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Patey AM, Fontaine G, Francis JJ, McCleary N, Presseau J, Grimshaw JM. Healthcare professional behaviour: health impact, prevalence of evidence-based behaviours, correlates and interventions. Psychol Health 2022; 38:766-794. [PMID: 35839082 DOI: 10.1080/08870446.2022.2100887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Healthcare professional (HCP) behaviours are actions performed by individuals and teams for varying and often complex patient needs. However, gaps exist between evidence-informed care behaviours and the care provided. Implementation science seeks to develop generalizable principles and approaches to investigate and address care gaps, supporting HCP behaviour change while building a cumulative science. We highlight theory-informed approaches for defining HCP behaviour and investigating the prevalence of evidence-based care and known correlates and interventions to change professional practice. Behavioural sciences can be applied to develop implementation strategies to support HCP behaviour change and provide valid, reliable tools to evaluate these strategies. There are thousands of different behaviours performed by different HCPs across many contexts, requiring different implementation approaches. HCP behaviours can include activities related to promoting health and preventing illness, assessing and diagnosing illnesses, providing treatments, managing health conditions, managing the healthcare system and building therapeutic alliances. The key challenge is optimising behaviour change interventions that address barriers to and enablers of recommended practice. HCP behaviours may be determined by, but not limited to, Knowledge, Social influences, Intention, Emotions and Goals. Understanding HCP behaviour change is a critical to ensuring advances in health psychology are applied to maximize population health.
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Affiliation(s)
- Andrea M. Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jillian J. Francis
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Nicola McCleary
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin Presseau
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeremy M. Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Bergeron L, Décary S, Djade CD, Daniel SJ, Tremblay M, Rivest LP, Légaré F. Factors Associated With Specialists' Intention to Adopt New Behaviors After Taking Web-Based Continuing Professional Development Courses: Cross-sectional Study. JMIR MEDICAL EDUCATION 2022; 8:e34299. [PMID: 35476039 PMCID: PMC9204572 DOI: 10.2196/34299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/02/2022] [Accepted: 04/26/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Web-based continuing professional development (CPD) is a convenient and low-cost way for physicians to update their knowledge. However, little is known about the factors that influence their intention to put this new knowledge into practice. OBJECTIVE We aimed to identify sociocognitive factors associated with physicians' intention to adopt new behaviors as well as indications of Bloom's learning levels following their participation in 5 web-based CPD courses. METHODS We performed a cross-sectional study of specialist physicians who had completed 1 of 5 web-based CPD courses offered by the Federation of Medical Specialists of Quebec. The participants then completed CPD-Reaction, a questionnaire based on Godin's integrated model for health professional behavior change and with evidence of validity that measures behavioral intention (dependent variable) and psychosocial factors influencing intention (n=4). We also assessed variables related to sociodemographics (n=5), course content (n=9), and course format (eg, graphic features and duration) (n=8). Content variables were derived from CanMEDS competencies, Bloom's learning levels, and Godin's integrated model. We conducted ANOVA single-factor analysis, calculated the intraclass correlation coefficient (ICC), and performed bivariate and multivariate analyses. RESULTS A total of 400 physicians participated in the courses (range: 38-135 physicians per course). Average age was 50 (SD 12) years; 56% (n=223) were female, and 44% (n=177) were male. Among the 259 who completed CPD-Reaction, behavioral intention scores ranged from 5.37 (SD 1.17) to 6.60 (SD 0.88) out of 7 and differed significantly from one course to another (P<.001). The ICC indicated that 17% of the total variation in the outcome of interest, the behavioral intention of physicians, could be explained at the level of the CPD course (ICC=0.17). In bivariate analyses, social influences (P<.001), beliefs about capabilities (P<.001), moral norm (P<.001), beliefs about consequences (P<.001), and psychomotor learning (P=.04) were significantly correlated with physicians' intention to adopt new behaviors. Multivariate analysis showed the same factors, except for social influences and psychomotor learning, as significantly correlated with intention. CONCLUSIONS We observed average to high behavioral intention scores after all 5 web-based courses, with some variations by course taken. Factors affecting physicians' intention were beliefs about their capabilities and about the consequences of adopting new clinical behaviors, as well as doubts about whether the new behavior aligned with their moral values. Our results will inform design of future web-based CPD courses to ensure they contribute to clinical behavior change.
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Affiliation(s)
- Lysa Bergeron
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, QC, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Simon Décary
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Codjo Djignefa Djade
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, QC, Canada
| | - Sam J Daniel
- Direction du Développement Professionnel Continu, Fédération des Médecins Spécialistes du Québec, Montreal, QC, Canada
- Department of Pediatric Surgery, McGill University, Montreal, QC, Canada
| | - Martin Tremblay
- Direction du Développement Professionnel Continu, Fédération des Médecins Spécialistes du Québec, Montreal, QC, Canada
| | - Louis-Paul Rivest
- Department of Mathematics and Statistics, Faculty of Science and Engineering, Université Laval, Quebec, QC, Canada
| | - France Légaré
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, QC, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, QC, Canada
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Assessment of healthcare workers' behavior in implementing a newborn screening program for congenital hypothyroidism in Perak, Malaysia. JOURNAL OF HEALTH RESEARCH 2020. [DOI: 10.1108/jhr-08-2019-0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PurposeThe aim of this study is to assess healthcare workers' behavior on the congenital hypothyroidism screening program implementation based on a framework protocol and its associated factors.Design/methodology/approachA cross-sectional study was conducted using the multistage random sampling method in recruiting health clinic workers and purposive sampling techniques for hospital workers. The demographics, providers' characteristic, occupational profile, attitude, perceived behavior control (PBC), knowledge, behavioral intention and adherence to protocol were gathered using validated and reliable self-administered questionnaires.FindingsPartial intention to adhere to protocol was 25.7%. Weak attitude (adjusted odds ratio [AOR]: 5.48, 95% confidence interval [CI]: 3.32–9.06), low PBC score (AOR: 0.91, 95% CI: 0.86–0.95) and low knowledge score (AOR: 0.85, 95% CI: 0.75–0.96) were associated with partial intention to adhere to protocol. In the self-rated adherence assessment, 92.6% of participants from health clinics, 79.1% from pediatric and 61.1% from pathology were found not adhering to protocol. There was a significant association between intention and adherence to protocol.Research limitations/implicationsDocumentations and observations in assessing program implementation were limited to perform in the present study. Using self-rated instruments and focusing on healthcare workers alone did not provide a comprehensive assessment.Practical implicationsAvailability of a training module at site and regular refreshing course training should be made available to harness knowledge, attitude and behavioral perception in implementing the program activities.Originality/valueIntegrating the Logical Framework Approach in assessing program implementation and application of the Theory of Planned Behavior and Attitude, Subjective Norms, Self-Efficacy Model in this study were beneficial.
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Presseau J, McCleary N, Lorencatto F, Patey AM, Grimshaw JM, Francis JJ. Action, actor, context, target, time (AACTT): a framework for specifying behaviour. Implement Sci 2019; 14:102. [PMID: 31806037 PMCID: PMC6896730 DOI: 10.1186/s13012-019-0951-x] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/22/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Designing implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention's effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system. METHODS AND RESULTS We used French et al.'s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions. CONCLUSIONS Describing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions.
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Affiliation(s)
- Justin Presseau
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada. .,School of Psychology, University of Ottawa, Ottawa, Canada.
| | - Nicola McCleary
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | | | - Andrea M Patey
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Jill J Francis
- School of Health Sciences, City University of London, London, UK
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López-López D, García-Mira R, Palomo-López P, Sánchez-Gómez R, Ramos-Galván J, Tovaruela-Carrión N, García-Sánchez M. Attitude and knowledge about foot health: a spanish view. Rev Lat Am Enfermagem 2017; 25:e2855. [PMID: 28403336 PMCID: PMC5396484 DOI: 10.1590/1518-8345.1643.2855] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/15/2016] [Indexed: 12/02/2022] Open
Abstract
Objective: to explore attitudes towards patients' self-reported data about foot health-related beliefs from a behavioural and attitudinal perspective. Methods: a sample of 282 participants of a mean age of 39.46 ± 16.026 came to a health centre where self-reported demographic, clinical characteristics and beliefs relating to foot health data were registered, informants' completed all the stages of the research process. Results: the results of the analysis revealed an 8-factor factorial structure based on (1) podiatric behaviours, (2) the intention to carry out protective behaviour, (3) attitudinal beliefs, (4) normative beliefs, (5) needs, (6) apathy, (7) self-care, and (8) the general perception of foot health. They all explained 62.78% of the variance, and were considered as independent variables in a regression analysis to determine which provided the best explanations for the importance attributed to foot health. Conclusions: the participants in the study revealed a positive attitude in relation to foot health care and responsible behaviour.
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Affiliation(s)
- Daniel López-López
- PhD, Assistant Professor, Facultade de Enfarmaría e Podoloxía, Universidade da Coruña, Ferrol, Spain
| | - Ricardo García-Mira
- PhD, Full Professor, Facultad de Ciencias da Educación, Universidade da Coruña, A Coruña, Spain
| | - Patricia Palomo-López
- PhD, Assistant Professor, Centro Universitario de Plasencia, Universidad de Extermadura, Plasencia, Spain
| | - Rubén Sánchez-Gómez
- PhD, Assistant Professor, Facultad de Ciencias de la Salud, Universidad Europea de Madrid, Madrid, Spain
| | - José Ramos-Galván
- PhD, Full Professor, Facultad de Enfermería Fisioterapia y Podología, Universidad de Sevilla, Sevilla, Spain
| | - Natalia Tovaruela-Carrión
- PhD, Assistant Professor, Facultad de Enfermería Fisioterapia y Podología, Universidad de Sevilla, Sevilla, Spain
| | - Matilde García-Sánchez
- PhD, Full Professor, Facultade de Enfarmaría e Podoloxía, Universidade da Coruña, Ferrol, Spain
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Mc Goldrick EL, Crawford T, Brown JA, Groom KM, Crowther CA. Identifying the barriers and enablers in the implementation of the New Zealand and Australian Antenatal Corticosteroid Clinical Practice Guidelines. BMC Health Serv Res 2016; 16:617. [PMID: 27793150 PMCID: PMC5084422 DOI: 10.1186/s12913-016-1858-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 10/18/2016] [Indexed: 01/22/2023] Open
Abstract
Background The ineffective implementation of evidence based practice guidelines can mean that the best health outcomes are not achieved. This study examined the barriers and enablers to the uptake and implementation of the new bi-national (Australia and New Zealand) antenatal corticosteroid clinical practice guidelines among health professionals, using the Theoretical Domains Framework. Methods Semi-structured interviews or online questionnaires were conducted across four health professional groups and three district health boards in Auckland, New Zealand. The questions were constructed to reflect the 14 behavioural domains from the Theoretical Domains Framework. Relevant domains were identified by the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour using thematic analysis. The influence of health professional group and organisation on the different barriers and enablers identified were explored. Results Seventy-three health professionals completed either a semi-structured interview (n = 35) or on-line questionnaire (n = 38). Seven behavioural domains were identified as overarching enablers: belief about consequences; knowledge; social influences; environmental context and resource; belief about capabilities; social professional role and identity; and behavioural regulation. Five behavioural domains were identified as overarching barriers: environmental context and resources; knowledge; social influences; belief about consequences; and social professional role and identity. Differences in beliefs between individual health professional groups were identified within the domains: belief about consequences; social professional role and identity; and emotion. Organisational differences were identified within the domains: belief about consequences; social influences; and belief about capabilities. Conclusion This study has identified some of the enablers and barriers to implementation of the New Zealand and Australian Antenatal Corticosteroid Clinical Practice Guidelines using the validated Theoretical Domains Framework, as perceived by health professionals. We have identified differences between individual health professional groups and organisations. The identification of these behavioural determinants can be used to enhance an implementation strategy, assist in the design of interventions to achieve improved implementation and facilitate process evaluations to understand why or how change interventions are effective. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1858-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E L Mc Goldrick
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - T Crawford
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - J A Brown
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - K M Groom
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand.,National Womens Health, 2 Park Road, Auckland, 1023, New Zealand
| | - C A Crowther
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand. .,The Liggins Institute, The University of Auckland, Building 503, Level 2, 85 Park Road, Auckland Private Bag 92019, Auckland, 1142, New Zealand.
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Presseau J, Grimshaw JM, Tetroe JM, Eccles MP, Francis JJ, Godin G, Graham ID, Hux JE, Johnston M, Légaré F, Lemyre L, Robinson N, Zwarenstein M. A theory-based process evaluation alongside a randomised controlled trial of printed educational messages to increase primary care physicians' prescription of thiazide diuretics for hypertension [ISRCTN72772651]. Implement Sci 2016; 11:121. [PMID: 27619339 PMCID: PMC5020459 DOI: 10.1186/s13012-016-0485-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 08/26/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pragmatic trials of implementation interventions focus on evaluating whether an intervention changes professional behaviour under real-world conditions rather than investigating the mechanism through which change occurs. Theory-based process evaluations conducted alongside pragmatic randomised trials address this by assessing whether the intervention changes theoretical constructs proposed to mediate change. The Ontario Printed Educational Materials (PEM) cluster trial was designed to increase family physicians' guideline-recommended prescription of thiazide diuretics. The trial found no intervention effect. Using the theory of planned behaviour (TPB), we hypothesised that changes in thiazide prescribing would be reflected in changes in intention, consistent with changes in attitude and subjective norm, with no change to their perceived behavioural control (PBC), and tested this alongside the RCT. METHODS We developed and sent TPB postal questionnaires to a random sub-sample of family physicians in each trial arm 2 months before and 6 months after dissemination of the PEMs. We used analysis of covariance to test for group differences using a 2 × 3 factorial design. We content-analysed an open-ended question about perceived barriers to thiazide prescription. Using control group data, we tested whether baseline measures of TPB constructs predicted self-reported thiazide prescribing at follow-up. RESULTS Four hundred twenty-six physicians completed pre- and post-intervention questionnaires. Baseline scores on measures of TPB constructs were high: intention mean = 5.9 out of 7 (SD = 1.4), attitude mean = 5.8 (SD = 1.1), subjective norm mean = 5.8 (SD = 1.1) and PBC mean = 6.2 (SD = 1.0). The arms did not significantly differ post-intervention on any of the theory-based constructs, suggesting a possible ceiling effect. Content analysis of perceived barriers suggested post-intentional barriers to prescribing thiazides most often focused on specific patient clinical characteristics and potential side effects. Baseline intention (β = 0.63, p < 0.01) but not PBC (β = 0.04, p = 0.78) predicted 42.6 % of the variance in self-reported behaviour at follow-up in the control group. CONCLUSIONS Congruent with the Ontario Printed Educational Messages trial results and aligned with the TPB, we saw no impact of the intervention on any TPB constructs. The theoretical basis of this evaluation suggests possible explanations for the failure of the PEM intervention to change professional behaviour, which can directly inform the design and content of future theory-based PEM interventions to change professional behaviour. TRIAL REGISTRATION ISRCTN, Canada ISRCTN72772651.
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Affiliation(s)
- Justin Presseau
- Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201B, Ottawa, Ontario K1H 8L6 Canada
- School of Epidemiology, Public Health and Preventive Medicine, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada
| | - Jeremy M. Grimshaw
- Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201B, Ottawa, Ontario K1H 8L6 Canada
- Department of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, Ontario K1H 8M5 Canada
| | | | - Martin P. Eccles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle Upon Tyne, NE2 4AX England
| | - Jill J. Francis
- School of Health Sciences, City University London, Northampton Square, London, EC1V 0HB UK
| | - Gaston Godin
- Faculty of Nursing, Laval University, Pavillon Ferdinand-Vandry, 1050 Avenue de la Medicine, Room 1445, Quebec City, Quebec G1V 0A6 Canada
| | - Ian D. Graham
- Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201B, Ottawa, Ontario K1H 8L6 Canada
- School of Epidemiology, Public Health and Preventive Medicine, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Rd, Ottawa, Ontario K1H 8M5 Canada
| | - Janet E. Hux
- Canadian Diabetes Association, 522 University Ave, Toronto, ON M5G 2A2 Canada
| | - Marie Johnston
- Institute of Applied Health Sciences, College of Life Sciences and Medicine, 2nd floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec G1K 7P4 Canada
| | - Louise Lemyre
- School of Psychology, University of Ottawa, 120 University, Social Sciences Building FSS-5052, Ottawa, Ontario K1N 6N5 Canada
| | - Nicole Robinson
- Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201B, Ottawa, Ontario K1H 8L6 Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, London, Ontario N6A 3K7 Canada
- Institute for Clinical Evaluative Sciences, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
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Abstract
BACKGROUND Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers. DISCUSSION Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks). This article proposes five categories of theoretical approaches to achieve three overarching aims. These categories are not always recognized as separate types of approaches in the literature. While there is overlap between some of the theories, models and frameworks, awareness of the differences is important to facilitate the selection of relevant approaches. Most determinant frameworks provide limited "how-to" support for carrying out implementation endeavours since the determinants usually are too generic to provide sufficient detail for guiding an implementation process. And while the relevance of addressing barriers and enablers to translating research into practice is mentioned in many process models, these models do not identify or systematically structure specific determinants associated with implementation success. Furthermore, process models recognize a temporal sequence of implementation endeavours, whereas determinant frameworks do not explicitly take a process perspective of implementation.
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Affiliation(s)
- Per Nilsen
- Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
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Theory-based predictors of multiple clinician behaviors in the management of diabetes. J Behav Med 2013; 37:607-20. [PMID: 23670643 DOI: 10.1007/s10865-013-9513-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 04/16/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Behavioral theory is often tested on one behavior in isolation from other behaviors and theories. We aimed to test the predictive validity of constructs from motivation and action theories of behavior across six diabetes-related clinician behaviors, within the same sample of primary care clinicians. Physicians and nurses (n = 427 from 99 practices in the United Kingdom) completed questionnaires at baseline and 12 months. PRIMARY OUTCOMES six self-reported clinician behaviors related to advising, prescribing and examining measured at 12 months; secondary outcomes: baseline intention and patient-scenario-based simulated behavior. Across six behaviors, each theory accounted for a medium amount of variance for 12-month behavior (median R adj (2) = 0.15), large and medium amount of variance for two intention measures (median R adj (2) = 0.66; 0.34), and small amount of variance for simulated behavior (median R adj (2) = 0.05). Intention/proximal goals, self-efficacy, and habit predicted all behaviors. Constructs from social cognitive theory (self-efficacy), learning theory (habit) and action and coping planning consistently predicted multiple clinician behaviors and should be targeted by quality improvement interventions.
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Chaudoir SR, Dugan AG, Barr CHI. Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures. Implement Sci 2013; 8:22. [PMID: 23414420 PMCID: PMC3598720 DOI: 10.1186/1748-5908-8-22] [Citation(s) in RCA: 484] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 02/01/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Two of the current methodological barriers to implementation science efforts are the lack of agreement regarding constructs hypothesized to affect implementation success and identifiable measures of these constructs. In order to address these gaps, the main goals of this paper were to identify a multi-level framework that captures the predominant factors that impact implementation outcomes, conduct a systematic review of available measures assessing constructs subsumed within these primary factors, and determine the criterion validity of these measures in the search articles. METHOD We conducted a systematic literature review to identify articles reporting the use or development of measures designed to assess constructs that predict the implementation of evidence-based health innovations. Articles published through 12 August 2012 were identified through MEDLINE, CINAHL, PsycINFO and the journal Implementation Science. We then utilized a modified five-factor framework in order to code whether each measure contained items that assess constructs representing structural, organizational, provider, patient, and innovation level factors. Further, we coded the criterion validity of each measure within the search articles obtained. RESULTS Our review identified 62 measures. Results indicate that organization, provider, and innovation-level constructs have the greatest number of measures available for use, whereas structural and patient-level constructs have the least. Additionally, relatively few measures demonstrated criterion validity, or reliable association with an implementation outcome (e.g., fidelity). DISCUSSION In light of these findings, our discussion centers on strategies that researchers can utilize in order to identify, adapt, and improve extant measures for use in their own implementation research. In total, our literature review and resulting measures compendium increases the capacity of researchers to conceptualize and measure implementation-related constructs in their ongoing and future research.
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Affiliation(s)
- Stephenie R Chaudoir
- Department of Psychology, College of the Holy Cross, 1 College St., Worcester, MA, 01610, USA
- Center for Health, Intervention, and Prevention, University of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT, 06269, USA
| | - Alicia G Dugan
- Connecticut Institute for Clinical and Translational Science, University of Connecticut, Dowling South, Suite 1030, UConn Health Center, 263 Farmington Ave, MC 6233, Farmington, CT, 06030-6233, USA
- Center for Health, Intervention, and Prevention, University of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT, 06269, USA
| | - Colin HI Barr
- Center for Health, Intervention, and Prevention, University of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT, 06269, USA
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Brennan SE, Bosch M, Buchan H, Green SE. Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implement Sci 2012; 7:121. [PMID: 23241168 PMCID: PMC3573896 DOI: 10.1186/1748-5908-7-121] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 11/05/2012] [Indexed: 12/19/2022] Open
Abstract
Background Continuous quality improvement (CQI) methods are widely used in healthcare; however, the effectiveness of the methods is variable, and evidence about the extent to which contextual and other factors modify effects is limited. Investigating the relationship between these factors and CQI outcomes poses challenges for those evaluating CQI, among the most complex of which relate to the measurement of modifying factors. We aimed to provide guidance to support the selection of measurement instruments by systematically collating, categorising, and reviewing quantitative self-report instruments. Methods Data sources: We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments, reference lists of systematic reviews, and citations and references of the main report of instruments. Study selection: The scope of the review was determined by a conceptual framework developed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). Papers reporting development or use of an instrument measuring a construct encompassed by the framework were included. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarising and comparing instruments. Instrument content was categorised using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care. Results We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited. Conclusions Many instruments are available for evaluating CQI, but most require further use and testing to establish their measurement properties. Further development and use of these measures in evaluations should increase the contribution made by individual studies to our understanding of CQI and enhance our ability to synthesise evidence for informing policy and practice.
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Affiliation(s)
- Sue E Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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Hanbury A, Farley K, Thompson C, Wilson P, Chambers D. Challenges in identifying barriers to adoption in a theory-based implementation study: lessons for future implementation studies. BMC Health Serv Res 2012; 12:422. [PMID: 23174000 PMCID: PMC3537535 DOI: 10.1186/1472-6963-12-422] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 11/21/2012] [Indexed: 11/16/2022] Open
Abstract
Background Exploring barriers to the uptake of research based recommendations into practice is an important part of the development of implementation programmes. Techniques to identify barriers can include use of theory-informed questionnaires and qualitative interviews. Conceptualising and measuring theory-informed factors, and engaging health professionals’ to uncover all potential barriers, can be a difficult task. This paper presents a case study of the process of trying to identify, systematically, the key factors influencing health professionals’ referrals for women diagnosed with mild to moderate postnatal depression for psychological treatment. The paper illustrates how the factors were conceptualised and measured and explores the real world challenges experienced, with implications for future implementation studies. Methods Theory-informed factors were conceptualised and measured using a questionnaire and interviews. The questionnaire was piloted, before being administered to general practitioners, practice nurses and health visitors working in general practices in one area of the UK NHS. The interviews were conducted with a small sample of general practitioners who had not completed the questionnaire, further exploring factors influencing their referral decisions in the local context. Results The response rate to the questionnaire was low (19%), despite selecting the recommendation to target through engagement with local stakeholders and surveying local health professionals, and despite using two reminders, an incentive prize, and phone calls to practice managers to bolster response rates. Conclusions Two significant challenges to achieving higher response rates and successfully exploring local context were identified: the difficulties of developing a robust- but feasible- questionnaire to explore theory-informed factors, and targeting recommendations that are important to policy makers, but which health professionals view as unimportant. This case study highlights the “trade-off” between scientifically rigorous collection of data against the pragmatism and flexibility requirements of “real world” implementation. Future implementation studies should explore different ways of identifying factors influencing the adoption of recommendations to bridge this gulf.
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Affiliation(s)
- Andria Hanbury
- Alcuin C, Department of Health Sciences, University of York, York, England, YO10 5DD, UK.
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Eccles MP, Hrisos S, Francis JJ, Stamp E, Johnston M, Hawthorne G, Steen N, Grimshaw JM, Elovainio M, Presseau J, Hunter M. Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study. Implement Sci 2011; 6:61. [PMID: 21658211 PMCID: PMC3130687 DOI: 10.1186/1748-5908-6-61] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 06/09/2011] [Indexed: 11/18/2022] Open
Abstract
Background Type 2 diabetes is an increasingly prevalent chronic illness and an important cause of avoidable mortality. Patients are managed by the integrated activities of clinical and non-clinical members of primary care teams. This study aimed to: investigate theoretically-based organisational, team, and individual factors determining the multiple behaviours needed to manage diabetes; and identify multilevel determinants of different diabetes management behaviours and potential interventions to improve them. This paper describes the instrument development, study recruitment, characteristics of the study participating practices and their constituent healthcare professionals and administrative staff and reports descriptive analyses of the data collected. Methods The study was a predictive study over a 12-month period. Practices (N = 99) were recruited from within the UK Medical Research Council General Practice Research Framework. We identified six behaviours chosen to cover a range of clinical activities (prescribing, non-prescribing), reflect decisions that were not necessarily straightforward (controlling blood pressure that was above target despite other drug treatment), and reflect recommended best practice as described by national guidelines. Practice attributes and a wide range of individually reported measures were assessed at baseline; measures of clinical outcome were collected over the ensuing 12 months, and a number of proxy measures of behaviour were collected at baseline and at 12 months. Data were collected by telephone interview, postal questionnaire (organisational and clinical) to practice staff, postal questionnaire to patients, and by computer data extraction query. Results All 99 practices completed a telephone interview and responded to baseline questionnaires. The organisational questionnaire was completed by 931/1236 (75.3%) administrative staff, 423/529 (80.0%) primary care doctors, and 255/314 (81.2%) nurses. Clinical questionnaires were completed by 326/361 (90.3%) primary care doctors and 163/186 (87.6%) nurses. At a practice level, we achieved response rates of 100% from clinicians in 40 practices and > 80% from clinicians in 67 practices. All measures had satisfactory internal consistency (alpha coefficient range from 0.61 to 0.97; Pearson correlation coefficient (two item measures) 0.32 to 0.81); scores were generally consistent with good practice. Measures of behaviour showed relatively high rates of performance of the six behaviours, but with considerable variability within and across the behaviours and measures. Discussion We have assembled an unparalleled data set from clinicians reporting on their cognitions in relation to the performance of six clinical behaviours involved in the management of people with one chronic disease (diabetes mellitus), using a range of organisational and individual level measures as well as information on the structure of the practice teams and across a large number of UK primary care practices. We would welcome approaches from other researchers to collaborate on the analysis of this data.
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Affiliation(s)
- Martin P Eccles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
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Hanbury A, Thompson C, Mannion R. Statistical synthesis of contextual knowledge to increase the effectiveness of theory-based behaviour change interventions. J Health Serv Res Policy 2011; 16:167-71. [PMID: 21543383 DOI: 10.1258/jhsrp.2010.010091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Tailored implementation strategies targeting health professionals' adoption of evidence-based recommendations are currently being developed. Research has focused on how to select an appropriate theoretical base, how to use that theoretical base to explore the local context, and how to translate theoretical constructs associated with the key factors found to influence innovation adoption into feasible and tailored implementation strategies. The reasons why an intervention is thought not to have worked are often cited as being: inappropriate choice of theoretical base; unsystematic development of the implementation strategies; and a poor evidence base to guide the process. One area of implementation research that is commonly overlooked is how to synthesize the data collected in a local context in order to identify what factors to target with the implementation strategies. This is suggested to be a critical process in the development of a theory-based intervention. The potential of multilevel modelling techniques to synthesize data collected at different hierarchical levels, for example, individual attitudes and team level variables, is discussed. Future research is needed to explore further the potential of multilevel modelling for synthesizing contextual data in implementation studies, as well as techniques for synthesizing qualitative and quantitative data.
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Affiliation(s)
- Andria Hanbury
- Department of Health Sciences, University of York, York, UK.
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Estabrooks CA, Morgan DG, Squires JE, Boström AM, Slaughter SE, Cummings GG, Norton PG. The care unit in nursing home research: evidence in support of a definition. BMC Med Res Methodol 2011; 11:46. [PMID: 21492456 PMCID: PMC3098823 DOI: 10.1186/1471-2288-11-46] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 04/14/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Defining what constitutes a resident care unit in nursing home research is both a conceptual and practical challenge. The aim of this paper is to provide evidence in support of a definition of care unit in nursing homes by demonstrating: (1) its feasibility for use in data collection, (2) the acceptability of aggregating individual responses to the unit level, and (3) the benefit of including unit level data in explanatory models. METHODS An observational study design was used. Research (project) managers, healthcare aides, care managers, nursing home administrators and directors of care from thirty-six nursing homes in the Canadian prairie provinces of Alberta, Saskatchewan and Manitoba provided data for the study. A definition of care unit was developed and applied in data collection and analyses. A debriefing session was held with research managers to investigate their experiences with using the care unit definition. In addition, survey responses from 1258 healthcare aides in 25 of the 36 nursing homes in the study, that had more than one care unit, were analyzed using a multi-level modeling approach. Trained field workers administered the Alberta Context Tool (ACT), a 58-item self-report survey reflecting 10 organizational context concepts, to healthcare aides using computer assisted personal interviews. To assess the appropriateness of obtaining unit level scores, we assessed aggregation statistics (ICC(1), ICC(2), η², and ω²), and to assess the value of using the definition of unit in explanatory models, we performed multi-level modeling. RESULTS In 10 of the 36 nursing homes, the care unit definition developed was used to align the survey data (for analytic purposes) to specific care units as designated by our definition, from that reported by the facility administrator. The aggregation statistics supported aggregating the healthcare aide responses on the ACT to the realigned unit level. Findings from the multi-level modeling further supported unit level aggregation. A significantly higher percentage of variance was explained in the ACT concepts at the unit level compared to the individual and/or nursing home levels. CONCLUSIONS The statistical results support the use of our definition of care unit in nursing home research in the Canadian prairie provinces. Beyond research convenience however, the results also support the resident unit as an important Clinical Microsystem to which future interventions designed to improve resident quality of care and staff (healthcare aide) worklife should be targeted.
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Affiliation(s)
| | - Debra G Morgan
- Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Janet E Squires
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Anne-Marie Boström
- Department of Neurobiology, Care Sciences and Science, Division of Nursing, Karolinska Institute, Stockholm, Sweden
| | | | | | - Peter G Norton
- Department of Family Medicine, University of Calgary, Calgary, Canada
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Ramsay CR, Thomas RE, Croal BL, Grimshaw JM, Eccles MP. Using the theory of planned behaviour as a process evaluation tool in randomised trials of knowledge translation strategies: A case study from UK primary care. Implement Sci 2010; 5:71. [PMID: 20920277 PMCID: PMC2959079 DOI: 10.1186/1748-5908-5-71] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Accepted: 09/29/2010] [Indexed: 11/10/2022] Open
Abstract
Background Randomised trials of knowledge translation strategies for professional behaviour change can provide robust estimates of effectiveness, but offer little insight into the causal mechanisms by which any change is produced. To illustrate the applicability of causal methods within randomised trials, we undertook a theory-based process evaluation study within an implementation trial to explore whether the cognitions of primary care doctors' predicted their test requesting behaviours and, secondly, whether the trial results were mediated by the theoretical constructs. Methods The process evaluation comprised a cross-sectional questionnaire survey of a random 50% sample of the randomised groups of primary care practices in Grampian (NHS Grampian), UK, who took part in a trial of the effect of enhanced feedback and brief educational reminders on test requesting behaviour. The process evaluation was based upon the Theory of Planned Behaviour and focussed on three of the test requesting behaviours that were targeted in the trial -- ferritin, follicle stimulating hormone (FSH), and Helicobacter Pylori serology (HPS). Results The questionnaire was completed by 131 primary care doctors (56%) from 42 (98%) of the sampled practices. Behavioural intention, attitude, and subjective norm were highly correlated for all the tests. There was no evidence that perceived behavioural control was correlated with any of the other measures. Simple linear regression analysis of the rate of test requests on minimum behavioural intentions had R2 of 11.1%, 12.5%, and 0.1% for ferritin, FSH, and HPS requesting, respectively. Mediational analysis showed that the trial results for ferritin and FSH were partially mediated (between 23% and 78% mediation) through intentions. The HPS trial result was not mediated through intention. Conclusions This study demonstrated that a theory-based process evaluation can provide useful information on causal mechanisms that aid not only interpretation of the trial but also inform future evaluations and intervention development.
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Affiliation(s)
- Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
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Kortteisto T, Kaila M, Komulainen J, Mäntyranta T, Rissanen P. Healthcare professionals' intentions to use clinical guidelines: a survey using the theory of planned behaviour. Implement Sci 2010; 5:51. [PMID: 20587021 PMCID: PMC2902417 DOI: 10.1186/1748-5908-5-51] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 06/29/2010] [Indexed: 01/13/2023] Open
Abstract
Background Finnish clinical guidelines are evolving toward integration of knowledge modules into the electronic health record in the Evidence-Based Medicine electronic Decision Support project. It therefore became important to study which factors affect professionals' intention to use clinical guidelines generally in their decision-making on patient care. A theory-based approach is a possible solution to explore determinants of professionals' behaviour. The study's aim was to produce baseline information for developers and implementers by using the theory of planned behaviour. Methods A cross-sectional internet-based survey was carried out in Finnish healthcare organisations within three hospital districts. The target population (n = 2,252) included physicians, nurses, and other professionals, of whom 806 participated. Indicators of the intention to use clinical guidelines were observed by using a theory-based questionnaire. The main data analysis was done by means of multiple linear regressions. Results The results indicated that all theory-based variables--the attitude toward the behaviour, the subjective norm, and the perceived behaviour control--were important factors associated with the professionals' intention to use clinical practice guidelines for their area of specialisation in the decisions they would make on the care of patients in the next three months. In addition, both the nurse and the physician factors had positive (p < 0.01) effects on this intention in comparison to other professionals. In the similar models for all professions, the strongest factor for the physicians was the perceived behaviour control, while the key factor for the nurses and the other professionals was the subjective norm. This means that context- and guideline-based factors either facilitate or hinder the intention to use clinical guidelines among physicians and, correspondingly, normative beliefs related to social pressures do so for nurses and other healthcare professionals. Conclusions The results confirm suggestions that the theory of planned behaviour is a suitable theoretical basis for implementing clinical guidelines in healthcare practices. Our new finding was that, in general, profession had an effect on intention to use clinical guidelines in patient care. Therefore, the study reaffirms the general contention that different strategies need to be in place when clinical guidelines are targeted at different professional groups.
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Affiliation(s)
- Tiina Kortteisto
- Tampere School of Public Health, University of Tampere, Medisiinarinkatu 3, Tampere, Finland.
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