Can the theoretical domains framework account for the implementation of clinical quality interventions?

Patients' testimonies, feelings, complaints and emotional experiences with dermatoses on open social media: The French infodemiologic patient's free speech study

BACKGROUND

Dermatoses represent a significant burden. Patients and their caregivers can turn to social media and digital communities to exchange with each other. These public exchanges constitute real-life data that can be analysed to better understand the patients' feelings and expectations, and the daily difficulties encountered.

OBJECTIVE

An infodemiologic study of public testimonies of patients and caregivers related to five dermatoses: eczema, rosacea, vitiligo, acne and psoriasis, over a 3-year time frame (September 2018 to September 2021) in France. To identify main topics of discussion, encountered difficulties and unmet medical needs.

METHODS

Data extraction was performed based on a list of pertinent keywords. Web-users' profiles were determined by a specifically trained machine learning algorithm. Encountered difficulties were identified by manual annotation based on a standardized search grid. Co-occurrence analysis of difficulties allowed contextualization of challenges and unmet needs for each dermatosis.

RESULTS

A total of 20,282 messages coming from 16,800 web users was extracted. The main topics of discussion were 'Impact on self- image and self-confidence' (23.6%), 'Generic discussion about therapeutics' (23.3%) and 'Burden of others' gaze' (12.8%). The top three mentioned difficulties for the five targeted dermatoses were similar and focused on 'Fear of/and management of symptoms', 'Impact on/and mood management' and 'Damaged self-image'.

CONCLUSION

This infodemiologic study highlighted the real-life management of five skin diseases by patients and their caregivers, who turned to social networks to openly express their suffering and seek solutions. The joined analysis of the five diseases enabled a common comprehension of what it is to live with a skin disease, from a patient-centric point of view. The specific analysis of each patient group objectified specific challenges, and main unmet medical needs.

The CFHealthHub Learning Health System: Using Real-Time Adherence Data to Support a Community of Practice to Deliver Continuous Improvement in an Archetypal Long-Term Condition

CFHealthHub is a learning health system active in over 50% of adult CF Centres in England, supporting people with CF to develop habits of self-care around adherence to preventative inhaled therapy. This is achieved through the delivery of a behaviour change intervention, alongside collection of objective adherence data. As is common to long-term conditions, adherence to prescribed therapy is low, despite clear evidence of beneficial long-term impact on outcomes. This article explains how CFHealthHub is underpinned by coherent conceptual frameworks. We discuss how application of implementation and quality improvement strategies has facilitated CFHealthHub's progression from a pilot study to a large, randomised control trial and now to a learning health system, becoming embedded within routine care. CFHealthHub is now able to support real-time health technology assessments, quality improvement and research trials and is in the process of being implemented in routine clinical care across participating centres.

Perceived Unmet Needs in Patients and Caregivers Living With Advanced Bladder Cancer: An Infodemiology Study Using Data From Social Media in the United States (Preprint)

Background

Locally advanced or metastatic bladder cancer (BC), which is generally termed advanced BC (aBC), has a very poor prognosis, and in addition to its physical symptoms, it is associated with emotional and social challenges. However, few studies have assessed the unmet needs and burden of aBC from patient and caregiver perspectives. Infodemiology, that is, epidemiology based on internet health-related content, can help obtain more insights on patients’ and caregivers’ experiences with aBC.

Objective

The study aimed to identify the main discussion themes and the unmet needs of patients with aBC and their caregivers through a mixed methods analysis of social media posts.

Methods

Social media posts were collected between January 2015 and April 2021 from US geolocalized sites using specific keywords for aBC. Automatic natural language processing (regular expressions and machine learning) methods were used to filter out irrelevant content and identify verbatim posts from patients and caregivers. The verbatim posts were analyzed to identify main discussion themes using biterm topic modeling. Difficulties or unmet needs were further explored using qualitative research methods by 2 independent annotators until saturation of concepts.

Results

A total of 688 posts from 262 patients and 1214 posts from 679 caregivers discussing aBC were identified. Analysis of 340 randomly selected patient posts and 423 randomly selected caregiver posts uncovered 33 unique unmet need categories among patients and 36 among caregivers. The main unmet patient needs were related to challenges regarding adverse events (AEs; 28/95, 29%) and the psychological impact of aBC (20/95, 21%). Other patient unmet needs identified were prognosis or diagnosis errors (9/95, 9%) and the need for better management of aBC symptoms (9/95, 9%). The main unmet caregiver needs were related to the psychological impacts of aBC (46/177, 26.0%), the need for support groups and to share experiences between peers (28/177, 15.8%), and the fear and management of patient AEs (22/177, 12.4%).

Conclusions

The combination of manual and automatic methods allowed the extraction and analysis of several hundreds of social media posts from patients with aBC and their caregivers. The results highlighted the emotional burden of cancer for both patients and caregivers. Additional studies on patients with aBC and their caregivers are required to quantitatively explore the impact of this disease on quality of life.

Implementing the use of objective medication adherence data in routine clinical practice via the digital CFHealthHub platform: situation analysis and strategy development using the theoretical domains framework

Background

Preventative inhaled treatments preserve lung function and reduce exacerbations in cystic fibrosis (CF). Self-reported adherence to these treatments is over-estimated. An online platform (CFHealthHub) has been developed with patients and clinicians to display real-time objective adherence data from dose-counting nebulisers, so that clinical teams can offer informed treatment support.

Methods

In this paper, we identify pre-implementation barriers to healthcare practitioners performing two key behaviours: accessing objective adherence data through the website CFHealthHub and discussing medication adherence with patients. We aimed to understand barriers during the pre-implementation phase, so that appropriate strategy could be developed for the scale up of implementing objective adherence data in 19 CF centres.

Thirteen semi-structured interviews were conducted with healthcare practitioners working in three UK CF centres. Qualitative data were coded using the theoretical domains framework (TDF), which describes 14 validated domains to implementation behaviour change.

Results

Analysis indicated that an implementation strategy should address all 14 domains of the TDF to successfully support implementation. Participants did not report routines or habits for using objective adherence data in clinical care. Examples of salient barriers included skills, beliefs in consequences, and social influence and professional roles. The results also affirmed a requirement to address organisational barriers. Relevant behaviour change techniques were selected to develop implementation strategy modules using the behaviour change wheel approach to intervention development.

Conclusions

This paper demonstrates the value of applying the TDF at pre-implementation, to understand context and to support the development of a situationally relevant implementation strategy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00263-9.

Barriers to implementation of pediatric emergency department interventions for parental tobacco use and dependence: a qualitative study using the theoretical domains framework

Background

Pediatric emergency department (PED) and urgent care (UC) professionals can play a key role in delivering evidence-based guidelines to address parental tobacco use and child tobacco smoke exposure (TSE). Understanding PED/UC professionals’ perceptions regarding these guidelines is the first step in developing and implementing a TSE screening and counseling intervention in these settings. This study aimed to use the theoretical domains framework (TDF) to identify current screening and counseling behaviors of PED/UC professionals related to parental tobacco use and child TSE, and determine barriers and enablers that influence these behaviors.

Methods

Semi-structured, focused interviews were conducted with 29 actively practicing PED/UC clinical staff who worked at one large, Midwestern children’s hospital. The interview guide was informed by the TDF and included open-ended questions. Content analysis of interview transcripts was guided by the TDF. Nurses, physicians, and healthcare administrators were assessed overall and by group membership to ensure each group was represented based on their varying PED/UC roles.

Results

Fifty-one percent were nurses, 38% were physicians, and 11% were healthcare administrators. Most PED/UC professionals did not currently follow the guidelines, but perceived addressing parental tobacco use as part of their role. All 14 TDF domains were identified by nurses, physicians, and administrators in relation to counseling for parental tobacco use and child TSE. Domains with the most sub-themes were (1) knowledge: lack of knowledge about tobacco counseling, including implementing counseling, cessation resources/referrals, and thirdhand smoke; (2) beliefs about capabilities: not comfortable counseling parents, easier to discuss with parents who are receptive and to ask and advise when patients have a TSE-related complaint, and more likely to discuss if there were resources/referrals; and (3) environmental context and resources: barriers include lack of time, training, and resources and referral information to give to parents, and an enabler is using TSE-related complaints as a context to offer counseling.

Conclusions

Study findings provide a strong foundation for developing and implementing clinical practice guidelines regarding parental tobacco use and child TSE in the PED/UC setting. Future intervention development will address all TDF domains and test the implementation of the intervention in the PED/UC setting.

Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework

BACKGROUND

delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol.

OBJECTIVES

we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients.

METHODS

we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified.

RESULTS

a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture.

CONCLUSION

this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

A Mixed-Methods Systematic Review of the Effectiveness and Experiences of Quality Improvement Interventions in Radiology

OBJECTIVE

This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients.

METHODS

Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design.

RESULTS

Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication.

CONCLUSIONS

The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.

Addressing the Scottish burden of wounds through the Lens of Profound Knowledge

The prevalence of wounds and the cost of treating them are increasing year on year. Improving the quality of wound care will improve patient outcomes and is a financial necessity. The Lens of Profound Knowledge is a tool that can be used to support quality improvement and identify where action is needed. It allows exploration of an organisation through four aspects-appreciate the system, understanding variation, psychology, and theory of knowledge-and working on all four aspects simultaneously is believed to increase the likelihood of achieving improvement. Improvements at and between all levels-microsystem (such as frontline services), mesosystem (health boards) and macrosystem (NHS Scotland)-would reduce variation in practice and prove to be both clinically and cost-effective. Given the rapidly growing population of people with unhealed wounds, wound care needs to be valued at all system levels and be adequately resourced.

Adherence to clinical practice guidelines (CPGs) for the treatment of cancers in Australia and the factors associated with adherence: a systematic review protocol

INTRODUCTION

Clinical practice guidelines (CPGs) synthesise the latest evidence to support clinical and patient decision-making. CPG adherent care is associated with improved patient survival outcomes; however, adherence rates are low across some cancer streams in Australia. Greater understanding of specific barriers to cancer treatment CPG adherence is warranted to inform future implementation strategies.This paper presents the protocol for a systematic review that aims to determine cancer treatment CPG adherence rates in Australia across a variety of common cancers, and to identify any factors associated with adherence to those CPGs, as well as any associations between CPG adherence and patient outcomes.

METHODS AND ANALYSIS

Five databases will be searched, Ovid Medline, PsychInfo, Embase, Scopus and Web of Science, for eligible studies evaluating adherence rates to cancer treatment CPGs in Australia. A team of reviewers will screen the abstracts in pairs according to predetermined inclusion criteria and then review the full text of eligible studies. All included studies will be assessed for quality and risk of bias. Data will be extracted using a predefined data extraction template. The frequency or rate of adherence to CPGs, factors associated with adherence to those CPGs and any reported patient outcome rates (eg, relative risk ratios or 5-year survival rates) associated with adherence to CPGs will be described. If applicable, a pooled estimate of the rate of adherence will be calculated by conducting a random-effects meta-analysis. The systematic review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

ETHICS AND DISSEMINATION

Ethics approval will not be required, as this review will present anonymised data from other published studies. Results from this study will form part of a doctoral dissertation (MB), will be published in a journal, presented at conferences, and other academic presentations.

PROSPERO REGISTRATION NUMBER

CRD42020222962.

Too Much Cancer Care?: Nurses' Perspectives on the Unnecessary Use of Oncology Services

BACKGROUND

"Unnecessary use of health services" refers to care that does not add value for patients and can lead to physical, emotional, and economical harm. High rates of overuse have been reported within oncology, and patients experience its consequences.

OBJECTIVE

The aim of this study was to explore perceptions and experiences of oncology nurses regarding unnecessary use of oncology services.

METHODS

In-depth, semistructured interviews were conducted with a convenience sample of 20 oncology nurses currently practicing in Israel. Interviews were recorded, transcribed, and analyzed thematically.

RESULTS

Themes included perceptions of unnecessary use of health services in cancer (causes and effects of unnecessary use, current and proposed solutions) and negative effects of unnecessary cancer care on patients, families, providers, and the system, including decreased quality of life, increased suffering, and emotional effects on patients and families. Causes were seen on provider, family, and patient levels, such as difficulty for providers to "give up," lack of registered nurses' authority, and family and patient demands. Multidisciplinary care provision, nurses' role, and the patient-provider relationship were seen as existing facilitators minimizing unnecessary use. Future improvement can be achieved by strengthening relationships, providing support to healthcare providers, and improving communication.

CONCLUSIONS

Nurses perceive unnecessary use of health services as a result of multiple, interlinked and complex causes, but few targeted interventions exist. Future research should explore quantifying unnecessary use to determine an accurate representation of the issue.

IMPLICATIONS FOR PRACTICE

Solutions should include engaging patients and families, involving nurses, and fostering multidisciplinary collaborative teamwork to positively affect care and treatment decision-making processes.

Using the Theoretical Domains Framework to Identify Barriers and Facilitators to Elder-Friendly Care Implementation Within a Multi-Site Academic Health Centre

BACKGROUND

Societal demographic shifts are occurring globally. Within Quebec, Canada, the percentage of adults over 65 (older adults) is predicted to increase from 19.3% to >25.9% by the year 2036. Older adults (OAs) experience hospitalizations more frequently than persons aged 15-64 years old, and hospitalizations for OAs can be detrimental due to naturally occurring physiological changes. To address the needs of this population, the Quebec government mandated that all acute care hospitals implement OA-friendly care standards called AAPA ("l'Approche Adaptée à la Personne Âgée").

AIMS

To describe an approach for identifying barriers and facilitators (BFs) to AAPA implementation at the McGill University Health Centre, an academic healthcare centre in Montreal that provides tertiary and quaternary care.

METHODS

Our approach included an organizational quality improvement (QI) model based on the Institute for Healthcare Improvement QI approach and the use of the Theoretical Domains Framework (TDF) to guide the assessment of BFs to AAPA implementation. To identify the BFs of AAPA implementation, themes were generated from the raw data.

RESULTS

In total, 32 barriers and 88 facilitators were identified. Each BF was linked to one or more corresponding domain from the TDF. Seven of the most frequently occurring domains were: (1) knowledge, (2) beliefs about consequences, (3) social/professional role and identity, (4) social influences, (5) environmental context and resources, (6) intentions, and (7) goals.

LINKING EVIDENCE TO ACTION

A theory-informed approach, such as the TDF, can be used to facilitate the implementation of evidence-based guidelines.

Barriers and facilitators to pharmacists integrating into the ward-based multidisciplinary team: A systematic review and meta-synthesis

BACKGROUND

Pharmacists who are integrated into the ward team are involved in initial decision making, therefore pre-empting pharmaceutical problems and optimising therapy from the outset. Identifying the barriers and facilitators (determinants) to successful pharmacist integration within a multidisciplinary ward team will facilitate design of strategies to support integration.

OBJECTIVE

The study aimed to identify the modifiable barriers and facilitators to pharmacist integration into the ward-based multidisciplinary team.

METHOD

Searches were conducted in May 2018 across 5 databases: MEDLINE, Embase, CINAHL, PsychINFO and ASSIA, combined with grey literature and manual searches. Qualitative and mixed-methods studies using a qualitative method of data collection and analysis were eligible if reporting at least 1 modifiable determinant. Framework synthesis using the Theoretical Domains Framework (TDF) as the a priori coding framework was undertaken. Behaviour change techniques for addressing the identified determinants were selected.

RESULTS

Twenty studies were included indicating 9 facilitators and 5 barriers to pharmacist integration. These were grouped into 3 themes. Professional knowledge and skills of the pharmacist were a facilitator to integration; interpersonal skills and relationships when representing positive interactions with team members were a facilitator whilst hierarchy was a barrier; working patterns were a facilitator when pharmacists were co-located with team members whilst profession-specific goals and excessive workload were barriers. These mapped to the TDF domains 'knowledge', 'social/professional role and identity', 'skills', 'reinforcement', 'social influence', 'goals', and 'environmental context and resources' respectively.

CONCLUSION

The identified determinants within TDF domains and their associated behaviour change techniques now enable researchers to design theory- and evidence-based interventions to facilitate pharmacist integration into the ward-based multidisciplinary team. Pharmacist integration is facilitated by their knowledge and skills being valued and through demonstrating effective interpersonal skills. Re-structuring pharmacist responsibilities and working patterns to align with those of multidisciplinary team members also promotes integration.

Ten statements to support nurse leaders implement e-health tools for nursing work in hospitals: A modified Delphi study

AIM

To use expert consensus to develop guidance for nurse leaders implementing e-health tools to support nursing work in hospitals.

BACKGROUND

Nurse leaders are increasingly required to make decisions about the selection, development, implementation and optimisation of e-health tools for nursing work in hospitals. Guidance in this rapidly evolving and complex space is limited.

DESIGN

A two-phase modified Delphi study.

METHODS

Phase one involved in-depth interviews with five nursing informatics experts. Analysis used the qualitative framework method, informed by the Theoretical Domains Framework (TDF), to develop statements for an anonymous online Delphi scoring survey. This was distributed using snowball sampling methods to Australian nurse informatics leaders and experts. Final analysis involved synthesis of qualitative and quantitative data. The study adheres to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist.

RESULTS

Ten guidance statements to support nurse leaders to implement e-health tools in hospitals were developed from the synthesis of qualitative interview data and 29 experts' responses to the 55-item Delphi response survey.

CONCLUSION

Implementation of e-health tools for nursing work is complex in health settings and requires careful examination of multiple factors and interactions between clinicians, tools, service users and the health organisation. This research proposes ten statements to support nurse leaders with decisions about implementing e-health tools to support nursing work in hospitals.

RELEVANCE TO CLINICAL PRACTICE

The ten statements developed by this research provide a resource to assist policy and practice decisions about e-tools to ensure they are suited to supporting nursing work. Nurse leaders can use the ten statements for guidance in the selection, development, implementation and optimisation of e-health tools to ensure suitability and adaptation for nursing work in hospitals.

Would they trust it? An exploration of psychosocial and environmental factors affecting prescriber acceptance of computerised dose-recommendation software

AIMS

Dose-prediction software can optimise vancomycin therapy, improving therapeutic drug monitoring processes and reducing drug toxicity. Success of software in hospitals may be dependent on prescriber uptake of software recommendations. This study aimed to identify the perceived psychosocial and environmental barriers and facilitators to prescriber acceptance of dose-prediction software.

METHODS

Semi-structured interviews, incorporating prescribing scenarios, were undertaken with 17 prescribers. Participants were asked to prescribe the next maintenance dose of vancomycin for a scenario(s) and then asked if they would accept a recommendation provided by a dose-prediction software. Interviews further explored opinions of dose-prediction software. Interview transcripts were analysed using an inductive approach to identify themes and the Theoretical Domains Framework was used to synthesise barriers and facilitators to software acceptance.

RESULTS

When presented with software recommendations, half of the participants were comfortable with accepting the recommendation. Key barriers to acceptance of software recommendations aligned with 2 Theoretical Domains Framework domains: Knowledge (uncertainty of software capability) and Beliefs about Consequences (perceived impact of software on clinical outcomes and workload). Key facilitators aligned with 2 domains: Beliefs about Consequences (improved efficiency) and Social Influences (influence of peers). A novel domain, Trust, was identified as influential.

CONCLUSION

Prescribers reported barriers to acceptance of dose-prediction software aligned with limited understanding of, and scepticism about, software capabilities, as well as concerns about clinical outcomes. Identification of key barriers and facilitators to acceptance provides essential information to design of implementation strategies to support the introduction of this intervention into the workplace.

Barriers and enablers to conducting cluster randomized control trials in hospitals: A theory-informed scoping review

BACKGROUND

Cluster randomized control trials (cRCTs) have unique challenges compared to single site trials with regards to conduct of the trial, and it is important to understand these barriers. The aim of this scoping review was to describe the current literature surrounding the implementation of the cRCTs in hospitals.

METHODS

The search strategy was designed to identify literature relevant to conduct of cRCTs, with hospitals as the unit of randomization. Data was extracted and was mapped using the Consolidated Framework for Implementation Research (CFIR) as a codebook, which contains 39 constructs organized into five domains.

RESULTS

Twenty-two articles met inclusion criteria and were included. 18 of 39 constructs of the CFIR were identified in coding, spanning four of the five domains. Barriers to the conduct of the trial were rarely reported as the main outcome of the study, and few details were included in the identified literature.

CONCLUSIONS

The review can provide guidance to future researchers planning cRCTs in hospitals. It also identified a large gap in reporting of conduct of these trials, demonstrating the need for a research agenda that further explores the barriers and facilitators, with the aim of garnering knowledge for improved guidance in the implementation.

Bending the quality curve

With this paper, we initiate the Supplement on Deepening our Understanding of Quality in Australia (DUQuA). DUQuA is an at-scale, cross-sectional research programme examining the quality activities in 32 large hospitals across Australia. It is based on, with suitable modifications and extensions, the Deepening our Understanding of Quality improvement in Europe (DUQuE) research programme, also published as a Supplement in this Journal, in 2014. First, we briefly discuss key data about Australia, the health of its population and its health system. Then, to provide context for the work, we discuss previous activities on the quality of care and improvement leading up to the DUQuA studies. Next, we present a selection of key interventional studies and policy and institutional initiatives to date. Finally, we conclude by outlining, in brief, the aims and scope of the articles that follow in the Supplement. This first article acts as a framing vehicle for the DUQuA studies as a whole. Aggregated, the series of papers collectively attempts an answer to the questions: what is the relationship between quality strategies, both hospital-wide and at department level? and what are the relationships between the way care is organised, and the actual quality of care as delivered? Papers in the Supplement deal with a multiplicity of issues including: how the DUQuA investigators made progress over time, what the results mean in context, the scales designed or modified along the way for measuring the quality of care, methodological considerations and provision of lessons learnt for the benefit of future researchers.

Barriers to managing medications appropriately when patients have restrictions on oral intake

RATIONALE, AIMS, AND OBJECTIVES

Investigation of several serious adverse events in our organization highlighted that medications were managed inappropriately when patients have oral intake restrictions. The aim of this work was to identify the barriers to optimal medication management when patients have restrictions on their oral intake.

METHOD

Data were feedback and comments obtained between 2011 and 2014 from a hospital-wide quality assurance project. Data had not been purposefully collected and were in response to a general request for feedback regarding managing oral medications when patients have oral intake restrictions. Data came from a range of clinical staff and from various forums associated with the quality assurance project, including 37 presentations, 34 group meetings, and over 50 one-on-one meetings, as well as emails and other sources. Data were analysed using the thematic analysis approach. Data were coded inductively, and the domains of the Theoretical Domains Framework were used to categorize the data. Subthemes and themes were then developed.

RESULTS

Barriers could be broadly grouped into systems-level issues (organizational guidance and work environment) and the individual person-level issues (staff knowledge and beliefs). These barriers highlight the complexity of the medication management task. The lack of standardized guidance and consistent terminology regarding medication administration when patients have restrictions on oral intake, particularly when fasting or nil by mouth, were important systems factors, as were workflow issues and the "culture" of the environment in which staff practiced. Lack of knowledge about medication administration, social influences, and role interpretation were important individual person factors.

CONCLUSION

Systems- and individual person-level issues were significant contributors to inappropriate medication management when patients have oral intake restrictions. Many of the barriers may be addressed with systems approaches such as hospital-wide guidance that simplifies and standardize oral medication administration instructions, particularly regarding fasting and nil by mouth terminology.

Influences on surgical antimicrobial prophylaxis decision making by surgical craft groups, anaesthetists, pharmacists and nurses in public and private hospitals

Background

Surgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in the hospital setting, with demonstrated high rates of inappropriateness. Decision-making for SAP is complex and multifactorial. A greater understanding of these factors is needed to inform the design of targeted antimicrobial stewardship interventions and strategies to support the optimization of SAP and its impacts on patient care.

Methods

A qualitative case study exploring the phenomenon of SAP decision-making. Focus groups were conducted with surgeons, anaesthetists, theatre nurses and pharmacists across one private and two public hospitals in Australia. Thematic analysis was guided by the Theoretical Domains Framework (TDF) and the Capabilities, Opportunities, Motivators-Behaviour (COM-B) model.

Results

Fourteen focus groups and one paired interview were completed. Ten of the fourteen TDF domains were identified as relevant. Thematic analysis revealed six significant themes mapped to the COM-B model, and subthemes mapped to the relevant TDF domains in a combined framework. Key themes identified were: 1) Low priority for surgical antimicrobial prophylaxis prescribing skills; 2) Prescriber autonomy takes precedence over guideline compliance; 3) Social codes of prescribing reinforce established practices; 4) Need for improved communication, documentation and collection of data for action; 5) Fears and perceptions of risk hinder appropriate SAP prescribing; and 6) Lack of clarity regarding roles and accountability.

Conclusions

SAP prescribing is a complex process that involves multiple professions across the pre-, intra- and post-operative surgical settings. The utilisation of behaviour change frameworks to identify barriers and enablers to optimal SAP prescribing supports future development of theory-informed antimicrobial stewardship interventions. Interventions should aim to increase surgeon engagement, enhance the prioritisation of and accountability for SAP, and address the underlying social factors involved in SAP decision-making, such as professional hierarchy and varied perceptions or risks and fears.

Barriers to Providing VTE Chemoprophylaxis to Hospitalized Patients: A Nursing-Focused Qualitative Evaluation

BACKGROUND

Venous thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality.

OBJECTIVES

The objective of this study was to identify nursing-related barriers to administration of VTE chemoprophylaxis to hospitalized patients.

DESIGN

This was a qualitative study including nurses from five inpatient units at one hospital.

METHODS

Observations were conducted on five units to gain insight into the process for administering chemoprophylaxis. Focus group interviews were conducted with nurses and were audio-recorded, transcribed verbatim, and analyzed using the Theoretical Domains Framework to identify barriers to providing VTE chemoprophylaxis.

RESULTS

We conducted 14 focus group interviews with nurses from five inpatient units to assess nurses' perceptions of barriers to administration of VTE chemoprophylaxis. The barriers identified included nurses' misconceptions that ambulating patients did not require chemoprophylaxis, nurses' uncertainty when counseling patients on the importance of chemoprophylaxis, and a lack of comparative data for nurses regarding their specific refusal rates.

CONCLUSIONS

Multiple factors act as barriers to patients receiving VTE chemoprophylaxis. These barriers are often modifiable targets for quality improvement. There is a need to focus on behavior changes that will remove or minimize barriers and equip nurses to ensure administration of VTE chemoprophylaxis by engaging patients in their care.

Community Perceptions of Alcohol Exposed Pregnancy Prevention Program for American Indian and Alaska Native Teens

A community needs assessment during a tribally-led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) intervention highlighted the need to reduce the risk for alcohol exposed pregnancy (AEP) among American Indian and Alaska Native (AIAN) adolescent girls. The CHOICES for American Indian Teens (CHAT) Program aims to reduce the risk of AEP among AIAN teens in one Northern Plains tribal community. The CHAT team adopted an iterative process to modify the tribally-led CHOICES curriculum for AIAN teens. This paper describes the iterative process as well as the community perception towards AEP prevention among AIAN teens. The CHAT team conducted several levels of formative and qualitative research, including one-on-one interviews (n = 15) with community members, AIAN elders and school counsellors; and three focus groups with AIAN adolescent girls (n = 15). A qualitative data analysis identified several recommendations that centered on making the information regarding alcohol and birth control appealing to teens; ensuring the confidentiality of the participants; making the program culturally relevant; and including boys in the program. This study outlines various components prioritized by community members in creating a culturally-relevant and age-appropriate AEP prevention program and provides community perceptions of AEP prevention for the teens in this community.

Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research

BACKGROUND

Providing health professionals with quantitative summaries of their clinical performance when treating specific groups of patients ("feedback") is a widely used quality improvement strategy, yet systematic reviews show it has varying success. Theory could help explain what factors influence feedback success, and guide approaches to enhance effectiveness. However, existing theories lack comprehensiveness and specificity to health care. To address this problem, we conducted the first systematic review and synthesis of qualitative evaluations of feedback interventions, using findings to develop a comprehensive new health care-specific feedback theory.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Data were synthesised by coding individual papers, building on pre-existing theories to formulate hypotheses, iteratively testing and improving hypotheses, assessing confidence in hypotheses using the GRADE-CERQual method, and summarising high-confidence hypotheses into a set of propositions.

RESULTS

We synthesised 65 papers evaluating 73 feedback interventions from countries spanning five continents. From our synthesis we developed Clinical Performance Feedback Intervention Theory (CP-FIT), which builds on 30 pre-existing theories and has 42 high-confidence hypotheses. CP-FIT states that effective feedback works in a cycle of sequential processes; it becomes less effective if any individual process fails, thus halting progress round the cycle. Feedback's success is influenced by several factors operating via a set of common explanatory mechanisms: the feedback method used, health professional receiving feedback, and context in which feedback takes place. CP-FIT summarises these effects in three propositions: (1) health care professionals and organisations have a finite capacity to engage with feedback, (2) these parties have strong beliefs regarding how patient care should be provided that influence their interactions with feedback, and (3) feedback that directly supports clinical behaviours is most effective.

CONCLUSIONS

This is the first qualitative meta-synthesis of feedback interventions, and the first comprehensive theory of feedback designed specifically for health care. Our findings contribute new knowledge about how feedback works and factors that influence its effectiveness. Internationally, practitioners, researchers, and policy-makers can use CP-FIT to design, implement, and evaluate feedback. Doing so could improve care for large numbers of patients, reduce opportunity costs, and improve returns on financial investments.

TRIAL REGISTRATION

PROSPERO, CRD42015017541.

What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis

BACKGROUND

Diabetic retinopathy screening (DRS) is effective but uptake is suboptimal.

OBJECTIVES

To determine the effectiveness of quality improvement (QI) interventions for DRS attendance; describe the interventions in terms of QI components and behaviour change techniques (BCTs); identify theoretical determinants of attendance; investigate coherence between BCTs identified in interventions and determinants of attendance; and determine the cost-effectiveness of QI components and BCTs for improving DRS.

DATA SOURCES AND REVIEW METHODS

Phase 1 - systematic review of randomised controlled trials (RCTs) evaluating interventions to increase DRS attendance (The Cochrane Library, MEDLINE, EMBASE and trials registers to February 2017) and coding intervention content to classify QI components and BCTs. Phase 2 - review of studies reporting factors influencing attendance, coded to theoretical domains (MEDLINE, EMBASE, PsycINFO and sources of grey literature to March 2016). Phase 3 - mapping BCTs (phase 1) to theoretical domains (phase 2) and an economic evaluation to determine the cost-effectiveness of BCTs or QI components.

RESULTS

Phase 1 - 7277 studies were screened, of which 66 RCTs were included in the review. Interventions were multifaceted and targeted patients, health-care professionals (HCPs) or health-care systems. Overall, interventions increased DRS attendance by 12% [risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14] compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted and general QI interventions were effective, particularly when baseline attendance levels were low. All commonly used QI components and BCTs were associated with significant improvements, particularly in those with poor attendance. Higher effect estimates were observed in subgroup analyses for the BCTs of 'goal setting (outcome, i.e. consequences)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes (consequences) of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients and of 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting HCPs. Phase 2 - 3457 studies were screened, of which 65 non-randomised studies were included in the review. The following theoretical domains were likely to influence attendance: 'environmental context and resources', 'social influences', 'knowledge', 'memory, attention and decision processes', 'beliefs about consequences' and 'emotions'. Phase 3 - mapping identified that interventions included BCTs targeting important barriers to/enablers of DRS attendance. However, BCTs targeting emotional factors around DRS were under-represented. QI components were unlikely to be cost-effective whereas BCTs with a high probability (≥ 0.975) of being cost-effective at a societal willingness-to-pay threshold of £20,000 per QALY included 'goal-setting (outcome)', 'feedback on outcomes of behaviour', 'social support' and 'information about health consequences'. Cost-effectiveness increased when DRS attendance was lower and with longer screening intervals.

LIMITATIONS

Quality improvement/BCT coding was dependent on descriptions of intervention content in primary sources; methods for the identification of coherence of BCTs require improvement.

CONCLUSIONS

Randomised controlled trial evidence indicates that QI interventions incorporating specific BCT components are associated with meaningful improvements in DRS attendance compared with usual care. Interventions generally used appropriate BCTs that target important barriers to screening attendance, with a high probability of being cost-effective. Research is needed to optimise BCTs or BCT combinations that seek to improve DRS attendance at an acceptable cost. BCTs targeting emotional factors represent a missed opportunity to improve attendance and should be tested in future studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016044157 and PROSPERO CRD42016032990.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers

BACKGROUND

The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation.

MATERIALS AND METHODS

We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research.

RESULTS

We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers' concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention.

CONCLUSIONS

We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation-as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Comparing the application of two theoretical frameworks to describe determinants of adverse medical device event reporting: secondary analysis of qualitative interview data

BACKGROUND

Post-market surveillance of medical devices is reliant on physician reporting of adverse medical device events (AMDEs). Few studies have examined factors that influence whether and how physicians report AMDEs, an essential step in the development of behaviour change interventions. This study was a secondary analysis comparing application of the Theoretical Domains Framework (TDF) and the Tailored Implementation for Chronic Diseases (TICD) framework to identify potential behaviour change interventions that correspond to determinants of AMDE reporting.

METHODS

A previous study involving qualitative interviews with Canadian physicians that implant medical devices identified themes reflecting AMDE reporting determinants. In this secondary analysis, themes that emerged from the primary analysis were independently mapped to the TDF and TICD. Determinants and corresponding intervention options arising from both frameworks (and both mappers) were compared.

RESULTS

Both theoretical frameworks were useful for identifying interventions corresponding to behavioural determinants of AMDE reporting. Information or education strategies that provide evidence about AMDEs, and audit and feedback of AMDE data were identified as interventions to target the theme of physician beliefs; improving information systems, and reminder cues, prompts and awards were identified as interventions to address determinants arising from the organization or systems themes; and modifying financial/non-financial incentives and sharing data on outcomes associated with AMDEs were identified as interventions to target device market themes. Numerous operational challenges were encountered in the application of both frameworks including a lack of clarity about how directly relevant to themes the domains/determinants should be, how many domains/determinants to select, if and how to resolve discrepancies across multiple mappers, and how to choose interventions from among the large number associated with selected domains/determinants.

CONCLUSIONS

Given discrepancies in mapping themes to determinants/domains and the resulting interventions offered by the two frameworks, uncertainty remains about how to choose interventions that best match behavioural determinants in a given context. Further research is needed to provide more nuanced guidance on the application of TDF and TICD for a broader audience, which is likely to increase the utility and uptake of these frameworks in practice.

Using the Behaviour Change Wheel to explore potential strategies for minimising harms from non-recreational prescription medicine sharing

INTRODUCTION

Non-recreational sharing of prescribed medicines can have positive outcomes under some circumstances, but can also result in negative health outcomes. This paper describes a theoretically underpinned and systematic approach to exploring potential interventions to reduce harm.

METHODS

Individual, semi-structured, face-to-face interviews were conducted with purposively sampled pharmacists (n = 8), doctors (n = 4), nurses (n = 6) and patients (n = 17) from Auckland, New Zealand. Thematic analysis of suggested interventions was undertaken, and these were linked to relevant intervention functions of the Behaviour Change Wheel (BCW). Analysis of previously defined factors influencing sharing were mapped onto the "Capability, Opportunity, Motivation - Behaviour" (COM-B) model of the BCW.

RESULTS

COM-B analysis of the factors influencing sharing behaviour revealed: (i) 'Capability'-related factors, such as patient misconceptions about the safety of certain medicines, forgetting to refill or to carry around own medicines, and lack of knowledge about safe disposal of leftover/unused medicines; (ii) 'Opportunity'-related factors included lack of access to health facilities, lack of time to see a doctor, linguistic and cultural barriers, lack of information from healthcare providers about risks of sharing, and having leftover/unused medicines, and (iii) 'Motivation'-related factors included altruism, illness denial, embarrassment about seeing a doctor, not carrying around own medicines, habit, and fear of negative health consequences from missing a few doses of medicines. Five intervention functions of the BCW appear to be the most likely candidates for targeting the factors which relate to medicine sharing. These are education, persuasion, enablement, environmental restructuring and restriction.

CONCLUSIONS

A variety of personal and external factors which influence sharing behaviours were identified, and the BCW provided a means by which theoretically underpinned interventions to reduce potential harms from this behaviour could be proposed. The findings can help with the design of approaches to reduce harm associated with non-recreational medicine sharing.

Barriers and facilitators to hospital pharmacists' engagement in medication safety activities: a qualitative study using the theoretical domains framework

Background

Hospital pharmacists play a central role in medication safety activities. However, in Ethiopia, this role has been launched recently and little is known regarding the current status of this extended service. Using the Theoretical Domains Framework (TDF), we aimed to identify the barriers and facilitators to hospital pharmacists’ engagement in medication safety activities across various public hospitals in the Amhara region of Ethiopia.

Methods

Eight focus group discussions, using an interview guide that was drawn upon the TDF, were conducted with 44 hospital pharmacists to explore their beliefs regarding their involvement in clinical services. Group discussions were audio-recorded, transcribed verbatim, and analysed using directed content analysis based on the TDF. Relevant domains were identified by applying relevance criteria to each of the domains in the TDF.

Results

Content analysis revealed six domains that influence hospital pharmacists’ engagement in medication safety activities. These domains included ‘Knowledge’, ‘Skills’, ‘Environmental context and resources’, ‘Motivations and goals’, ‘Social influences’ and ‘Social/professional role’. Most hospital pharmacists believed knowledge gap was an issue, as was the lack of training and supportive skills although some expressed as they were competent enough for their skills in identifying medication related problems. Most participants were very much enthusiastic for their extended roles and were positive towards the future of the profession; however, competing priorities along with the lack of remuneration and awareness (of other health care professionals) regarding the profession’s role were barriers to service delivery. There were also a number of resource constraints, such as staffing, infrastructure and government funding, and acceptance rate of pharmacist’s recommendation that were likely to influence the clinical practice of pharmacists.

Conclusion

Using the TDF, this study identified a wide range of barriers and facilitators to hospital pharmacists’ engagement in medication safety activities in resource-limited settings. There existed considerable interrelationships between domains that were perceived to influence hospital pharmacists’ behaviours, and this may assist in designing behaviour change interventions that target common behavioural domains.

Electronic supplementary material

The online version of this article (10.1186/s40545-018-0129-y) contains supplementary material, which is available to authorized users.

Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Improving discharge care: the potential of a new organisational intervention to improve discharge after hospitalisation for acute stroke, a controlled before-after pilot study

OBJECTIVE

Provision of a discharge care plan and prevention therapies is often suboptimal. Our objective was to design and pilot test an interdisciplinary, organisational intervention to improve discharge care using stroke as the case study using a mixed-methods, controlled before-after observational study design.

SETTING

Acute care public hospitals in Queensland, Australia (n=15). The 15 hospitals were ranked against a benchmark based on a composite outcome of three discharge care processes. Clinicians from a 'top-ranked' hospital participated in a focus group to elicit their success factors. Two pilot hospitals then participated in the organisational intervention that was designed with experts and consumers.

PARTICIPANTS

Hospital clinicians involved in discharge care for stroke and patients admitted with acute stroke or transient ischaemic attack.

INTERVENTION

A four-stage, multifaceted organisational intervention that included data reviews, education and facilitated action planning.

PRIMARY AND SECONDARY OUTCOME MEASURES

Three discharge processes collected in Queensland hospitals within the Australian Stroke Clinical Registry were used to select study hospitals: (1) discharge care plan; (2) antihypertensive medication prescription and (3) antiplatelet medication prescription (ischaemic events only). Primary measure: composite outcome. Secondary measures: individual adherence changes for each discharge process; sensitivity analyses. The performance outcomes were compared 3 months before the intervention (preintervention), 3 months postintervention and at 12 months (sustainability).

RESULTS

Data from 1289 episodes of care from the two pilot hospitals were analysed. Improvements from preintervention adherence were: antiplatelet therapy (88%vs96%, p=0.02); antihypertensive prescription (61%vs79%, p<0.001); discharge planning (72%vs94%, p<0.001); composite outcome (73%vs89%, p<0.001). There was an insignificant decay effect over the 12-month sustainability period (composite outcome: 89% postintervention vs 85% sustainability period, p=0.08).

CONCLUSION

Discharge care in hospitals may be effectively improved and sustained through a staged and peer-informed, organisational intervention. The intervention warrants further application and trialling on a larger scale.

Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses' use of electronic medication management systems in two Australian hospitals

Background

Medication errors harm hospitalised patients and increase health care costs. Electronic Medication Management Systems (EMMS) have been shown to reduce medication errors. However, nurses do not always use EMMS as intended, largely because implementation of such patient safety strategies requires clinicians to change their existing practices, routines and behaviour. This study uses the Theoretical Domains Framework (TDF) to identify barriers and targeted interventions to enhance nurses’ appropriate use of EMMS in two Australian hospitals.

Methods

This qualitative study draws on in-depth interviews with 19 acute care nurses who used EMMS. A convenience sampling approach was used. Nurses working on the study units (N = 6) in two hospitals were invited to participate if available during the data collection period. Interviews inductively explored nurses’ experiences of using EMMS (step 1). Data were analysed using the TDF to identify theory-derived barriers to nurses’ appropriate use of EMMS (step 2). Relevant behaviour change techniques (BCTs) were identified to overcome key barriers to using EMMS (step 3) followed by the identification of potential literature-informed targeted intervention strategies to operationalise the identified BCTs (step 4).

Results

Barriers to nurses’ use of EMMS in acute care were represented by nine domains of the TDF. Two closely linked domains emerged as major barriers to EMMS use: Environmental Context and Resources (availability and properties of computers on wheels (COWs); technology characteristics; specific contexts; competing demands and time pressure) and Social/Professional Role and Identity (conflict between using EMMS appropriately and executing behaviours critical to nurses’ professional role and identity).

The study identified three potential BCTs to address the Environmental Context and Resources domain barrier: adding objects to the environment; restructuring the physical environment; and prompts and cues. Seven BCTs to address Social/Professional Role and Identity were identified: social process of encouragement; pressure or support; information about others’ approval; incompatible beliefs; identification of self as role model; framing/reframing; social comparison; and demonstration of behaviour. It proposes several targeted interventions to deliver these BCTs.

Conclusions

The TDF provides a useful approach to identify barriers to nurses’ prescribed use of EMMS, and can inform the design of targeted theory-based interventions to improve EMMS implementation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0572-1) contains supplementary material, which is available to authorized users.

What influences general practitioners' use of exercise for patients with chronic knee pain? Results from a national survey

Background

Exercise is a recommended ‘core’ treatment for chronic knee pain (CKP), however it appears to be underused by general practitioners (GPs). While behavioural theories suggest that attitudes and beliefs influence behaviours, no single theory reliably predicts GPs’ behaviours. A theoretical analysis framework, developed from sociocognitive theories, was used to underpin investigation of the key influences associated with GPs’ use of exercise for patients with CKP, to inform future interventions to optimise GPs’ use of exercise.

Methods

A cross-sectional postal questionnaire survey investigated UK GPs’ reported use of exercise based on a patient case vignette. Factors influencing GPs’ exercise use (behaviour) were examined using attitude statements, free-text questions and multiple response option questions related to factors within the analysis framework. Unadjusted logistic regression analyses explored the associations between GPs’ attitudes/beliefs and behaviour.

Results

From a total sample of 5000 GPs, 835 (17%) returned a questionnaire. Most respondents (n = 729, 87%) reported that they would use exercise. Factors significantly associated with exercise use (OR (95% CI)) included GPs’ beliefs about their role (belief that GPs should give information on type, duration and frequency of exercise (30.71 (5.02,188.01)), beliefs about consequences (agreement that knee problems are improved by local (3.23 (1.94,5.39)) and general exercise (2.63 (1.38,5.02))), moral norm (agreement that GPs should prescribe all patients local (3.08 (1.96,4.83)) and general exercise (2.63 (1.45,4.76))), and GP-related beliefs about capabilities (prior experience of insufficient expertise to give detailed exercise information (0.50 (0.33,0.76)). Whilst perceived time limitations were not associated with exercise use (1.00 (0.33,3.01)), GPs who disagreed that they experienced time limitations were more likely to suggest general (2.17 (1.04,4.55)), or demonstrate local (2.16 (1.06,4.42)), exercises.

Conclusion

GPs’ attitudes and beliefs are associated with their use of exercise for patients with CKP, particularly beliefs about role, responsibilities and skills in initiating exercise, and about the efficacy of exercise. Although the low response risks response bias, these results can inform future interventions to optimise GPs’ behaviour. The role of GP uncertainty and influences on clinical decision-making need further exploration, thus an amended analysis framework is suggested, which should be tested in future research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0570-4) contains supplementary material, which is available to authorized users.

Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF)

Background

Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED.

Methods

Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy.

Results

Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of “environmental, context and resources” (such as stressful working conditions or lack of resources) and “knowledge” (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of “knowledge” (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and “skills” (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were “focus on past success” and “information about health consequences.”

Conclusions

Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.

General Practitioners' and patients' perceptions towards stratified care: a theory informed investigation

Background

Stratified primary care involves changing General Practitioners’ (GPs) clinical behaviour in treating patients, away from the current stepped care approach to instead identifying early treatment options that are matched to patients’ risk of persistent disabling pain. This article explores the perspectives of UK-based GPs and patients about a prognostic stratified care model being developed for patients with the five most common primary care musculoskeletal pain presentations. The focus was on views about acceptability, and anticipated barriers and facilitators to the use of stratified care in routine practice.

Methods

Four focus groups and six semi-structured telephone interviews were conducted with GPs (n = 23), and three focus groups with patients (n = 20). Data were analysed thematically; and identified themes examined in relation to the Theoretical Domains Framework (TDF), which facilitates comprehensive identification of behaviour change determinants. A critical approach was taken in using the TDF, examining the nuanced interrelationships between theoretical domains.

Results

Four key themes were identified: Acceptability of clinical decision-making guided by stratified care; impact on the therapeutic relationship; embedding a prognostic approach within a biomedical model; and practical issues in using stratified care. Whilst within each theme specific findings are reported, common across themes was the identified relationships between the theoretical domains of knowledge, skills, professional role and identity, environmental context and resources, and goals. Through analysis of these identified relationships it was found that, for GPs and patients to perceive stratified care as being acceptable, it must be seen to enhance GPs’ knowledge and skills, not undermine GPs’ and patients’ respective identities and be integrated within the environmental context of the consultation with minimal disruption.

Conclusions

Findings highlight the importance of taking into account the context of general practice when intervening to support GPs to make changes to their clinical behaviour. Findings will inform further stages of the research programme; specifically, the intervention format and content of support packages for GPs participating in a future randomised controlled trial (RCT). This study also contributes to the theoretical debate on how best to encourage clinical behaviour change in general practice, and the possible role of the TDF in that process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0511-2) contains supplementary material, which is available to authorized users.

Barriers and enablers to diabetic retinopathy screening attendance: Protocol for a systematic review

BACKGROUND

Diabetic retinopathy is a serious complication of diabetes which, if left untreated, can result in blindness. Population screening among people with diabetes has been shown to be clinically effective; however, suboptimal attendance with wide demographic disparities has been reported. To develop quality improvement interventions to maximise attendance, it is important to understand the theoretical determinants (i.e. barriers and enablers) of screening behaviour. The aim of this systematic review is to identify and synthesise the modifiable barriers and enablers associated with diabetic retinopathy screening attendance.

METHODS/DESIGN

Primary and secondary studies will be included if they report perceived barriers/enablers of diabetic retinopathy screening attendance, from the perspectives of people with diabetes and healthcare providers. There will be no restrictions on study design. Studies will be identified from published and grey literature through multiple sources. Bibliographic databases will be searched using synonyms in four search domains: diabetic retinopathy; screening; barriers/enablers; and theoretical constructs relating to behaviour. Search engines and established databases of grey literature will be searched to identify additional relevant studies. Extracted data will include: participant quotations from qualitative studies, statistical analyses from questionnaire and survey studies, and interpretive descriptions and summaries of results from reports. All extracted data will be coded into domains from the Theoretical Domains Framework (TDF) and (for organisational level data) the Consolidated Framework of Implementation Research (CFIR); with domains representing theoretical barriers/enablers proposed to mediate behaviour change. The potential role of each domain in influencing retinopathy screening attendance will be investigated through thematic analysis of the TDF/ CFIR coding. Domain importance will be identified using pre-specified criteria: "frequency" and "expressed importance". Variations in perceived barriers and enablers between demographic groups (e.g., socio-economic, ethnic) will be explored.

DISCUSSION

This review will identify important barriers and enablers likely to influence attendance for diabetic retinopathy screening. The results will be used to assess the extent to which existing interventions targeting attendance address the theoretical determinants of attendance behaviour. Findings will inform recommendations for future intervention design.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016032990.

Interactive Dissemination: Engaging Stakeholders in the Use of Aggregated Quality Improvement Data for System-Wide Change in Australian Indigenous Primary Health Care

Background

Integrating theory when developing complex quality improvement interventions can help to explain clinical and organizational behavior, inform strategy selection, and understand effects. This paper describes a theory-informed interactive dissemination strategy. Using aggregated quality improvement data, the strategy seeks to engage stakeholders in wide-scale data interpretation and knowledge sharing focused on achieving wide-scale improvement in primary health-care quality.

Methods

An iterative process involving diverse stakeholders in Australian Aboriginal and Torres Strait Islander health-care delivery uses aggregated audit data collected across key areas of care. Phases of reporting and online feedback are used to identify: (1) priority areas for improvement; (2) health center, system, and staff attributes that may be important in addressing the identified priority evidence-practice gaps; and (3) strategies that could be introduced or strengthened to enable improvement. A developmental evaluation is being used to refine engagement processes and reports as the project progresses.

Discussion

This innovative dissemination approach is being used to encourage wide-scale interpretation and use of service performance data by policy-makers, managers, and other stakeholders, and to document knowledge about how to address barriers to achieving change. Through the developmental evaluation, the project provides opportunities to learn about stakeholders’ needs in relation to the way data and findings are described and distributed, and elements of the dissemination strategy and report design that impact on the useability and uptake of findings.

Conclusion

The project can contribute to knowledge about how to facilitate interactive wide-scale dissemination and about using data to co-produce knowledge to improve health-care quality.

Development of a scale to evaluate midwives' beliefs about assessing alcohol use during pregnancy

Background

Prenatal alcohol exposure is an important modifiable cause of adverse fetal outcomes during and following pregnancy. Midwives are key providers of antenatal care, and it is important to understand the factors which influence their ability to provide appropriate advice and support to women about alcohol use in pregnancy. The main aim of this study was to develop a psychometrically valid scale to evaluate midwives’ beliefs about assessing alcohol use during pregnancy.

Method

A self-administered questionnaire was developed to evaluate midwives’ beliefs about assessing alcohol use during pregnancy, including beliefs about positive and negative consequences of asking about alcohol use, and beliefs about capacity to assess alcohol use. The questionnaire was sent to 245 midwives working for a state-wide country health service in Western Australia. Exploratory factor analysis was used to identify the latent constructs assessed by the 36 belief items and provide initial construct validation of the Asking About Alcohol (AAA) Scale.

Results

Of the 166 (67.8 %) midwives who responded to the survey, 160 (96.4 %) completed one or more of the belief items and were included in this analysis. Factor analysis identified six subscales which assessed beliefs about discomfort, capacity, effectiveness, role, trust and knowledge. Midwives held the most positive beliefs about their capacity to ask and the effectiveness of asking about alcohol use, and the least positive beliefs about women’s knowledge about alcohol use and discomfort associated with asking about alcohol use in pregnancy. Midwives’ beliefs about their role and the effectiveness of asking were most strongly associated with the intention to ask all pregnant women about alcohol use during pregnancy (r = −0.59, p < 0.001 and r = −0.52, p < 0.001).

Conclusions

Our analysis has identified key constructs underlying midwives’ beliefs about the assessment of alcohol use during pregnancy. The AAA Scale provides a basis for improved clarity and consistency in the conceptualisation and measurement of midwives’ beliefs which can be used to enhance our understanding of factors influencing midwives’ ability to deliver interventions to prevent alcohol use during pregnancy. The constructs identified in this exploratory analysis require confirmatory analysis to support their validity and generalizability.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0779-6) contains supplementary material, which is available to authorized users.

Clinical leadership and prevention in practice: is a needs led preventive approach to the delivery of care to improve quality, outcomes and value in primary dental care practice a realistic concept?

Background

There is a need to improve access to, and the quality of, service delivery in NHS primary dental care. Building public health thinking and leadership capacity in clinicians from primary care teams was seen as an underpinning component to achieving this goal. Clinical teams contributed to service redesign concepts and were contractually supported to embrace a preventive approach.

Methods

Improvement in quality and preventive focus of dental practice care delivery was explored through determining the impact of several projects, to share how evidence, skill mix and clinical leadership could be utilised in design, implementation and measurement of care outcomes in general dental practice in order to champion and advocate change, during a period of substantial change within the NHS system.

The projects were:

1. A needs-led, evidence informed preventive care pathway approach to primary dental care delivery with a focus on quality and outcomes.

2. Building clinical leadership to influence and advocate for improved quality of care; and spread of learning through local professional networks. This comprised two separate projects: improved access for very young children called “Baby Teeth DO Matter” and the production of a clinically led, evidence-based guidance for periodontyal treatment in primary care called “Healthy Gums DO Matter”.

Results

What worked and what hindered progress, is described. The projects developed understanding of how working with ‘local majorities’ of clinicians influenced, adoption and spread of learning, and the impact in prompting wider policy and contract reform in England.

Conclusions

The projects identified issues that required change to meet population need. Clinicians were allowed to innovate in an evironment working together with commissioners, patients and public health colleagues. Communication and the development of clinical leadership led to the development of an infrastructure to define care pathways and decision points in the patient's journey.

Experiences of using the Theoretical Domains Framework across diverse clinical environments: a qualitative study

Background

The Theoretical Domains Framework (TDF) is an integrative framework developed from a synthesis of psychological theories as a vehicle to help apply theoretical approaches to interventions aimed at behavior change.

Purpose

This study explores experiences of TDF use by professionals from multiple disciplines across diverse clinical settings.

Methods

Mixed methods were used to examine experiences, attitudes, and perspectives of health professionals in using the TDF in health care implementation projects. Individual interviews were conducted with ten health care professionals from six disciplines who used the TDF in implementation projects. Deductive content and thematic analysis were used.

Results

Three main themes and associated subthemes were identified including: 1) reasons for use of the TDF (increased confidence, broader perspective, and theoretical underpinnings); 2) challenges using the TDF (time and resources, operationalization of the TDF) and; 3) future use of the TDF.

Conclusion

The TDF provided a useful, flexible framework for a diverse group of health professionals working across different clinical settings for the assessment of barriers and targeting resources to influence behavior change for implementation projects. The development of practical tools and training or support is likely to aid the utility of TDF.

A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Despite the widespread availability of evidence-based clinical guidelines and validated risk predication equations for prevention and management of CVD, their translation into routine practice is limited. We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support, patient risk communication tools, computerised audit and feedback tools, and monthly, peer-ranked performance feedback via a web portal. The intervention was implemented in a cluster randomised controlled trial in 60 primary healthcare services in Australia. Overall, there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals, but it is unclear how this intervention was used in practice and what factors promoted or hindered its use. This information is necessary to optimise intervention impact and maximally implement it in a post-trial context. In this study protocol, we outline our methods to conduct a theory-based, process evaluation of the intervention. Our aims are to understand how, why, and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination.

METHODS/DESIGN

We will conduct four discrete but inter-related studies taking a mixed methods approach. Our quantitative studies will examine (1) the longer term effectiveness of the intervention post-trial, (2) patient and health service level correlates with trial outcomes, and (3) the health economic impact of implementing the intervention at scale. The qualitative studies will (1) identify healthcare provider perspectives on implementation barriers and enablers and (2) use video ethnography and patient semi-structured interviews to understand how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention. We will also assess the costs of implementing the intervention in Australian primary healthcare settings which will inform scale-up considerations.

DISCUSSION

This mixed methods evaluation will provide a detailed understanding of the process of implementing a quality improvement intervention and identify the factors that might influence scalability and sustainability.

TRIALS REGISTRATION

12611000478910.