Family supplemented patient monitoring after surgery (SMARTER): process evaluation of a complex intervention in Uganda

BackgroundImproving outcomes after surgery in Africa is a priority. The SMARTER Pilot Trial was a step-wedge cluster-randomised trial of family member supplemented vital signs monitoring after surgery. A concurrent process evaluation provides contextual understanding of intervention delivery. MethodsMixed methods approach with qualitative data sources including field notes from a research team diary and focus group discussions. Deductive analysis used the consolidated framework for implementation research. Quantitative data evaluating the efficacy of family members recognising abnormal vital signs and reporting them to nursing staff were collected following a prespecified intervention review held after two months. FindingsFocus group discussions were conducted with 16 nurses and research assistants. Field notes included 88 episodes documented throughout the trial in a research team diary. Quantitative data were collected in the final 397 patients following ethics amendments. Intervention facilitators included: relative advantage, inner context factors including tension for change and relative priority, and individual characteristics centred around knowledge and beliefs. Available resources, culture, and compatibility were identified as important barriers, with a smaller negative influence from self-efficacy and intervention complexity. Family members recognised 91.3% (42/46) of abnormal sets of vital signs and communicated 100% (42/42) of these to a member of the nursing or medical team. The team responded 90.5% (38/42) of the time. InterpretationFamily members were able to supplement nurse led monitoring of patients after surgery. This complex intervention was affected by context specific positive and negative influences. Scaling this intervention requires careful consideration of local context during planning. Trial registrationSMARTER Pilot Trial registered on clinicaltrials.gov - NCT04341558