Gillian Hawthorne

Reflective and Automatic Processes in Health Care Professional Behaviour: a Dual Process Model Tested Across Multiple Behaviours

BackgroundClinicians’ behaviours require deliberate decision-making in complex contexts and may involve both impulsive (automatic) and reflective (motivational and volitional) processes.PurposeThe purpose of this study was to test a dual process model applied to clinician behaviours in their management of type 2 diabetes.MethodsThe design used six nested prospective correlational studies. Questionnaires were sent to general practitioners and nurses in 99 UK primary care practices, measuring reflective (intention, action planning and coping planning) and impulsive (automaticity) predictors for six guideline-recommended behaviours: blood pressure prescribing (N = 335), prescribing for glycemic control (N = 288), providing diabetes-related education (N = 346), providing weight advice (N = 417), providing self-management advice (N = 332) and examining the feet (N = 218).ResultsRespondent retention was high. A dual process model was supported for prescribing behaviours, weight advice, and examining the feet. A sequential reflective process was supported for blood pressure prescribing, self-management and weight advice, and diabetes-related education.ConclusionsReflective and impulsive processes predict behaviour. Quality improvement interventions should consider both reflective and impulsive approaches to behaviour change.

Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study

BackgroundType 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.MethodsThe 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.ResultsAll 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.DiscussionWe 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.

Diabetes Care Provision in UK Primary Care Practices

Background Although most people with Type 2 diabetes receive their diabetes care in primary care, only a limited amount is known about the quality of diabetes care in this setting. We investigated the provision and receipt of diabetes care delivered in UK primary care. Methods Postal surveys with all healthcare professionals and a random sample of 100 patients with Type 2 diabetes from 99 UK primary care practices. Results 326/361 (90.3%) doctors, 163/186 (87.6%) nurses and 3591 patients (41.8%) returned a questionnaire. Clinicians reported giving advice about lifestyle behaviours (e.g. 88% would routinely advise about calorie restriction; 99.6% about increasing exercise) more often than patients reported having received it (43% and 42%) and correlations between clinician and patient report were low. Patients’ reported levels of confidence about managing their diabetes were moderately high; a median (range) of 21% (3% to 39%) of patients reporting being not confident about various areas of diabetes self-management. Conclusions Primary care practices have organisational structures in place and are, as judged by routine quality indicators, delivering high quality care. There remain evidence-practice gaps in the care provided and in the self confidence that patients have for key aspects of self management and further research is needed to address these issues. Future research should use robust designs and appropriately designed studies to investigate how best to improve this situation.

Diabetes in care homes: current care standards and residents' experience.

Diabet. Med. 29, 132–135 (2012)

Undiagnosed diabetes in the over-60s: performance of the Association of Public Health Observatories (APHO) Diabetes Prevalence Model in a general practice

Diabet. Med. 29, 115–120 (2012)

Cluster randomised Trial of a theory-based multiple behavior change intervention aimed at primary healthcare professionals' management of type 2 diabetes

A systematic review of randomized controlled trials studying the preventive effects of physical exercise, manual and behavioural treatments in acute low back pain and neck painIntroduction: The global financial crisis has left governments struggling to reduce their budget deficits. Loans and taxes are two important financial instruments for governments to close their budget gaps. According to models of temporal discounting and expected utility individuals should experience loans as a greater loss than taxes, depleting psychological resources and reducing individuals’ capacity to cope with stressors. The present research examined patterns of cardiovascular (CV) reactivity associated with exposure to loans or taxes. Methods: We randomised 73 students to one of three groups: loans, taxes, control (baseline). Participants in the experimental groups imagined finishing university with debts and having to repay the sums outstanding as a proportion of their salaried income over the next 30 years either via a loan repayment, or via taxes. Participants in the control group imagined finishing university, and then working in salaried employment over the next 30 years. All participants then performed a variant of the Trier Social Stress Test (TSST), whilst CV responses were monitored [BP (blood pressure), ECG (electrocardiogram), ICG (impedance cardiogram)]. Results: Compared to the control group, participants in the loan group exhibited maladaptive CV responses during the stress task (higher BP and higher total peripheral resistance [TPR]). Conversely, participants in the taxes group exhibited more adaptive CV responses and did not differ from the control group. Conclusions: Economic considerations have dominated debates surrounding macro-financial performance. The present research highlights the need to consider the psychological costs and benefits of tax-based and loan-based financial instruments.

Improving the delivery of care for patients with diabetes through understanding optimised team work and organisation in primary care

BackgroundType 2 diabetes is an increasingly prevalent chronic illness and is an important cause of avoidable mortality. Patients are managed by the integrated activities of clinical and non-clinical members of the primary care team. Studies of the quality of care for patients with diabetes suggest less than optimum care in a number of areas.AimThe aim of this study is to improve the quality of care for patients with diabetes cared for in primary care in the UK by identifying individual, team, and organisational factors that predict the implementation of best practice.DesignParticipants will be clinical and non-clinical staff within 100 general practices sampled from practices who are members of the MRC General Practice Research Framework. Self-completion questionnaires will be developed to measure the attributes of individual health care professionals, primary care teams (including both clinical and non-clinical staff), and their organisation in primary care. Questionnaires will be administered using postal survey methods. A range of validated theories will be used as a framework for the questionnaire instruments. Data relating to a range of dimensions of the organisational structure of primary care will be collected via a telephone interview at each practice using a structured interview schedule. We will also collect data relating to the processes of care, markers of biochemical control, and relevant indicator scores from the quality and outcomes framework (QOF). Process data (as a proxy indicator of clinical behaviours) will be collected from practice databases and via a postal questionnaire survey of a random selection of patients from each practice. Levels of biochemical control will be extracted from practice databases. A series of analyses will be conducted to relate the individual, team, and organisational data to the process, control, and QOF data to identify configurations associated with high quality care.Study registrationUKCRN ref:DRN120 (ICPD)

Cardiovascular Risk, Glucose and Targets for Management of Diabetes in Older People

Older people make up a large proportion of people with diabetes, and although there is much guidance for the treatment of people with type 2 diabetes, these do not take into account the real situation in the elderly such as co-morbidities and frailty. Indeed, frail elderly are routinely excluded from large clinical trials, where cardiovascular risk, hypertension and risk of death are so much higher. This chapter discusses current trial evidence for cardiovascular risk, glucose and targets for management of diabetes in older people, allowing for the heterogeneous nature of this group and offering some practical guidance for practising clinicians in this difficult area.

Recent clinical trials in diabetes – implications for managing older patients

The prevalence of type 2 diabetes is set to increase, and with it the complications associated with diabetes. Since 2007 there have been a number of significant trials that may change the way we think about treating people with diabetes, especially our older patients. These trials include the Steno-2 trial, UKPDS legacy trial, ADVANCE, ACCORD and VADT. These trials are reviewed in detail in this article, including the implications for the patients we treat. Recent work assessing the effect of HbA1c on cognitive function and the effects of hypoglycaemia are also discussed. We conclude with suggestions for targets for glycated haemoglobin level based on NICE guidance.

Improving the delivery of care for patients with diabetes through understanding optimised team work and organisation in primary care: Study protocol

BackgroundType 2 diabetes is an increasingly prevalent chronic illness and is an important cause of avoidable mortality. Patients are managed by the integrated activities of clinical and non-clinical members of the primary care team. Studies of the quality of care for patients with diabetes suggest less than optimum care in a number of areas.AimThe aim of this study is to improve the quality of care for patients with diabetes cared for in primary care in the UK by identifying individual, team, and organisational factors that predict the implementation of best practice.DesignParticipants will be clinical and non-clinical staff within 100 general practices sampled from practices who are members of the MRC General Practice Research Framework. Self-completion questionnaires will be developed to measure the attributes of individual health care professionals, primary care teams (including both clinical and non-clinical staff), and their organisation in primary care. Questionnaires will be administered using postal survey methods. A range of validated theories will be used as a framework for the questionnaire instruments. Data relating to a range of dimensions of the organisational structure of primary care will be collected via a telephone interview at each practice using a structured interview schedule. We will also collect data relating to the processes of care, markers of biochemical control, and relevant indicator scores from the quality and outcomes framework (QOF). Process data (as a proxy indicator of clinical behaviours) will be collected from practice databases and via a postal questionnaire survey of a random selection of patients from each practice. Levels of biochemical control will be extracted from practice databases. A series of analyses will be conducted to relate the individual, team, and organisational data to the process, control, and QOF data to identify configurations associated with high quality care.Study registrationUKCRN ref:DRN120 (ICPD)