scholarly journals LO17: Barriers and enablers that influence guideline-based care of geriatric falls patients presenting to the emergency department

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S13
Author(s):  
A. Parks ◽  
D. Eagles ◽  
W. Cheung ◽  
Y. Ge ◽  
I. Stiell
Keyword(s):  
Emergency Department ◽  
Allied Health ◽  
Theoretical Domains Framework ◽  
Health Coverage ◽  
Structured Interviews ◽  
Training Interventions ◽  
Barriers And Enablers ◽  
Interview Guide ◽  
Health Support ◽  
Belief Statements

Introduction: Geriatric patients commonly present to the emergency department (ED) after a fall. Unfortunately, recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric falls guidelines. This study applied a theoretical domains framework (TDF)-driven approach to systematically investigate barriers and enablers in the provision of guideline-based care to older patients presenting to the ED with a fall. Methods: From June to September 2017, semi-structured interviews of staff ED physicians practicing in Ontario, Canada were conducted and analyzed. An interview guide based on the TDF was used to capture 14 domains that may influence provision of guideline-based care. Interview transcripts were analyzed, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs, and evidence of strong beliefs that would influence provision of guideline-based care. Results: Eleven interviews were conducted with practicing ED physicians. Thirty specific belief statements across 13 different TDF domains (all except Optimism) were identified as relevant. Overall, Ontario ED physicians are supportive of providing guideline-based care and believe it would lead to better outcomes for geriatric falls patients. Important barriers include knowledge, skills, time and workload constraints, and inconsistent allied health support. Conclusion: This study identified important barriers and enablers to provision of guideline-based care in geriatric ED falls patients. These results will help guide implementation of guidelines nationally and internationally, with a focus on improved knowledge dissemination, implementation of training interventions, and improvements in allied health coverage and supports.

Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department

2019 ◽  
pp. emermed-2018-208260
Author(s):  
Adam Parks ◽  
Debra Eagles ◽  
Yipeng Ge ◽  
Ian G Stiell ◽  
Warren J Cheung
Keyword(s):  
Positive Reinforcement ◽  
Allied Health ◽  
Health Workers ◽  
Guideline Implementation ◽  
Theoretical Domains Framework ◽  
Barriers And Enablers ◽  
Clinical Encounters ◽  
Semistructured Interviews ◽  
Interview Guide ◽  
Health Support

BackgroundGeriatric patients commonly present to the ED after a fall. Recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric fall guidelines. This study applied a theoretical domains framework (TDF) approach to systematically investigate barriers and enablers in the provision of guideline-based care to ED geriatric fall patients.MethodsFrom June to September 2017, semistructured interviews of staff ED physicians practising in Ontario, Canada, were conducted and analysed. An interview guide based on the TDF was used to capture 14 domains influencing provision of guideline-based care. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs and evidence of strong beliefs that would influence provision of guideline-based care.ResultsEleven interviews were conducted with practising ED physicians. Thirty belief statements were identified across 13 relevant TDF domains (all except Optimism). Prominent themes included lack of knowledge, paucity of evidence, heterogeneous self-perceived skills, perceived increased time and workload, importance of allied health support, inconsistently available allied health workers, lack of positive reinforcement, emotions negatively impacting these clinical encounters and support for memory aids. Overall, ED physicians were supportive of guideline implementation, and believe it will lead to better outcomes for geriatric fall patients.ConclusionThis study identified important barriers and enablers to provision of guideline-based care in geriatric ED fall patients. Based on these findings, future implementation of guidelines nationally and internationally should focus on improving knowledge and training on guidelines, improving positive reinforcement for guideline-appropriate management, greater allied health support and further research to support guidelines.

scholarly journals P041: Patient perspectives on emergency department use for acute atrial fibrillation: a qualitative study using the theoretical domains framework

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S71-S71 ◽  
Author(s):  
D. Eagles ◽  
W.J. Cheung ◽  
E. Lee ◽  
T. Tang ◽  
I.G. Stiell
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Hospital Admissions ◽  
Theoretical Domains Framework ◽  
Patient Perspectives ◽  
Third Party ◽  
Structured Interviews ◽  
Management Options ◽  
Ed Visits ◽  
Belief Statements

Introduction: Acute atrial fibrillation (AAF) is the most common arrhythmia managed in the Emergency Department (ED). Direct costs of AAF are primarily attributed to ED visits and subsequent admission to hospital. A better understanding of patients attitudes regarding ED attendance is necessary to develop strategies to improve the patient care experience while simultaneously reducing ED presentation and inappropriate hospital admissions. This study aims to describe patient perspectives on ED use for AAF using in-depth qualitative interviews. Methods: An interview template designed to explore why patients attend the ED for AAF was constructed based on the Theoretical Domains Framework, a theory-informed approach that utilizes 14 domains to describe influencers of behavior. We conducted audio-recorded, semi-structured interviews of patients following their presentation to the ED for management of AAF. Interviews were anonymized, transcribed and imported into NVivo for coding and analysis. Two independent reviewers used a direct approach to code participant statements. Discrepancies were resolved by a third party. Belief statements were generated and relevant domains identified based on high frequency scores, conflicting belief statements or evidence of strong influencing beliefs. Results: 12 patient interviews, mean age 63.1 years, 91.7% male, 75.0% recurrent AAF, were completed. Patients stated that they attended the ED because: 1) symptom severity; 2) they were instructed by physicians to attend the ED should their AAF recur; and 3) they were encouraged by family members to attend. Their primary goal was to have relief of their symptoms. There was no expectation of specialist consultation or admission to hospital. Even though most patients stated they were open to managing these episodes independently, they reported that they did not have the knowledge or tools to do so. Conclusion: Patients with AAF present to the ED because of their symptom burden, social influences (physician and family) and lack of other management options. This study demonstrates the need for development of patient self-management strategies which will empower patients in their disease management and may decrease future ED visits.

scholarly journals Barriers and enablers to the implementation of protocol-based imaging in pancreatic cancer: A qualitative study using the theoretical domains framework

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0243312
Author(s):  
Ashika D. Maharaj ◽  
Sue M. Evans ◽  
John R. Zalcberg ◽  
Liane J. Ioannou ◽  
Marnie Graco ◽  
...  
Keyword(s):  
Pancreatic Cancer ◽  
Theoretical Domains Framework ◽  
Vital Role ◽  
Common Belief ◽  
Structured Interviews ◽  
Barriers And Enablers ◽  
Radiation Oncologists ◽  
Effective Manner ◽  
Personalise Therapy ◽  
Belief Statements

Background Accurate pre-operative imaging plays a vital role in patient selection for surgery and in allocating stage-appropriate therapies to patients diagnosed with pancreatic cancer (PC). This study aims to: (1) understand the current diagnosis and staging practices for PC; and (2) explore the factors (barriers and enablers) that influence the use of a pancreatic protocol computed tomography (PPCT) or magnetic resonance imaging (MRI) to confirm diagnosis and/or accurately stage PC. Methods Semi-structured interviews were conducted with radiologists, surgeons, gastroenterologists, medical and radiation oncologists from the states of New South Wales (NSW) and Victoria, Australia. Interviews were conducted either in person or via video conferencing. All interviews were recorded, transcribed verbatim, de-identified and data were thematically coded according to the 12 domains explored within the Theoretical Domains Framework (TDF). Common belief statements were generated to compare the variation between participant responses. Findings In total, 21 clinicians (5 radiologists, 10 surgeons, 2 gastroenterologists, 4 medical and radiation oncologists) were interviewed over a four-month-period. Belief statements relevant to the TDF domains were generated. Across the 11 relevant domains, 20 themes and 30 specific beliefs were identified. All TDF domains, with the exception of social influences were identified by participants as relevant to protocol-based imaging using either a PPCT or MRI, with the domains of knowledge, skills and environmental context and resources being offered by most participants as being relevant in influencing their decisions. Conclusions To maximise outcomes and personalise therapy it is imperative that diagnosis and staging investigations using the most appropriate imaging modalities are conducted in a timely, efficient and effective manner. The results provide an understanding of specialists’ opinion and behaviour in relation to a PPCT or MRI and should be used to inform the design of future interventions to improve compliance with this practice.

scholarly journals “What is the actual goal of the pathway?”: examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Anh Ly ◽  
Roger Zemek ◽  
Bruce Wright ◽  
Jennifer Zwicker ◽  
Kathryn Schneider ◽  
...  
Keyword(s):  
Emergency Department ◽  
Health Care Providers ◽  
Clinical Pathways ◽  
Theoretical Domains Framework ◽  
Local Context ◽  
Emergency Department Physician ◽  
Evidence Based ◽  
Care Providers ◽  
Structured Interviews ◽  
Pediatric Concussion

Abstract Background Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion. Methods Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation. Results The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2–4 predominant topics that can be condensed into six overarching themes regarding clinicians’ views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes. Conclusion Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

scholarly journals Perceived barriers and enablers influencing physical activity in heart failure: a qualitative one-to-one interview study

2021 ◽  
Author(s):  
Aliya Amirova ◽  
Rebecca Lucas ◽  
Martin R Cowie ◽  
Mark Haddad
Keyword(s):  
Physical Activity ◽  
Heart Failure ◽  
Physical Activity Intervention ◽  
Theoretical Domains Framework ◽  
Action Planning ◽  
Activity Levels ◽  
Structured Interviews ◽  
Barriers And Enablers ◽  
One To One ◽  
Specialist Nurses

AbstractIn heart failure (HF), increased physical activity is associated with improved quality of life, reduced hospitalisation, and increased longevity and is an important aim of treatment. However, physical activity levels in individuals living with HF are typically extremely low. This qualitative study with one-to-one interviews systematically explores perceived clinical, environmental, and psychosocial barriers and enablers in older adults (>70 years old) living with HF. Semi-structured interviews (N = 16) based on the Theoretical Domains Framework elicited 78 belief statements describing the barriers and enablers to physical activity. Theoretical domains containing these beliefs and corresponding constructs that were both pervasive and common were deemed most relevant. These were: concerns about physical activity (Beliefs about Consequences), self-efficacy (Beliefs about Capabilities), social support (Social Influences), major health event (Environmental Context and Resources), goal behavioural (Goal), action planning (Behavioural Regulation). This work extends the limited research on the modifiable barriers and enablers for physical activity participation by individuals living with HF. The research findings provide insights for cardiologists, HF-specialist nurses, and physiotherapists to help co-design and deliver a physical activity intervention more likely to be effective for individuals living with HF.

scholarly journals LO37: Barriers and enablers to direct observation of clinical performance a qualitative study using the theoretical domains framework

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S19-S20
Author(s):  
W. J. Cheung ◽  
A. M. Patey ◽  
J. R. Frank ◽  
M. Mackay ◽  
S. Boet
Keyword(s):  
Residency Training ◽  
Direct Observation ◽  
Medical Training ◽  
Tertiary Care ◽  
Theoretical Domains Framework ◽  
Teaching Hospitals ◽  
Pedagogical Practice ◽  
Structured Interviews ◽  
Barriers And Enablers ◽  
Social Expectation

Introduction: Direct observation is essential to assess medical trainees and provide them with feedback to support their progression from novice to competent physicians. However, learners consistently report infrequent observations, and calls to increase direct observation in medical training abound. In this study, a theory-driven approach using the Theoretical Domains Framework (TDF) was applied to systematically investigate factors that serve as barriers and enablers to direct observation in residency training. Methods: Semi-structured interviews of faculty and residents from various specialties at two large tertiary-care teaching hospitals were conducted. An interview guide based on the TDF was used to capture 14 theoretical domains that may influence direct observation. Interview transcripts were independently coded using direct content analysis by two researchers, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on the frequencies of beliefs reported, presence of conflicting beliefs, and perceived influence on direct observation practices. Results: Data saturation was achieved after 12 resident and 13 faculty interviews, with a total of 10 different specialties represented. Median postgraduate year among residents was 4 (range 1-6), and mean years of independent practice among faculty was 10.3 (SD=8.6). Ten TDF domains were identified as influencing direct observation: knowledge, skills, beliefs about consequences, social professional role and identity, intention, goals, memory/attention/decision-making, environmental context and resources, social influences, and behavioural regulation. Discord between faculty and resident intentions to engage in direct observation, coupled with the social expectation that residents should be responsible for ensuring observations occur, was identified as a key barrier. Additionally, competing demands identified across multiple TDF domains emerged as an important and pervasive theme. Conclusion: This study identified key barriers and enablers to direct observation. The influencing factors identified in this study provide a basis for the development of potential strategies aimed at embedding direct observation as a routine pedagogical practice in residency training.

Barriers and enablers to the implementation of multidisciplinary team meetings: a qualitative study using the theoretical domains framework

2020 ◽  
pp. bmjqs-2020-011793
Author(s):  
Ashika D Maharaj ◽  
Sue M Evans ◽  
John R Zalcberg ◽  
Liane J Ioannou ◽  
Marnie Graco ◽  
...  
Keyword(s):  
Pancreatic Cancer ◽  
Palliative Care ◽  
Multidisciplinary Team ◽  
Social Influences ◽  
Theoretical Domains Framework ◽  
Environmental Context ◽  
Evidence Based ◽  
Common Belief ◽  
Barriers And Enablers ◽  
Belief Statements

BackgroundEvidence-based clinical practice guidelines recommend discussion by a multidisciplinary team (MDT) to review and plan the management of patients for a variety of cancers. However, not all patients diagnosed with cancer are presented at an MDT.Objectives(1) To identify the factors (barriers and enablers) influencing presentation of all patients to, and the perceived value of, MDT meetings in the management of patients with pancreatic cancer and; (2) to identify potential interventions that could overcome modifiable barriers and enhance enablers using the theoretical domains framework (TDF).MethodsSemistructured interviews were conducted with radiologists, surgeons, medical and radiation oncologists, gastroenterologists, palliative care specialists and nurse specialists based in New South Wales and Victoria, Australia. Interviews were conducted either in person or via videoconferencing. All interviews were recorded, transcribed verbatim, deidentified and data were thematically coded according to the 12 domains explored within the TDF. Common belief statements were generated to compare the variation between participant responses.ResultsIn total, 29 specialists were interviewed over a 4-month period. Twenty-two themes and 40 belief statements relevant to all the TDF domains were generated. Key enablers influencing MDT practices included a strong organisational focus (social/professional role and identity), beliefs about the benefits of an MDT discussion (beliefs about consequences), the use of technology, for example, videoconferencing (environmental context and resources), the motivation to provide good quality care (motivation and goals) and collegiality (social influences). Barriers included: absence of palliative care representation (skills), the number of MDT meetings (environmental context and resources), the cumulative cost of staff time (beliefs about consequences), the lack of capacity to discuss all patients within the allotted time (beliefs about capabilities) and reduced confidence to participate in discussions (social influences).ConclusionsThe internal and external organisational structures surrounding MDT meetings ideally need to be strengthened with the development of agreed evidence-based protocols and referral pathways, a focus on resource allocation and capabilities, and a culture that fosters widespread collaboration for all stages of pancreatic cancer.

scholarly journals “What is the actual goal of the pathway?”: Examining emergency department clinicians’ perspectives on the implementation of a pediatric concussion pathway using the Theoretical Domains Framework

2019 ◽  
Author(s):  
Anh Ly ◽  
Roger Zemek ◽  
Bruce Wright ◽  
Jennifer Zwicker ◽  
Kathryn Schneider ◽  
...  
Keyword(s):  
Emergency Department ◽  
Health Care Providers ◽  
Clinical Pathway ◽  
Clinical Pathways ◽  
Theoretical Domains Framework ◽  
Local Context ◽  
Evidence Based ◽  
Care Providers ◽  
Structured Interviews ◽  
Pediatric Concussion

Abstract Background Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion. Methods Semi-structured interviews were conducted with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation. Results The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the clinical behaviours, thematic areas, and other issues raised by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2-4 predominant topics that can be condensed into six overarching themes regarding clinicians’ views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes. Conclusion Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to best implement a concussion clinical pathway. These overarching themes must be addressed to successfully implement a CP for pediatric concussion.

scholarly journals Overcoming the barriers of mobile health that hamper sustainability in low-resource environments

2021 ◽  
Author(s):  
Maike Greve ◽  
Alfred Benedikt Brendel ◽  
Nils van Osten ◽  
Lutz M. Kolbe
Keyword(s):  
Mobile Health ◽  
Process Model ◽  
Sustainable Use ◽  
Sub Saharan Africa ◽  
Health Coverage ◽  
Structured Interviews ◽  
Theoretical Contribution ◽  
Low Resource ◽  
Response Strategies ◽  
Sustainable Implementation

Abstract Aim This research aims to identify response strategies that non-profit organizations (NPOs) can apply to overcome the barriers that hamper the sustainable use of mobile health (mHealth) interventions in low-resource environments (LREs), such as in Sub-Saharan Africa (SSA). Subject and method A qualitative study on mHealth initiatives in SSA is conducted through semi-structured interviews with 15 key informants of NPOs that operate and manage mHealth interventions in this region. The interviews focus on identifying existing barriers and response strategies that NPOs apply to enable sustainable and long-term running interventions. Results Building on grounded theory techniques, the collected data guided us towards a process model that identifies four aggregated categories of challenging areas that require response strategies (economy, environment, technology, and user acceptance). Conclusion This study provides contributions from and implications for NPOs and researchers. Health practitioners are provided with a knowledge base of what barriers to expect and how to overcome them, to strive for sustainable implementation from the very beginning of an intervention. A process model is identified that structures the response strategies in a time-based agenda of mHealth initiatives and thus makes a theoretical contribution. Overall, this study addresses the need for a theoretical consideration of the “pilotitis” phenomenon, which currently hampers the sustainable implementation and scaling up of mHealth initiatives. While the focus is specifically on mHealth initiatives, the overall findings help prevent discontinuance of projects in the future after the pilot, and help facilitate LREs on their way to sustainable health interventions and universal health coverage.

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