intervention wards had varying uptake of BCMA at baseline and represented a range of specialties. A bespoke feedback intervention comprising three behavioural science constructs (gamification, the messenger effect and framing) was delivered to each intervention ward each week. A linear difference-in-difference analysis was used to evaluate the impact of our intervention on scan rates, both for the overall 18-week period and at two weekly intervals within this timeframe. We identified a 23.1 percentage point increase in medication scan rates (from an average baseline of 15.0% to 38.1%) on the intervention wards compared with control (p<0.001) following implementation of the intervention. Feedback had most impact in the first 6 weeks, with an initial percentage point increase of 26.3 (p<0.001), which subsequently plateaued. Neither clinical specialty nor number of beds on each ward were significant factors in our models. Our study demonstrated that a feedback intervention, codesigned with end users and incorporating behavioural science constructs, can lead to a significant increase in the adoption of BCMA scanning.

Over one in five UK doctors reports feeling burnt out because of their work. This study aimed to determine if a novel text message intervention could reduce burnout in UK trainee anaesthetists. In this two-arm, non-blinded, randomised controlled trial, we recruited 2nd to 4th year trainees registered with the Royal College of Anaesthetists, UK. Eligible trainees were given information about the trial and asked to provide their mobile phone numbers to indicate consent to participate. Participation was optional. Participants who signed up to the trial were randomly assigned (using a random number generator in the statistical programme Stata) to receive either fortnightly text messages over 10 months (treatment group) or no intervention messages (control group). Randomisation was stratified by training year and region. A literature review and qualitative study informed the intervention design and content: our intervention was low cost to deliver and minimally time-intensive for participants (contrasting many previous interventions), and it aimed to address factors identified as contributing to burnout. The message content also drew on 11 themes from the behavioural science and wellbeing literature (eg, gratitude, social support, self-compassion) to improve burnout and wellbeing. The co-primary outcomes were burnout (measured by the work-related subscale of the Copenhagen Burnout Inventory) and wellbeing (Short Warwick-Edinburgh Mental Wellbeing Scale). Secondary outcomes were meaning in work, professional value, sickness absence, and consideration of career break. Exploratory outcomes were factors potentially affecting wellbeing, including COVID-19. Outcomes were measured via an online survey. Intervention impact for those who completed the endline survey was evaluated using regression adjusting for gender, training year, training region, and baseline measurement. We conducted exploratory analyses of intervention impact in subgroups of participants using the same regression model. The Imperial College Research Ethics Committee approved the study on Aug 14, 2019 (reference number 19IC5205). The Imperial Joint Research Compliance Office approved the additional exploratory outcomes in an amendment on July 21, 2020. This trial is registered with the ISRCTN registry, ISRCTN11418903. In September-October 2019, 279 trainees were randomised, of whom 153 (80 female; 73 male) completed the endline survey (74 in the treatment group; 79 in the control group). There were no significant group differences in burnout (β=–1·82, 95% CI –6·54 to 2·91, p=0·45), wellbeing (–0·52, –1·73 to 0·69, p=0·40), or secondary outcomes (all p values ≥0·24). However, 49 (66%) of 74 participants in the treatment group recommended the messages be sent to future trainees. Exploratory analyses found the intervention was associated with reduced burnout in participants who reported personal or work-related difficulties (β=–9·56, –17·35 to –1·77), and those for whom COVID-19 had a large negative wellbeing impact (β=–10·38, –20·57 to –0·19). The intervention had no impact overall, but was recommended by most, and associated with reduced burnout in participants reporting difficult personal or work circumstances. Given this intervention is low cost and requires minimal time commitment, it may warrant adaptation (eg, based on participant feedback) and further evaluation. National Institute for Health Research.