Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses’ use of electronic medication management systems in two Australian hospitals
© The Author(s). 2017
Received: 12 October 2016
Accepted: 16 March 2017
Published: 27 March 2017
Medication errors harm hospitalised patients and increase health care costs. Electronic Medication Management Systems (EMMS) have been shown to reduce medication errors. However, nurses do not always use EMMS as intended, largely because implementation of such patient safety strategies requires clinicians to change their existing practices, routines and behaviour. This study uses the Theoretical Domains Framework (TDF) to identify barriers and targeted interventions to enhance nurses’ appropriate use of EMMS in two Australian hospitals.
This qualitative study draws on in-depth interviews with 19 acute care nurses who used EMMS. A convenience sampling approach was used. Nurses working on the study units (N = 6) in two hospitals were invited to participate if available during the data collection period. Interviews inductively explored nurses’ experiences of using EMMS (step 1). Data were analysed using the TDF to identify theory-derived barriers to nurses’ appropriate use of EMMS (step 2). Relevant behaviour change techniques (BCTs) were identified to overcome key barriers to using EMMS (step 3) followed by the identification of potential literature-informed targeted intervention strategies to operationalise the identified BCTs (step 4).
Barriers to nurses’ use of EMMS in acute care were represented by nine domains of the TDF. Two closely linked domains emerged as major barriers to EMMS use: Environmental Context and Resources (availability and properties of computers on wheels (COWs); technology characteristics; specific contexts; competing demands and time pressure) and Social/Professional Role and Identity (conflict between using EMMS appropriately and executing behaviours critical to nurses’ professional role and identity).
The study identified three potential BCTs to address the Environmental Context and Resources domain barrier: adding objects to the environment; restructuring the physical environment; and prompts and cues. Seven BCTs to address Social/Professional Role and Identity were identified: social process of encouragement; pressure or support; information about others’ approval; incompatible beliefs; identification of self as role model; framing/reframing; social comparison; and demonstration of behaviour. It proposes several targeted interventions to deliver these BCTs.
The TDF provides a useful approach to identify barriers to nurses’ prescribed use of EMMS, and can inform the design of targeted theory-based interventions to improve EMMS implementation.
KeywordsImplementation Theoretical Domains Framework Behaviour change Electronic Medication Management Systems Medication administration Workarounds
Medication errors cause significant iatrogenic harm in hospitals worldwide [1–6] and are estimated to occur in 5–10% of in-hospital medication administrations . In addition to harming patients, medication errors undermine patients’ confidence in the healthcare system, extend hospital length of stay and are costly [7–9].
Internationally, sustained efforts endeavour to reduce medication error rates . One common approach has been the implementation of Electronic Medication Management Systems (EMMS) . EMMS are designed to digitise administration processes, structure medication-related tasks, provide information support and promote adherence to medication administration policies .
Implementing EMMS has reduced errors in documentation  and prescribing and administration [14–17] and has improved adherence to safety guidelines [18, 19]. Yet, nurses do not always use EMMS as intended. Rather, nurses use ‘workarounds’—practices that differ from organisationally prescribed or intended procedures—to circumvent perceived or actual hindrances to achieving a goal . EMMS workarounds include not taking an electronic medication administration record to the patient [21–23]; preparing medications for multiple patients concurrently ; entering medication as administered before having done so ; and signing off medication in the EMMS that has been administered by another nurse . While there is little empirical evidence for the impact (negative or positive) of these workarounds on patient safety, not using EMMS appropriately undermines the potential to isolate and measure the impact of EMMS on medication error and may increase the potential for error [21, 25–28].
Given that some EMMS-related workarounds may be unsafe, it is important to understand the barriers associated with EMMS use. To date, examination of these barriers has focused largely on the mismatch between workflow and introduced technology, and on shortcomings in EMMS design, posing barriers to using computers in clinical settings [21, 22, 24, 26–32]. While useful, this research does not directly recognise that patient safety interventions, such as EMMS implementation, require healthcare professionals to change their behaviour. Theoretical approaches to identifying barriers to behaviour change and to designing targeted interventions to address them have been demonstrated to be more successful in changing behaviour than non-theory-driven approaches [33–36]. For example, one meta-analysis identified that studies that explicitly used theory for intervention design were significantly more effective in changing behaviour than interventions that did not . To date, we have not identified any theory-driven behaviour change strategies that have tackled nurses' resistance to the use of EMMS. This research used the Theoretical Domains Framework (TDF) to address this gap.
An awareness of the existence of something
An ability or proficiency acquired through practice
Social/professional role and identity
A coherent set of behaviors and displayed personal qualities of an individual in a social or work setting
Beliefs about capabilities
Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use
The confidence that things will happen for the best or that desired goals will be attained
Beliefs about consequences
Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation
Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus
A conscious decision to perform a behavior or a resolve to act in a certain way
Mental representations of outcomes or end states that an individual wants to achieve
Memory, attention and decision processes
The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives
Environmental context and resources
Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behavior
Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours
A complex reaction pattern, involving experiential, behavioral, and physiological elements, by which the individual attempts to deal with a personally significant matter or event
Anything aimed at managing or changing objectively observed or measured actions
The theoretical domains have been mapped to specific behaviour change techniques (BCTs) [37, 42], which are the active components of interventions related to each domain . A taxonomy of BCTs, linked to theoretical constructs associated with changes in specific behaviours [37, 42], can generate targeted remedial interventions to elicit behaviour change and improve patient outcomes (e.g. [44, 45]).
The TDF has been used to identify barriers to implementing a range of practices with implications for patient safety including reporting adverse drug events in hospitals , reducing prescribing errors among trainee doctors , preventing misplaced nasogastric feeding tubes [44, 45], implementing stroke guideline recommendations , and encouraging hand hygiene practices .
This study focuses on barriers to nurses’ appropriate use of EMMS, because nurses are the predominant users of EMMS to prepare and administer medication in acute care settings. It used the TDF to characterise emergent barriers to nurses’ appropriate use of EMMS, to identify the most relevant (pre-defined) BCTs that have been mapped to specific domain barriers [37, 42] from the literature and to propose targeted interventions that could potentially address barriers [37, 39, 42, 43, 49]. It therefore fills an identified gap in theory-based interventions to address medication error . Appropriate use of EMMS is anticipated to improve patient safety through reduction of medication error.
Step 1: collecting data using semi-structured interviews
At the time of the study, a statewide phased implementation of IT, including medication management, had been recommended for New South Wales (NSW) acute care hospitals [54, 55], but this was not yet fully realised. Data were collected at two large metropolitan university-affiliated teaching hospitals (over 300 beds) in NSW, Australia (henceforth, hospital 1 (H1) and hospital 2 (H2)), that had commenced staged rollout of EMMS approximately six years before data collection. At each hospital, the sample included three units that used different EMMS and models of nursing care to maximise variation .
Sampling and study participants
Given the ever-changing demands across nurses’ shifts, a convenience sampling strategy was used. Nurses who used EMMS were opportunistically invited by the researcher to participate if they were available when interviews were being conducted; one nurse declined to participate. This sampling approach allowed for the inclusion of nurses with varying experience using EMMS [52, 57]. Participants were allocated a randomly selected unique identification number.
Could you explain the electronic medication management system that is used in this unit to me please?
Can you tell me about the medication process that is used in this unit? [Prompts: Is there a medication round, nurse dedicated to medication delivery, pharmacy round etc]?
Can you tell me about how has using the electronic medication management system changed aspects of your work?
Are there times when it is difficult to use the electronic system in administering medication? Can you tell me about some of the things that make it difficult?
Can you tell me about what do you do when something makes it difficult to get the medication to the patient?
Does everyone use the same practices to get the medication to the patient? Can you tell me about how the practices differ between nurses?
Can you tell me about whether and how you workaround the system to get the medication to the patient?
Can you tell me about whether and how other people workaround the system the system to get the medication to the patient?
Would you explain for me if there are times when it is OK to workaround the system to get the medication to the patient and when it is not OK ? Is this the same for everyone?
Can you tell me about times when it is OK for some nurses to workaround the system the system to get the medication to the patient but not OK for others to workaround?
Are there times when it is easier to use the electronic system in administering medication? Can you tell me about some of the things that make using the electronic medication management system easier?
Can you tell me what impact you think the electronic medication management system has had on quality and safety?
What sort of things impact on the use of the electronic medication management system? [For example, experience with the system, business of the shift, staff levels]
Step 2: using the TDF to identify key barriers to implementation of EMMS
Number of interviews coded using TDF by unit
Number of interviews coded using TDF
Step 3: identifying appropriate BCTs to address barriers to EMMS use as intended
To identify potential BCTs to address the barriers identified in step 2, we drew upon literature that maps particular BCTs to the behavioural determinants (domains) they are effective in changing [37, 42, 49]. We selected BCT groupings from Michie et al.’s BCT Taxonomy (v1) of 93 hierarchically clustered techniques . We then selected individual BCTs that appeared to address key barriers to nurses’ use of EMMS and that would be easiest to operationalise in a given context. To illustrate, Identification of self as role model, within the BTC taxonomy grouping Identity, can be an effective BCT to address barriers related to the Social/Professional Role and Identity domain.
Step 4: generating potential intervention strategies to address barriers to appropriate use of EMMS
Where possible, we used successful examples offered in the literature [44, 45, 49, 61, 62], and the expertise of the research team, to propose interventions to operationalise the relevant BCTs identified in step 3.
To ensure validity and credibility, we double-coded as described above, frequently debriefed with the research team and member checked  with participants during feedback sessions in 2014 and 2015. Nurses indicated their agreement with the identified barriers, in some cases offering additional examples or counter-examples.
Ethics approval was granted by a health service Human Research Ethics Committee (HREC) and ratified by a University HREC (approval number: HC09223 ). Participants provided written informed consent.
Role and experience of participants
Role (years in role)
Number of participants
Registered nurse (more than 10 years)
Registered nurse (1–10 years)
Newly graduated nurse (less than 1 year)
Endorsed enrolled nurse (3–10 years)
Medication management and EMMS
At both hospitals, medications were stored in a medication room when they required injection, refrigeration or co-signature for administration. Other prescribed oral medications were stored in each patient’s bedside cabinet, in a locked drawer to which nurses had a key.
Key behaviours involved in using EMMS to administer medication
Nurses endorsed to do so use the EMMS to administer medication.
The administering nurse logs into the EMMS and opens the patient’s eMAR.
When leaving the eMAR, the administering nurse logs off the eMAR or changes user.
Open a single patient’s eMAR at a time. With only their eMAR open prepare medication for one patient at a time immediately before intended use (includes medications requiring a second person check or witness).
Check the eMAR to identify when medications are due.
Check the eMAR to ascertain when the medication was previously administered.
Within scope of practice limitations nurse select medications in the eMAR.
Check medication preparation and administration instructions and alerts/icons in the eMAR.
Check the purpose, action and safe dose range of the medication to be administered prior to administering the medication.
Complete associated medication-related tasks and enter information in the eMAR prior to administering medication (e.g. blood glucose level, blood pressure, heart rate).
Check medication-associated test results (e.g. electrolyte levels) on the system prior to administering medication.
Take an eMAR to the patient to check the 5 Rights of medication administration prior to administration of a medication. Check the 5 Rights of medication administration against the patient’s eMAR and the patient prior to administering medication.
Ascertain that the patient is not allergic to the medication to be administered by checking the patient’s allergies listed in the eMAR and with the patient prior to administering the medication. This requires that a responsive eMAR be taken to the patient when administering medication.
Medications requiring a witness: a responsive eMAR must be taken to the patient to check the 5 Rights of medication administration prior to administration of a medication. Check the 5 Rights of medication administration against the patient’s eMAR and the patient prior to administering medication. In addition, preparation, administration and discarding of unused medications must be witnessed and the witness must enter their username and password in the eMAR following medication administration and discarding of unused medication (at the time of medication administration).
Medications requiring a second person check: a responsive eMAR must be taken to the patient to check the 5 Rights of medication administration prior to administration of a medication. The administering and checking nurse check the 5 Rs verifying the patient identification, allergies and order in the eMAR. The administering nurse is logged into the eMAR, and the details of the checking nurse should be recorded in the eMAR at the time of medication administration.
Assess whether it is safe to administer medication (is there any reason why the medication should not be administered (e.g. oral medication when patient is unconscious; administration of medication is contraindicated on the basis of tests, fasting, etc).
If appropriate (see B16), administer medications according to a time frame prescribed in the eMAR.
Relevant information about medication administration is recorded and communicated. Medication administration is to be recorded in the eMAR by the administering nurse once it has successfully been administered (at the time of administration). Oral medication must be observed to be consumed by the patient before the administering nurse enters it as administered in the eMAR. Unadministered medication should be recorded accordingly—‘not given’, ‘withheld’, ‘rescheduled’, ‘delayed’ and a reason entered. If a variable medication dose is ordered, the dose administered should be recorded in the eMAR. If the administered dose is different from the prescribed dose, the amount administered and the reason for the difference should be entered in the eMAR.
When the administration information has been entered, the screen should be refreshed/the eMAR closed.
Barriers to appropriate use of EMMS
Nine domains of the TDF collectively captured the major barriers to nurses’ use of EMMS: Environmental Context and Resources; Social/Professional Role and Identity; Knowledge; Beliefs about Consequences; Beliefs about Capabilities; Social Influences; Memory, Attention and Decision Processes; Emotion; and Intention. Additional file 1: Table S6 contains descriptions of these domains, behaviours for which they are a barrier, and related evidence from the interviews. Some barriers could be attributed to more than one domain depending on the context.
Of these nine domains, two were more richly described than the others: Environmental Context and Resources and Social/Professional Role and Identity. We include illustrative data excerpts from the manuscript to highlight barriers relevant to these two domains. Further evidence is provided in (Additional file 2: Table S7) in the form TableNumber_QuoteNumber (e.g. T7_Q1).
We then identify BCTs that have been shown to be effective in influencing these two theoretical domains. For each barrier, we present an example of a BCT operationalised into a potential context-specific intervention strategy, italicised in brackets (see Additional file 2: Table S7).
Environmental Context and Resources
According to the TDF, available resources and the environment in which a behaviour must be performed influence a person’s inclination to perform it . Environmental Context and Resources emerged as a key barrier to appropriate use of EMMS and is frequently affected by availability and properties of COWs; technology characteristics; specific contexts; and competing demands and time pressure.
Availability and properties of COWs
If we don’t have a laptop for every nurse that’s on, that’s the big impact. There’s always one in the morning that doesn’t get the computer. (Interview 91)
If they find out it’s too much equipment, too many furnishings in the room and it’s high risk for a fall for the patients, they can leave it outside and get the drawer. Just take the single drawer, put it on the COW and dispense the medication, put it back, check their MRN number and go to the patient and give it. (Interview 42)
At night, the noise of the COWs, the risk of bumping into things and the bright screens were likely to wake sleeping patients or agitate confused patients. Nurses worked around this by not taking a COW to their bedsides (T7_3).
Specific contexts, such as when patients were isolated, presented additional barriers. Infection control policies required equipment to be left in the isolation room or to be cleaned down when being removed. There were insufficient COWs to dedicate to isolation rooms, and their physical properties made them difficult and time-consuming to disinfect (T7_Q4).
Possible targeted interventions
Increasing the number of COWs (BCT: adding objects to the environment) and introducing handheld devices that can be easily cleaned or encased in disposable covering for use with isolated patients (BCT: restructuring the physical environment).
Features of the EMMS
It only lasts a while before it logs out so you can’t be taking someone to the toilet or whatever, it’ll log out and you’ve got to log back in and you’ll have lost everything (Interview 3)
the doctor ceased the medication on the other terminal. I was giving out the medication and gave it to the patient, was going to sign the order and then find out the order is not there anymore. (Interview 30)
Sometimes with the paper charts, if the times weren’t suitable or something needed to be given with meals, we just changed the times ourselves or even ceased drugs if you knew they were just for 48 h.
I'll sometimes give it at the - what I'd think is the correct time and then sign it later and maybe change it later on. (Interview 57)
Possible targeted interventions
Lengthening logout time (H1), introducing an automatic screen lock without logout, restructuring the EMMS to allow one authorised user at a time (H2) (BCT: restructuring the physical environment), and introducing an alert in eMAR or providing stickers on computers to remind doctors to consider local context when prescribing (e.g. ‘06:30 is 1 h before breakfast on Unit X’) (BCT: prompts/cues) .
Time pressure and competing demands
If you’re in a rush and sometimes you just can’t—it’s more accessible for you just to do your stuff at the computer, run to the patient and run back (Interview 39)
Time pressure was exacerbated by limited staff authorised to use EMMS and the timing of medication rounds. In one unit, where the medication round had been rescheduled, nurses described a reduction in competing demands.
Possible targeted interventions
Ensuring there are sufficient resources, including staff authorised to administer and check medication by either changing the times of ward rounds or personal care or adding staff to the medication administration process (e.g. appointing one nurse to have the role of checking/witnessing medications) (BCT: adding objects to the environment) ).
Social/Professional Role and Identity
According to the TDF, the degree to which a behaviour is believed to align with, strengthen or undermine a person’s social or professional role and identity will influence whether they will implement the behaviour . Nurses’ appropriate use of EMMS was strongly influenced by whether it supported or challenged their Social/Professional Role and Identity.
Using the EMMS appropriately hindered nurses from effectively executing behaviours that were an important part of their professional role and identity, including having the authority to administer medications, being time-efficient, considering patient preferences, promoting patient safety and demonstrating respect for colleagues.
Having the authority to administer medications
that affects their routine then, because they’re then waiting for us to come and do something for them that might be stopping them from doing something else. So it holds them back in their patient care. Most of the EENs here will—are happy to—once they’ve had it checked by one of us, they’re happy to administer it. (Interview 61)
Possible targeted interventions
Visual images to convey approval of nursing professional bodies, lawyers and managers to adherence to sign off requirements in the EMMS, for example posters of opinion leaders saying Sign it only if you administered it positioned in places where nurses prepare medications (BCT: information about others’ approval).
I think even the juniors, they’re a lot more anxious they want to get it done before anyone else, before anyone else has to check on them (Interview 39)
Like on a busy morning shift, 9 o’clock you’re only up to two patients and there are four patients with alarm clock next to it and you feel like a sense of failure maybe … you’re slower than the others. Yeah like you’re no good, you’ve got poor time management. (Interview 31)
Possible targeted interventions
Persuasive communication during professional development sessions to draw attention to the discrepancies between nurses’ practice of rushing and administering medication earlier than prescribed and their self-image as a nurse who takes the time to administer medication safely (BCT: incompatible beliefs) and facilitated workshops to challenge the view that OMAs reflect poor practice—particularly where they are used as a reminder that medication is yet to be administered  (BCT: social comparison).
Delivering patient-centred care
Sometimes when patients want Panadol early, sometimes it won’t be available in the system but you want to give it, so sometimes you just give it, then go in later and click it off. (Interview 91)
Possible targeted intervention
Introducing professional development sessions to present a persuasive message emphasising that the EMMS aims to protect patients from medication error and staff from legal retribution, and is just as important as other dimensions of patient-centred care (BCT: framing/reframing) .
Delivering safe care
But the more I’m at the bedside, patients start asking questions, and that’s kind of when you lose your thoughts. So I’d rather look at the doses in the drug room where it’s quiet, rather than at the bedside where other patients are … (Interview 91)
Possible targeted interventions
Prompting nurses to deliberately adopt a new perspective on the benefits of using the EMMS appropriately (BCT: framing/reframing), e.g. indicating that taking the COW into an isolated room saves time by providing easy access to information about tests and point-of-care information, and improving legibility of medication orders or providing other options for cleaning the COW efficiently; demonstrating how to manage interruptions during medication administration (BCT: demonstration of behaviour) may be done face-to-face during group professional development sessions or by using a video.
Collegiality and teamwork were considered important to nursing professional behaviour. The professional importance nurses placed on not impinging on their colleagues’ time was therefore a barrier to using the EMMS appropriately. Rather than ask a colleague to check medications for one patient at a time, nurses therefore prepared and signed off medications for multiple patients in the EMMS when a colleague was available (T7_Q16).
Nurses did not consider that it was consistent with their position to log doctors and pharmacists out of the eMAR. Rather than log a colleague out or reclaim the COW they were using, nurses used desktop computers to administer medication and to protect against losing information if they were logged out. Alternatively, nurses signed off medication in the eMAR as having administered it to the patient before doing so (T7_Q17).
Possible targeted interventions
Using persuasive communication to draw attention to the discrepancies between safe medication administration (part of the image of an ideal nurse) and signing medication as administered before doing so (BCT: incompatible beliefs), highlighting the potential implications of a medication error for the patient, and the administering and checking nurses or demonstrating to nurses how to discuss with colleagues the impact of logging them off the eMAR and taking the COW when they are doing medication administration (BCT: demonstration of the behaviour).
We find it difficult keeping them maintained. People a) don’t take responsibility for them so won’t initiate if they notice something wrong with it, if it is physically broken or if it is a software problem they won’t initiate it, it will just be left in the corridor to the side so it decreases the number of resources. (Interview 65)
Yeah, and you’re setting, it’s out of your place, if you’re younger, to say, ‘Look aren’t you going to take [the COW] with you?’ (Interview 39)
Possible targeted interventions
Using posters with pictures of senior members of staff, opinion leaders and patients to advocate nurses’ professional responsibility to their patients and team members to report broken equipment to ensure availability of working laptops for medication administration (BCT: information about others’ approval), displaying information on how to report problems with equipment and computers, reminding senior nurses that their medication administration behaviour is a role model for others, encouraging them to identify the importance of their actions in shaping their unit’s professional culture and inviting them to present information about medication administration as a part of ongoing education to encourage them to identify as role models (BCT: identification of self as role model).
Consistent with the literature on nurses’ use of EMMS, we identified several forms of non-compliance and ‘working around’ in response to perceived barriers to using EMMS [21–23]. More theory-driven implementation and evaluation of patient safety practice interventions have been called for [64, 65]. To our knowledge, this was the first study using the TDF to identify key barriers to nurses’ use of EMMS and to formulate targeted, theoretically based interventions to facilitate improvements. Applying the tested TDF approach, for the first time, to examine barriers to appropriate use of EMMS within the Australian healthcare system adds to the growing body of evidence for the utility of the TDF.
Our study found that nine (overlapping) TDF domains represented barriers to nurses’ appropriate use of EMMS, including two which were particularly richly described. Environmental context and resources proved key barriers to nurses’ appropriate use of EMMS. Other studies have highlighted barriers such as design shortcomings [21, 22, 26–28, 30, 66], time pressure and competing demands. The availability, size and characteristics of COWs and log-in time influenced nurses’ likelihood of taking them to the bedside, leaving unattended COWs logged in, or signing off medications before administration.
Proposed theoretically informed interventions support non-theoretically generated interventions previously offered to address specific features and contextual configuration barriers to EMMS use [32, 67]. Targeted interventions might include introducing handheld devices that can be easily used with isolated patients. It is crucial that ergonomic design improvements are based on assessment of workflow and environment and pilot-tested prior to implementation [29, 32]. McLeod and colleagues reported, for example, nurses preferred a smaller tablet over a COW but found that because the tablet was too small, medications were signed off at the desktop . Previous findings highlight the benefits of point-of-care access to information about test results, medication administration instructions and patient information [68, 69]. These features should all be preserved on smaller devices.
Our results also highlight the role of social/professional identity as a key barrier to implementing EMMS. The introduction of technology changes nursing practices, processes, patient care and the meaning of nursing work [70–72], potentially undermining nurses’ confidence and threatening professional identity . Nurses’ professional identity includes administering medication and efficiently delivering safe care, where possible, according to patient’s requests and needs. Behaviour change interventions may require nurses to prioritise one over another. Future studies should explore moderating variables influencing nurses’ judgements about using EMMS as intended.
Implications for implementation
Implementation of these theoretically derived interventions requires consideration of location-specific relevance, feasibility and leadership. One strategy is to encourage a culture that facilitates staff-management trust to facilitate reporting and rectification of barriers.
Measures in other contexts have attempted to build upon the TDF in order to facilitate the development and implementation of strategies. The Theoretical Domains Framework Implementation (TDFI) approach has six steps to implementing interventions and has demonstrated efficacy in co-designing, with frontline clinicians and interventions to address local factors to affecting behaviour change [44, 45]. Applying the TDFI in the EMMS context would incorporate co-design, implementation and evaluation of intervention strategies to improve EMMS use.
One challenge in operationalising the TDF is mapping individual barriers to a single theoretical domain  and dealing with inevitable overlap between domains . Barriers may fall into different TDF domains. For example, administering medications at prescribed times did not match with meal times (environmental context and resources), were considered to be not in patient’s best interests (beliefs about consequences), were not when the patient wanted to take medication (social/professional roles and identity) or should not be changed by nurses (social/professional roles and identity). Identifying which barriers and appropriate BCTs to target them requires an understanding of local context. This underlines the importance of involving healthcare professionals in identifying and interpreting barriers and co-designing specific interventions.
However, overlap between domains can provide practical advantages. Understanding the many facets to what initially appears to be a single barrier domain (e.g. difficulties cleaning COWs) allows for a multipronged approach for which the effect of different strategies may be synergistic. Theory-based interventions incorporating multiple BCTs and modes of delivery have a greater effect than those that do not [35, 73]. It is vital to ensure that the reports of these interventions are transparent and replicable to enhance understanding of change mechanisms.
Study limitations, strengths and future directions
Interview data were coded retrospectively using the TDF approach. While this allowed for identification of the issues that are most salient to practising nurses, using the TDF to inform questionnaire design may have elicited reports of barriers that are not spontaneously reported . Designing an interview schedule based on a theoretical framework could, therefore, supplement future studies of barriers to appropriate use of EMMS.
To enhance generalisability, studies examining healthcare professionals’ use of technology must consider its use across contexts . A strength of this study was its sampling from two hospitals, multiple units and different types of EMMS, maximising variation and applicability of findings to other contexts. However, the participants were all nurses, therefore limiting the generalisability of study findings to other professions. This is particularly important given the relevance of the Social/Professional Role and Identity domain for nurses as a key barrier to EMMS implementation.
Nurses’ ability to adapt and balance competing demands during medication rounds has been documented . Nurses in this study employed numerous workarounds to circumvent barriers in order to administer medication. Future work could usefully map these intuitively developed strategies to BCTs. Do they, for example, address some barriers to behaviour change while concurrently creating barriers to others? Do all nurses use workarounds to address barriers to performing the required practice or do certain factors moderate when they are implemented and by whom? Understanding how intuitively derived interventions for addressing key problems align with theory-based BCTs and barriers could further advance the science of implementation .
This study identified barriers to the use of EMMS in daily practice to examine potential solutions to these barriers. Garnering the perspectives of nurses was an essential component of this process given their role in medication administration. The study demonstrated that the TDF provided a useful framework both to categorise and assess barriers to nurses’ appropriate use of EMMS and to suggest theory-based interventions to target these barriers.
When presenting raw data as illustrative quotes, they have been minimally edited to remove filler words such as ‘um’, ‘ah’, ‘mm’ that do not add meaning to the content and synonyms used for words that, because they were particular to individuals, potentially identified them.
Behaviour change technique
Computers on wheels
Electronic medication administration record
Electronic medication management systems
New South Wales
Overdue medication alerts
Theoretical Domains Framework
Theoretical Domains Framework Implementation
We would like to thank the nurses who participated in this study.
This work was supported by the National Health and Medical Research Council Program Funding Scheme (grant number 568612). JB’s work is funded by a National Health and Medical Research Council Program Grant (APP1054146).
Availability of data and materials
The qualitative data sets generated during and/or analysed during the current study are not available for sharing as ethical approval for this study precludes data sharing.
DD collected, coded and analysed the data and wrote the first draft of the manuscript. NT assisted with the data analysis and contributed to the writing of the manuscript. WL and DG assisted with the data analysis through peer review of emergent findings. DD, DG, DB and JB had extensive planning discussions about the design and conduct of this work over time. NT, WL, DG, JT, DB and JB reviewed and contributed to the writing of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
Ethics approval was granted by a Lead Human Research Ethics Committee (HREC) with site-specific ethics approvals gained from participating hospitals. The University [anonymised for review] HREC was a ratifying HREC (approval number: HC09223). The participants provided written informed consent.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Australian Commission on Safety and Quality in Health Care. Literature review: medication safety in Australia. Sydney: Australian Commission on Safety and Quality in Health Care; 2013.Google Scholar
- Australian Government Productivity Commission. Productivity commission report on government services. Australia: Australian Productivity Commission; 2015.Google Scholar
- De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216–23. doi:10.1136/qshc.2007.023622.View ArticlePubMedPubMed CentralGoogle Scholar
- Mansouri A, Ahmadvand A, Hadjibabaie M, Kargar M, Javadi M, Gholami K. Types and severity of medication errors in Iran; a review of the current literature. Daru. 2013;21(1):1.View ArticleGoogle Scholar
- Saghafi F, Zargarzadeh AH. Medication error detection in two major teaching hospitals: what are the types of errors? J Res Med Sci. 2014;19(7):617–23.PubMedPubMed CentralGoogle Scholar
- Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. Ann Surg. 2013;257(1):1–5.View ArticlePubMedGoogle Scholar
- Pinilla J, Murillo C, Carrasco G, Humet C. Case-control analysis of the financial cost of medication errors in hospitalized patients. Eur J Health Econ. 2006;7(1):66–71.View ArticlePubMedGoogle Scholar
- Choi I, Lee SM, Flynn L, Kim CM, Lee S, Kim NK et al. Incidence and treatment costs attributable to medication errors in hospitalized patients. Res Social Adm Pharm. 2016;12(3):428–37.
- Glavin RJ. Drug errors: consequences, mechanisms, and avoidance. Br J Anaesth. 2010;105(1):76–82.
- Patel I, Balkrishnan R. Medication error management around the globe: an overview. Indian J Pharm Sci. 2010;72(5):539.View ArticlePubMedPubMed CentralGoogle Scholar
- Agrawal A. Medication errors: prevention using information technology systems. Brit J Clin Pharmacol. 2009;67(6):681–6.View ArticleGoogle Scholar
- Yang Z, Ng B-Y, Kankanhalli A, Luen Yip JW. Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system. Int J Hum Comput Stud. 2012;70(1):43–65. doi:10.1016/j.ijhcs.2011.08.002.View ArticleGoogle Scholar
- Westbrook J, Lo C, Reckmann M, Runciman W, Braithwaite J, Day R, editors. The effectiveness of an electronic medication management system to reduce prescribing errors in hospital. HIC 2010: Proceedings; 18th Annual Health Informatics Conference: Informing the Business of Healthcare; 2010 24-26 August 2010; Melbourne Convention and Exhibition Centre. Brunswick East, Vic: Health Informatics Society of Australia. 2010.
- Barber N, Cornford T, Klecun E. Qualitative evaluation of an electronic prescribing and administration system. Qual Saf Health Care. 2007;16(4):271–8. doi:10.1136/qshc.2006.019505.View ArticlePubMedPubMed CentralGoogle Scholar
- Franklin G, O’Grady K, Donyai P, Jacklin A, Barber N. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care. 2007;16:279–84.View ArticlePubMedPubMed CentralGoogle Scholar
- Morriss Jr FH, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN, et al. Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. J Pediatr. 2009;154(3):363–8.View ArticlePubMedGoogle Scholar
- Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, et al. Effect of bar-code technology on the safety of medication administration. NEJM. 2010;362(18):1698–707.View ArticlePubMedGoogle Scholar
- Eslami S, Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in hospitalized patients: a systematic review. Int J Med Inform. 2008;77(6):365–76.View ArticlePubMedGoogle Scholar
- Samaranayake NR, Cheung STD, Cheng K, Lai K, Chui WCM, Cheung BMY. Implementing a bar-code assisted medication administration system: effects on the dispensing process and user perceptions. Int J Med Inform. 2014;83(6):450–8.View ArticlePubMedGoogle Scholar
- Debono D, Greenfield D, Travaglia J, Long J, Black D, Johnson J, et al. Nurses’ workarounds in acute healthcare settings: a scoping review. BMC Health Serv Res. 2013;13:175.View ArticlePubMedPubMed CentralGoogle Scholar
- Koppel R, Wetterneck T, Telles JL, Karsh B. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. JAMIA. 2008;15(4):408–23.PubMedPubMed CentralGoogle Scholar
- McLeod M, Barber N, Franklin BD. Facilitators and barriers to safe medication administration to hospital inpatients: a mixed methods study of nurses’ medication administration processes and systems (the MAPS study). PLoS One. 2015;10(6), e0128958.View ArticlePubMedPubMed CentralGoogle Scholar
- Hardmeier A, Tsourounis C, Moore M, Abbott W, Guglielmo B. Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. J Healthc Qual. 2014;36(4):54–63.View ArticlePubMedGoogle Scholar
- Patterson E, Cook R, Render M. Improving patient safety by identifying side effects from introducing bar coding in medication administration. JAMIA. 2002;9:540–53.PubMedPubMed CentralGoogle Scholar
- Niazkhani Z. Evaluating the impact of CPOE systems on medical workflow: a mixed method study. Stud Health Technol Inform. 2008;136:881–2.PubMedGoogle Scholar
- Niazkhani Z, Pirnejad H, van der Sijs H, Aarts J. Evaluating the medication process in the context of CPOE use: the significance of working around the system. Int J Med Inform. 2011;80:490–506.View ArticlePubMedGoogle Scholar
- Patterson ES, Rogers ML, Chapman RJ, Render ML. Compliance with intended use of bar code medication administration in acute and long-term care: an observational study. Hum Factors Ergon. 2006;48:15–22.View ArticleGoogle Scholar
- Pirnejad H, Niazkhani Z, van der Sijs H, Berg M, Bal R. Evaluation of the impact of a CPOE system on nurse-physician communication - a mixed method study. Methods Inf Med. 2009;48(4):350–60.View ArticlePubMedGoogle Scholar
- Carayon P, Wetterneck T, Hundt A, Ozkaynak M, DeSilvey J, Ludwig B, et al. Evaluation of nurse interaction with bar code medication administration technology in the work environment. J Patient Saf. 2007;3(1):34–42.View ArticleGoogle Scholar
- Rack L, Dudjak L, Wolf G. Study of nurse workarounds in a hospital using bar code medication administration system. J Nurs Care Qual. 2012;7(3):232–9.View ArticleGoogle Scholar
- Eley R, Fallon T, Soar J, Buikstra E, Hegney D. Barriers to use of information and computer technology by Australia’s nurses: a national survey. J Clin Nurs. 2009;18(8):1151–8.View ArticlePubMedGoogle Scholar
- Lee BC, Lee S, Kwon BC, Yi JS. What are the causes of noncompliance behaviors in bar code medication administration system processes? Int J Hum Comput Interact. 2015;31(4):227–52.View ArticleGoogle Scholar
- Dyson J, Lawton R, Jackson C, Cheater F. Does the use of a theoretical approach tell us more about hand hygiene behaviour? The barriers and levers to hand hygiene. J Infect Prev. 2011;12:17–24.View ArticleGoogle Scholar
- Albarracin D, Johnson BT, Fishbein M, Muellerleile PA. Theories of reasoned action and planned behavior as models of condom use: a meta-analysis. Psychol Bull. 2001;127(1):142.View ArticlePubMedPubMed CentralGoogle Scholar
- Taylor N, Conner M, Lawton R. The impact of theory on the effectiveness of worksite physical activity interventions: a meta-analysis and meta-regression. Health Psychol Rev. 2012;6(1):33–73. doi:10.1080/17437199.2010.533441.View ArticleGoogle Scholar
- Cheater F, Baker R, Gillies C, Hearnshaw H, Flottorp S, Robertson N, et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009;1:1–32.Google Scholar
- Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57(4):660–80.View ArticleGoogle Scholar
- Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26–33.View ArticlePubMedPubMed CentralGoogle Scholar
- Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37.View ArticlePubMedPubMed CentralGoogle Scholar
- Lipworth W, Taylor N, Braithwaite J. Can the theoretical domains framework account for the implementation of clinical quality interventions? BMC Health Serv Res. 2013;13(1):530.View ArticlePubMedPubMed CentralGoogle Scholar
- Phillips CJ, Marshall AP, Chaves NJ, Jankelowitz SK, Lin IB, Loy CT, et al. Experiences of using the Theoretical Domains Framework across diverse clinical environments: a qualitative study. J Multidiscip Healthc. 2015;8:139.PubMedPubMed CentralGoogle Scholar
- Cane J, Richardson M, Johnston M, Ladha R, Michie S. From lists of behaviour change techniques (BCTs) to structured hierarchies: comparison of two methods of developing a hierarchy of BCTs. Br J Health Psychol. 2015;20(1):130–50.View ArticlePubMedGoogle Scholar
- Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81–95.View ArticlePubMedGoogle Scholar
- Taylor N, Lawton R, Moore S, Craig J, Slater B, Cracknell A, et al. Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline. BMC Health Serv Res. 2014;14(1):648.View ArticlePubMedPubMed CentralGoogle Scholar
- Taylor N, Lawton R, Slater B, Foy R. The demonstration of a theory-based approach to the design of localized patient safety interventions. Implement Sci. 2013;8(1):123.View ArticlePubMedPubMed CentralGoogle Scholar
- Mirbaha F, Shalviri G, Yazdizadeh B, Gholami K, Majdzadeh R. Perceived barriers to reporting adverse drug events in hospitals: a qualitative study using theoretical domains framework approach. Implement Sci. 2015;10(1):110.View ArticlePubMedPubMed CentralGoogle Scholar
- Duncan EM, Francis JJ, Johnston M, Davey P, Maxwell S, McKay GA, et al. Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. Implement Sci. 2012;7(1):1.View ArticleGoogle Scholar
- McCluskey A, Vratsistas-Curto A, Schurr K. Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study. BMC Health Serv Res. 2013;13(1):323.View ArticlePubMedPubMed CentralGoogle Scholar
- Yorkshire Quality and Safety Research Group. ABC for patient safety. Bradford: Improvement Academy, Yorkshire & Humber Academic Health Science Network partners; 2013.Google Scholar
- Keers RN, Williams SD, Cooke J, Walsh T, Ashcroft DM. Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review. Drug Saf. 2014;37(5):317–32.View ArticlePubMedGoogle Scholar
- Debono D. Learning the rules of the game: how ‘good nurses’ negotiate workarounds [Doctoral Thesis]. Sydney: University of New South Wales; 2014.Google Scholar
- Bowling A. Research methods in health: investigating health and health services. Buckingham: Open University Press; 1997.Google Scholar
- Miles MB, Huberman AM. Qualitative data analysis. 2nd ed. London: Sage Ltd; 1994.Google Scholar
- Garling P. Final report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals: Overview Report. Sydney: State of NSW through the Special Commission of Inquiry: Acute Care Services in New South Wales Public Hospitals; 2008.Google Scholar
- NSW Department of Health. Caring together: the health action plan for NSW. Sydney: NSW Department of Health; 2009.Google Scholar
- Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks: Sage Publications; 2007.Google Scholar
- Liamputtong P. The science of words and the science of numbers: research methods as foundations for evidence-based practice in health. In: Liamputtong P, editor. Research methods in health foundations for evidence based practice. Melbourne: Oxford University Press; 2010. p. 3–26.Google Scholar
- Charmaz K. The search for meanings—grounded theory. In: Smith J, Harré R, Van Langenhove L, editors. Rethinking methods in psychology. London: Sage; 1996. p. 27–49.Google Scholar
- Taylor N, Lawton R, Conner M. Development and initial validation of the determinants of physical activity questionnaire. Int J Behav Nutr Phys Act. 2013;10(1):74.View ArticlePubMedPubMed CentralGoogle Scholar
- Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability. Field Methods. 2006;18(1):59–82. doi:10.1177/1525822x05279903.View ArticleGoogle Scholar
- Backman R, Foy R, Michael BD, Defres S, Kneen R, Solomon T. The development of an intervention to promote adherence to national guidelines for suspected viral encephalitis. Implement Sci. 2015;10(1):37.View ArticlePubMedPubMed CentralGoogle Scholar
- French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012;7(1):38.View ArticlePubMedPubMed CentralGoogle Scholar
- Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract. 2000;39(3):124–30.View ArticleGoogle Scholar
- Foy R, Ovretveit J, Shekelle PG, Pronovost PJ, Taylor SL, Dy S, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. BMJ Qual Saf. 2011;20(5):453–9.View ArticlePubMedGoogle Scholar
- Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in improvement. BMJ Qual Saf. 2015. doi: 10.1136/bmjqs-2014-003627.
- Cohen JF, Coleman E, Kangethe MJ. An importance-performance analysis of hospital information system attributes: A nurses' perspective. Int J Med Inform. 2016;86:82–90. doi:10.1016/j.ijmedinf.2015.10.010.
- Gavriloff C. A performance improvement plan to increase nurse adherence to use of medication safety software. J Pediatr Nurs. 2012;27(4):375–82. doi:10.1016/j.pedn.2011.06.004.
- Doran D, Haynes BR, Estabrooks CA, Kushniruk A, Dubrowski A, Bajnok I, et al. The role of organizational context and individual nurse characteristics in explaining variation in use of information technologies in evidence based practice. Implement Sci. 2012;7(122):38.Google Scholar
- Hurley A, Bane A, Fotakis S, Duffy M, Sevigney A, Poon EG, et al. Nurses’ satisfaction with medication administration point-of-care technology. JONA. 2007;37(7/8):343–9.View ArticleGoogle Scholar
- Barnard A, Gerber R. Understanding technology in contemporary surgical nursing: a phenomenographic examination. Nurs Inq. 1999;6:157–66.View ArticlePubMedGoogle Scholar
- Courtney KL, Alexander GL, Demiris G. Information technology from novice to expert: implementation implications. J Nurs Manag. 2008;16(6):692–9. doi:10.1111/j.1365-2834.2007.00829.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Courtney KL, Demiris G, Alexander GL. Information technology: changing nursing processes at the point-of-care. Nurs Admin Quart. 2005;29(4):315–22.View ArticleGoogle Scholar
- Webb T, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res. 2010;12(1), e4.View ArticlePubMedPubMed CentralGoogle Scholar
- Fitzpatrick G, Ellingsen G. A review of 25 years of CSCW research in healthcare: contributions, challenges and future agendas. Comput Support Coop Work. 2013;22(4-6):609–65.View ArticleGoogle Scholar
- American Psychological Associations’ Dictionary of Psychology, Washington, DC: American Psychological Association; 2007. APA Dictionary of Psychology.