Andrea M. Patey

Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests

BackgroundRoutine pre-operative tests for anesthesia management are often ordered by both anesthesiologists and surgeons for healthy patients undergoing low-risk surgery. The Theoretical Domains Framework (TDF) was developed to investigate determinants of behaviour and identify potential behaviour change interventions. In this study, the TDF is used to explore anaesthesiologists’ and surgeons’ perceptions of ordering routine tests for healthy patients undergoing low-risk surgery.MethodsSixteen clinicians (eleven anesthesiologists and five surgeons) throughout Ontario were recruited. An interview guide based on the TDF was developed to identify beliefs about pre-operative testing practices. Content analysis of physicians’ statements into the relevant theoretical domains was performed. Specific beliefs were identified by grouping similar utterances of the interview participants. Relevant domains were identified by noting the frequencies of the beliefs reported, presence of conflicting beliefs, and perceived influence on the performance of the behaviour under investigation.ResultsSeven of the twelve domains were identified as likely relevant to changing clinicians’ behaviour about pre-operative test ordering for anesthesia management. Key beliefs were identified within these domains including: conflicting comments about who was responsible for the test-ordering (Social/professional role and identity); inability to cancel tests ordered by fellow physicians (Beliefs about capabilities and social influences); and the problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources). Often, tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery while surgeons ordered tests they thought anesthesiologists may need (Social influences). There were also conflicting comments about the potential consequences associated with reducing testing, from negative (delay or cancel patients’ surgeries), to indifference (little or no change in patient outcomes), to positive (save money, avoid unnecessary investigations) (Beliefs about consequences). Further, while most agreed that they are motivated to reduce ordering unnecessary tests (Motivation and goals), there was still a report of a gap between their motivation and practice (Behavioural regulation).ConclusionWe identified key factors that anesthesiologists and surgeons believe influence whether they order pre-operative tests routinely for anesthesia management for a healthy adults undergoing low-risk surgery. These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering.

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework

BackgroundThe Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays.MethodsSix focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF.ResultsFive domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge).ConclusionsChiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.

A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems

BackgroundImplementing new practices requires changes in the behaviour of relevant actors, and this is facilitated by understanding of the determinants of current and desired behaviours. The Theoretical Domains Framework (TDF) was developed by a collaboration of behavioural scientists and implementation researchers who identified theories relevant to implementation and grouped constructs from these theories into domains. The collaboration aimed to provide a comprehensive, theory-informed approach to identify determinants of behaviour. The first version was published in 2005, and a subsequent version following a validation exercise was published in 2012. This guide offers practical guidance for those who wish to apply the TDF to assess implementation problems and support intervention design. It presents a brief rationale for using a theoretical approach to investigate and address implementation problems, summarises the TDF and its development, and describes how to apply the TDF to achieve implementation objectives. Examples from the implementation research literature are presented to illustrate relevant methods and practical considerations.MethodsResearchers from Canada, the UK and Australia attended a 3-day meeting in December 2012 to build an international collaboration among researchers and decision-makers interested in the advancing use of the TDF. The participants were experienced in using the TDF to assess implementation problems, design interventions, and/or understand change processes. This guide is an output of the meeting and also draws on the authors’ collective experience. Examples from the implementation research literature judged by authors to be representative of specific applications of the TDF are included in this guide.ResultsWe explain and illustrate methods, with a focus on qualitative approaches, for selecting and specifying target behaviours key to implementation, selecting the study design, deciding the sampling strategy, developing study materials, collecting and analysing data, and reporting findings of TDF-based studies. Areas for development include methods for triangulating data, e.g. from interviews, questionnaires and observation and methods for designing interventions based on TDF-based problem analysis.ConclusionsWe offer this guide to the implementation community to assist in the application of the TDF to achieve implementation objectives. Benefits of using the TDF include the provision of a theoretical basis for implementation studies, good coverage of potential reasons for slow diffusion of evidence into practice and a method for progressing from theory-based investigation to intervention.

Understanding the Canadian adult CT head rule trial: use of the theoretical domains framework for process evaluation

BackgroundThe Canadian CT Head Rule was prospectively derived and validated to assist clinicians with diagnostic decision-making regarding the use of computed tomography (CT) in adult patients with minor head injury. A recent intervention trial failed to demonstrate a decrease in the rate of head CTs following implementation of the rule in Canadian emergency departments. Yet, the same intervention, which included a one-hour educational session and reminders at the point of requisition, was successful in reducing cervical spine imaging rates in the same emergency departments. The reason for the varied effect of the intervention across these two behaviours is unclear. There is an increasing appreciation for the use of theory to conduct process evaluations to better understand how strategies are linked with outcomes in implementation trials. The Theoretical Domains Framework (TDF) has been used to explore health professional behaviour and to design behaviour change interventions but, to date, has not been used to guide a theory-based process evaluation. In this proof of concept study, we explored whether the TDF could be used to guide a retrospective process evaluation to better understand emergency physicians’ responses to the interventions employed in the Canadian CT Head Rule trial.MethodsA semi-structured interview guide, based on the 12 domains from the TDF, was used to conduct telephone interviews with project leads and physician participants from the intervention sites in the Canadian CT Head Rule trial. Two reviewers independently coded the anonymised interview transcripts using the TDF as a coding 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.ResultsEight physicians from four of the intervention sites in the Canadian CT Head Rule trial participated in the interviews. Barriers likely to assist with understanding physicians’ responses to the intervention in the trial were identified in six of the theoretical domains: beliefs about consequences; beliefs about capabilities; behavioural regulation; memory, attention and decision processes; environmental context and resources; and social influences. Despite knowledge that the Canadian CT Head Rule was highly sensitive and reliable for identifying clinically important brain injuries and strong beliefs about the benefits for using the rule, a number of barriers were identified that may have prevented physicians from consistently applying the rule.ConclusionThis proof of concept study demonstrates the use of the TDF as a guiding framework to design a retrospective theory-based process evaluation. There is a need for further development and testing of methods for using the TDF to guide theory-based process evaluations running alongside behaviour change intervention trials.

IL-7-dependent STAT-5 activation and CD8+ T cell proliferation are impaired in HIV infection

This study tests the hypothesis that IL‐7 signaling and activity of CD8+ T cells are impaired in HIV infection. IL‐7 is necessary for optimal CTL activity and T cell survival and proliferation. Defects in IL‐7R signaling may contribute to impaired activity of IL‐7 observed in progressive HIV disease. A decreased proportion of CD8+ T cells expressing the IL‐7Rα chain (CD127) in progressive HIV disease would be expected to affect IL‐7 activity. Alternatively, disease‐associated defects of remaining CD8+CD127+ T cells may influence IL‐7 responsiveness. Therefore, the IL‐7 responsiveness of CD8+CD127+ T cells from HIV– and untreated or treated HIV+ individuals was investigated. Blood was collected from HIV– and untreated or effectively treated HIV+ (<50 viral copies/ml for >1 year) individuals, and CD8+CD127+ T cells were isolated and cultured with IL‐7. Indicators of IL‐7 signaling (P‐STAT5) and activity (Bcl‐2 and proliferation) were evaluated by flow cytometry. Isolated CD8+CD127+ T cells from untreated HIV+ individuals expressed significantly less P‐STAT5 in response to IL‐7 compared with CD8+CD127+ T cells from HIV– individuals. In effectively treated HIV+ individuals, CD8+CD127+ T cells also expressed significantly lower levels of P‐STAT5 compared with HIV– individuals. IL‐7‐dependent proliferation of CD8+CD127+ T cells from untreated HIV+ individuals was similarly impaired. In contrast, IL‐7‐induced Bcl‐2 expression was not impaired in CD8+CD127+ T cells from HIV+ individuals. These data demonstrate that IL‐7/IL‐7R dysfunction in HIV infection may contribute to IL‐7‐specific signaling defects. Decreased, IL‐7‐dependent activation of STAT5 and impaired proliferation may negatively impact the maintenance of CD8+ T cell responsiveness in HIV infection.

Intermittent auscultation versus continuous fetal monitoring: exploring factors that influence birthing unit nurses’ fetal surveillance practice using theoretical domains framework

BackgroundIntermittent Auscultation (IA) is the recommended method of fetal surveillance for healthy women in labour. However, the majority of women receive continuous electronic monitoring. We used the Theoretical Domains Framework (TDF) to explore the views of Birthing Unit nurses about using IA as their primary method of fetal surveillance for healthy women in labour.MethodsUsing a semi-structured interview guide, we interviewed a convenience sample of birthing unit nurses throughout Ontario, Canada to elicit their views about fetal surveillance. Interviews were recorded and transcribed verbatim. Transcripts were content analysed using the TDF and themes were framed as belief statements. Domains potentially key to changing fetal surveillance behaviour and informing intervention design were identified by noting the frequencies of beliefs, content, and their reported influence on the use of IA.ResultsWe interviewed 12 birthing unit nurses. Seven of the 12 TDF domains were perceived to be key to changing birthing unit nurses’ behaviour The nurses reported that competing tasks, time constraints and the necessity to multitask often limit their ability to perform IA (domains Beliefs about capabilities; Environmental context and resources). Some nurses noted the decision to use IA was something that they consciously thought about with every patient while others stated it their default decision as long as there were no risk factors (Memory, attention and decision processes, Nature of behaviour). They identified positive consequences (e.g. avoid unnecessary interventions, mother-centered care) and negative consequences of using IA (e.g. legal concerns) and reported that the negative consequences can often outweigh positive consequences (Beliefs about consequences). Some reported that hospital policies and varying support from care teams inhibited their use of IA (Social influences), and that support from the entire team and hospital management would likely increase their use (Social influences; Behavioural regulation).ConclusionWe identified potential influences on birthing unit nurses’ use of IA as their primary method of fetal surveillance. These beliefs suggest potential targets for behaviour change interventions to promote IA use.

047 Identifying Factors Predictive of Managing Patients with Low Back Pain without Using X-Rays Among North American Chiropractors: Applying Psychological Theories to Evidence-Based Clinical Practice

Background This study aimed to identify theoretically based modifiable factors that predict whether chiropractors manage patients with low back pain without ordering lumbar x-rays. Methods A mailed survey with psychological measures was collected from a random sample of Ontario (Canada) and Practice Network (US) chiropractors. The outcome measures were behavioural intention and behavioural simulation (scenario decision-making). Explanatory variables included constructs from motivational theories (Theory of Planned Behaviour (TPB), Theory of Interpersonal Behaviour (TIB)), action theories (Operant Learning Theory (OLT) and Planning (action and coping)), and two other constructs: personal moral norm and habit as measured by the Self-Reported Habit Index (SRHI). Multiple regression analyses examined the predictive value of each theoretical model individually for simulation and intention outcomes. Results 31% of North American chiropractors returned completed questionnaires. Overall, TPB and TIB, followed by personal moral norms and OLT best explained behavioural simulation. Theory level variance explained among Ontario and US chiropractors was respectively: TPB 59%; 52.0%, TIB 57%; 54.0%, personal moral norm 49%; 46.0%, OLT 49%; 52.0%, action planning 28%; 29%, and SRHI 42%; 48%. Constructs from TPB and TIB best explained behavioural intention. Theory level variance explained was respectively: TPB 85%; 74%, TIB; 83%; 81%, OLT 62%; 69%, and SRHI 59% and 52% for SRHI. Conclusion These models explained up to 59% of the variation in behavioural simulation and up to 85% in intention to manage back pain patients without x-rays. Results may inform development of theory-based behaviour change interventions to implement imaging guideline recommendations among North American chiropractors. These models explained up to 59% of the variation in behavioural simulation and up to 85% in intention to manage back pain patients without x-rays. Results may inform development of theory-based behaviour change interventions to implement imaging guideline recommendations among North American chiropractors.