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 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 Implementation strategies, and barriers and facilitators for implementation of physical activity at work: a scoping review

2019 ◽  
Vol 27 (1) ◽  
Author(s):  
Anne Garne-Dalgaard ◽  
Stephanie Mann ◽  
Thomas Viskum Gjelstrup Bredahl ◽  
Mette Jensen Stochkendahl
Keyword(s):  
Physical Activity ◽  
Scoping Review ◽  
Social Influences ◽  
Theoretical Domains Framework ◽  
Implementation Strategies ◽  
Professional Role ◽  
Environmental Context ◽  
Barriers And Facilitators ◽  
Factors Affecting ◽  
Study Characteristics

Abstract Background Inactivity and sedentary lifestyle have led experts to recommend an increase in structured, workplace-based physical activity (PA) initiatives. Previous studies on workplace-based PA have only shown moderate and short-term effects. This has been attributed to the lack of clear implementation strategies and understanding of factors that may hinder or enable uptake of PA. To ensure long-term, sustainable outcomes, there is a need for a better understanding of implementation strategies, and barriers and facilitators to workplace-based PA. Method A scoping review of studies investigating implementation approaches and factors affecting uptake of workplace-based PA was conducted. Qualitative and quantitative articles published in MEDLINE, Embase, Scopus, or PsycINFO between 2008 and 2018 evaluating the implementation of PA were included. Data on study characteristics, evaluation, and implementation methods applied were systematically extracted. Two reviewers extracted, coded, and organised factors affecting uptake using the Theoretical Domains Framework (TDF). Results After dual, blinded screening of titles and abstracts, 16 articles reporting on eight studies were included in the review. Several different methods of implementation were applied, including information meeting, kick-off events, and “change agents” as the most common. A total of 109 factors influencing implementation were identified, consisting of 57 barriers and 52 facilitators. Barriers most often related to the TDF domains Environmental Context and Resources (n = 34, 36.2%), Social influences (n = 13, 13.8%), and Social/Professional Role and Identity (n = 8, 8.5%). Likewise, facilitators most often related to the TDF domains Social influences (n = 17, 19.5%), Environmental Context and Resources (n = 16, 18.4%), and Social/Professional Role and Identity (n = 9, 10.3%). Conclusion Our review has highlighted the multilevel factors affecting the uptake of workplace-based PA and underpins the complexities in implementation of such initiatives. The published literature predominantly provides details from the employees’ perspectives on factors that need to be addressed and a lack of attention to these factors will cause them to hamper uptake of PA. The analysis of barriers and facilitators provides a theoretical foundation to guide future intervention design. However, further research is needed to fully understand the success or failure of implementation processes.

scholarly journals Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists

2019 ◽  
Vol 49 (1) ◽  
pp. 102-110 ◽  
Author(s):  
Sion Scott ◽  
Michael J Twigg ◽  
Allan Clark ◽  
Carol Farrow ◽  
Helen May ◽  
...  
Keyword(s):  
Patient Monitoring ◽  
Hospital Setting ◽  
Theoretical Domains Framework ◽  
Evidence Based ◽  
Focus Group Study ◽  
Implementation Framework ◽  
Barriers And Enablers ◽  
Behavioural Determinants ◽  
Caregiver Attachment ◽  
Influence Perceptions

Abstract Background over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians’ and pharmacists’ barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing. Methods fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains. Results geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists’ working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. Conclusion the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.

scholarly journals Clinicians’ delirium treatment practice, practice change, and influences: A national online survey

2021 ◽  
pp. 026921632110221
Author(s):  
Annmarie Hosie ◽  
Meera Agar ◽  
Gideon A Caplan ◽  
Brian Draper ◽  
Stephen Hedger ◽  
...  
Keyword(s):  
Palliative Care ◽  
Nurse Practitioners ◽  
Online Survey ◽  
Theoretical Domains Framework ◽  
Practice Change ◽  
Evidence Based ◽  
Pharmacological Interventions ◽  
Treatment Practice ◽  
Off Label ◽  
Cast Doubt

Background: Recent studies cast doubt on the net effect of antipsychotics for delirium. Aim: To investigate the influence of these studies and other factors on clinicians’ delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework. Design: Australia-wide online survey of relevant clinicians. Setting/participants: Registered nurses (72%), doctors (16%), nurse practitioners (6%) and pharmacists (5%) who cared for patients with delirium in diverse settings, recruited through health professionals’ organisations. Results: Most of the sample ( n = 475): worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). Fifty-five percent reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common Theoretical Domains Framework categories of influences on respondents’ delirium practice were: emotion (54%); knowledge (53%) and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named key study of antipsychotics for delirium (73% vs 39%, p < 0.001); changed delirium treatment (73% vs 53%, p = 0.017); decreased pharmacological interventions (60% vs 15%, p < 0.001); off-label medication use (86% vs 51%, p < 0.001: antipsychotics 79% vs 44%, p < 0.001; benzodiazepines 61% vs 26%, p < 0.001) and emotion as an influence (82% vs 39%, p < 0.001). Conclusion: Clinicians’ use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium practice requires further work.

scholarly journals Professional Roles of General Practitioners, Community Pharmacists and Specialist Providers in Collaborative Medication Deprescribing - A Qualitative Study

2020 ◽  
Author(s):  
Navina Gerlach ◽  
Matthias Michiels-Corsten ◽  
Annika Viniol ◽  
Tanja Schleef ◽  
Ulrike Junius-Walker ◽  
...  
Keyword(s):  
Qualitative Study ◽  
General Practitioners ◽  
Collaborative Care ◽  
Social Influences ◽  
Theoretical Domains Framework ◽  
Community Pharmacists ◽  
Environmental Context ◽  
Structural Factors ◽  
Role Perceptions ◽  
Medication Optimization

Abstract Background: Collaborative care approaches between general practitioners (GPs) and pharmacists have received international recognition for medication optimization and deprescribing efforts. Although specialist providers have been shown to influence deprescribing, their profession so far remains omitted from collaborative care approaches for medication optimization. Similarly, while explorative studies on role perception and collaboration between GPs and pharmacists grow, interaction with specialists for medication optimization is neglected. Our qualitative study therefore aims to explore GPs’, community pharmacists’ and specialist providers’ role perceptions of deprescribing, and to identify interpersonal as well as structural factors that may influence collaborative medication optimization approaches.Method: Seven focus-group discussions with GPs, community pharmacists and community specialists were conducted in Hesse and Lower Saxony, Germany. The topic guide focused on views and experiences with deprescribing with special attention to inter-professional collaboration. We conducted conventional content analysis and conceptualized emerging themes using the Theoretical Domains Framework.Results: 26 GPs, four community pharmacists and three community specialists took part in the study. The main themes corresponded to the four domains ´Social/professional role and identity` (1), ´Social influences’ (2), ´Reinforcement` (3) and ´Environmental context and resources’ (4) which were further described by beliefs statements, that is inductively developed key messages. For (1), GPs emerged as central medication managers while pharmacists and specialists were assigned confined or subordinated tasks in deprescribing. Social influences (2) encompassed patients’ trust in GPs as a support, while specialists and pharmacists were believed to threaten GPs’ role and deprescribing attempts. Reinforcements (3) negatively affected GPs’ and pharmacists’ effort in medication optimization by social reprimand and lacking reward. Environmental context (4) impeded deprescribing efforts by deficient reimbursement and resources as well as fragmentation of care, while informational and gate-keeping resources remained underutilized. Conclusion: Understanding stakeholders’ role perceptions on collaborative deprescribing is a prerequisite for joint approaches to medication management. We found that clear definition and dissemination of roles and responsibilities are premise for avoiding intergroup conflicts. Role performance and collaboration must further be supported by structural factors like adequate reimbursement, resources and a transparent continuity of care.

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.

scholarly journals Investigating primary health care practitioners’ barriers and enablers to referral of COPD patients to Pulmonary Rehabilitation: an exploratory sequential mixed methods study using the Theoretical Domains Framework

2020 ◽  
Author(s):  
Jane Suzanne Watson ◽  
Rachel Elizabeth Jordan ◽  
Peymane Adab ◽  
Ivo Vlaev ◽  
Alexandra Enocson ◽  
...  
Keyword(s):  
Health Care ◽  
Pulmonary Rehabilitation ◽  
Social Influences ◽  
Theoretical Domains Framework ◽  
Mixed Methods Study ◽  
Barriers And Enablers ◽  
Primary Health ◽  
Health Care Practitioners ◽  
Sequential Mixed Methods ◽  
Copd Patients

Abstract BackgroundPulmonary rehabilitation is a highly effective, globally recommended intervention for patients with Chronic Obstructive Pulmonary Disease (COPD). Understanding why referral rates remain persistently low is important and enables the development of targeted interventions in order to improve future uptake. MethodsWe undertook an exploratory sequential mixed methods study to investigate the referral practices of Primary Health Care Practitioners (PHCPs) in the United Kingdom (UK). In phase 1 semi structured interviews were undertaken. Content analysis was used to map arising themes to the Theoretical Domains Framework (TDF) and the development of a 54-item TDF based questionnaire.In Phase 2 we distributed the questionnaire through relevant conferences and organisation memberships, to obtain views from a larger, more generalisable PHCP population. We used descriptive analyses to identify the most important barriers and enablers, and key TDF domains. Mixing of data occurred at 2 time points; instrument design and interpretation. Results19 PHCP took part in interviews and 233 responded to the survey. Integrated results revealed that PHCPs with a post qualifying respiratory qualification (154/241; 63.9%) referred more frequently (91/154; 59.1%) than those without (28/87; 32.2%).There were more barriers than enablers for referral in all 13 mapped TDF domains. Key barriers included: infrequent engagement from PR provider to referrer, concern around patient’s physical ability and access to PR (particularly for those in work), assumed poor patient motivation, no clear practice referrer and few referral opportunities. These mapped to the following domains: belief about capabilities, social influences, environment, optimism, skills and social and professional role.Enablers to referral were observed within the knowledge, social influences memory and environment domains. Many PHCPs believed in the physical and psychological value of PR, and helpful enablers were out-of-practice support from respiratory interested colleagues, dedicated referral time (annual review) and on-screen referral prompts. ConclusionsReferral to PR is a complex process. Barriers outweighed enablers. Aligning these findings to behaviour change techniques will identify practice-based interventions to overcome current barriers and strengthen enablers, thereby increasing referral of COPD patients to PR as recommended by international COPD guidelines

scholarly journals Barriers and enablers to access childhood cataract services across India. A qualitative study using the Theoretical Domains Framework (TDF) of behaviour change

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0261308
Author(s):  
Sheeladevi Sethu ◽  
John G. Lawrenson ◽  
Ramesh Kekunnaya ◽  
Rahul Ali ◽  
Rishi R. Borah ◽  
...  
Keyword(s):  
Cataract Surgery ◽  
Social Influences ◽  
Theoretical Domains Framework ◽  
Analysis Data ◽  
Perceived Barriers ◽  
Early Presentation ◽  
Integrative Framework ◽  
Barriers And Enablers ◽  
Depth Interviews ◽  
Childhood Cataract

Early presentation for childhood cataract surgery is an important first step in preventing related visual impairment and blindness. In the absence of neonatal eye screening programmes in developing countries, the early identification of childhood cataract remains a major challenge. The primary aim of this study was to identify potential barriers to accessing childhood cataract services from the perspective of parents and carers, as a critical step towards increasing the timely uptake of cataract surgery. In-depth interviews were conducted using a pre-designed topic guide developed for this study to seek the views of parents and carers in nine geographic locations across eight states in India regarding their perceived barriers and enablers to accessing childhood cataract services. A total of 35 in-depth interviews were conducted including 30 at the hospital premises and 5 in the participants’ homes. All interviews were conducted in the local language and audio taped for further transcription and analysis. Data were organised using NVivo 11 and a thematic analysis was conducted utilising the Theoretical Domains Framework (TDF), an integrative framework of behavioural theories. The themes identified from interviews related to 11 out of 12 TDF domains. TDF domains associated with barriers included: ‘Environmental context and resources’, ‘Beliefs about consequences’ and ‘Social influences’. Reported enablers were identified in three theoretical domains: ‘Social influences’, ‘Beliefs about consequences’ and ‘Motivations and goals’. This comprehensive TDF approach enabled us to understand parents’ perceived barriers and enablers to accessing childhood cataract services, which could be targeted in future interventions to improve timely uptake.

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