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Table 4 Key content relating to the Theoretical Domains Framework for each indicator

From: Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study

  Risky prescribing Treatment targets in type 2 diabetes Anticoagulation in atrial fibrillation Blood pressure targets in treated hypertension
Knowledge GPs more knowledgeable compared to other staff
Awareness of drug interactions and patient history
Variable awareness of recommended HbA1c levels
Important to know the rationale and evidence behind recommendations
Guidance generally familiar as standard practice
Indicators familiar because of QOF
Important to have access to specialist knowledge
Treatment often initiated in secondary care
Lack of staff experience in starting treatment given relatively infrequent clinical presentation in primary care
Indicators familiar because of QOF
Indicators ingrained as ‘bread and butter’ of general practice
Skills Communication skills for effective patient counselling
Limited time to use skills (e.g. communication)
Communication skills for effective patient counselling
Having technical skills such as medication titration
Skills for monitoring and managing blood pressure more common than those for HbA1c
Communication skills for effective patient counselling Communication skills for effective patient counselling
Technical skills such as using blood pressure machines, obtaining reliable readings and titrating treatment
Social professional role and identity Prescribing perceived to be mainly the role of GPs. Practice nurses viewed their input as restricted to reviewing medication if required
GP autonomy to deviate from guidance
Threat of litigation reinforces nurse prescribers’ adherence to guidance
Recognition of role of pharmacist
Prescribing practice driven by perceived patient needs and professional ethos rather than guidance
Refer to diabetic lead if patient taking multiple medications
Clarity of roles and responsibilities
Tailoring care to patient needs and professional ethos more important than achieving strict targets
Tailored patient care can both help and hinder adherence (e.g. in elderly patients and patients with multiple conditions)
Role more focused on long-term rather than acute care as atrial fibrillation often initially presents to secondary care
Hospitals not always as up to date with guidance as they should be, resulting in wrong or contradictory advice for primary care
Clinicians with more cardiac expertise tend to be responsible for most patients
Practice nurses viewed their input as restricted to reviewing medication if required
Clarity of roles and responsibilities
Professional ethics and threat of litigation promote adherence
Tailoring care to patient needs and professional ethos more important than achieving strict targets
Beliefs about capabilities Clear guidance and access to specialist knowledge and training
Adequacy of information technology system support
Confidence in ability to achieve targets depends on patient factors such as attendance and motivation
Many clinicians confident with blood pressure and cholesterol but less so with HbA1c and any associated medication changes
Organised links between primary and secondary care
Confidence in diabetes lead
Information technology capability to identify patients not achieving targets
Confidence related to availability of specialist staff, training and updates
Supportive, organised links between primary and secondary care
Confidence helped by relative simplicity of guidance and decision support
Confidence hindered by patient factors and limited resources for referrals
Beliefs about consequences Ensuring quality of care, patient health and patient safety
Reputation for following guidance reflects well on practice and professional
Perceived threat of litigation to nurse prescribers if guidance not followed
Immediate financial and time costs (prescribing budget, increased appointments, auditing) outweighed by the potential longer term NHS cost reduction
Achieving targets linked to quality of care and better patient outcomes
Achieving targets associated with short term gains in QOF income and longer term NHS savings
Job satisfaction in achieving targets
Perceived pressure to achieve targets undermines rapport with patients
Achieving targets requires time and increases workload
Costs for patients and side effects from additional prescribing to achieve targets
Ensuring quality of care, patient health and patient safety
Achieving targets associated with short term gains in QOF income and longer term NHS savings
Strict adherence to guidance inappropriate for some patients (e.g. elderly and those on multiple medications)
Ensuring quality of care and patient health
Achieving targets associated with short term gains in QOF income and longer term NHS savings
Perceived increased workload associated with following guidance (e.g. consultation length)
Motivation and goals Adherence ensures quality of care, patient health and patient safety
Promoting a positive reputation for the practice
Guarding against litigation
Incentivisation of good prescribing
Generally high motivation to follow guidance
Achieving targets associated with short term gains in QOF income and longer term NHS savings
Achieving targets linked to quality of care, better patient outcomes and job satisfaction
Ensuring quality of care, patient health, and patient safety
Achieving targets associated with short term gains in QOF income and longer term NHS savings
Ensuring quality of care, better patient health and job satisfaction
Achieving targets associated with short term gains in QOF income and longer term NHS savings
Generally high motivation to follow guidance
Memory, attention and decision processes Information technology systems often not in line with intuitive cognitive processes
Decision aids and prompts for drug interactions
Patient history provides important information for decision making
Automatic cognitive processes useful in high-risk situations
Awareness of patient characteristics such as older age can influence decision of whether or not to aim for targets
System prompts useful for embedding targets into memory
Relatively infrequent presentation of atrial fibrillation hinders commitment of guidance to memory
Prompts and the ability to view guidance support decision making
High prevalence of hypertension helps embed guidance into routine practice
Patient characteristics (e.g. older age) can influence tailored care to meet patient’s needs
Guidance considered easy to retain
Prompts useful for supporting adherence to guidance
Environmental context and resources Practice nurses pick up medication issues during reviews but lack knowledge and suitable templates sometimes impede this
Prescribing policies, support and advice available from CCG medicines management teams and pharmacists
Lack of time (e.g. training and education) and decision support. Inadequate information technology systems and communications with secondary care
External support from CCG, information technology systems and training opportunities
Low staffing levels and high workloads
Communication between primary and secondary care could be improved to support achievement of targets
Communication systems and established lines of responsibility within the practice are needed in order to identify potential issues around professionals’ adherence
Inadequate communication between primary and secondary care
Time and workload, especially as current information technology systems do not support easy identification of eligible patients
Established lines of responsibility, clear templates and access to training and education (e.g. motivational interviewing and titration for nurses)
Limited availability of home blood pressure machines, heavy workload and short duration of consultation makes it difficult to schedule a specific time to measure blood pressure which contributes to difficulties in achieving targets
Social influences Patient preferences
General approach and support of practice team
Pressure from QOF to achieve targets
Practice managers aware that achieving targets is linked to practice QOF performance
Benchmarking performance against other practices
Overall team approach in practice
Pressure from QOF to achieve targets
General approach and support of practice team
Patient preferences
Pressure from QOF to achieve targets
Team factors and support within and outside the practice (e.g. network meetings
Benchmarking performance against other practices
Patient preferences
Emotion Emotion generally not considered an influence
Discomfort when guidance conflicts with patient-centred care
Feeling constrained by guidance
Feelings of caution and worry when prescribing additional medication
Workload-related fatigue restricted ability to have in-depth conversations with patients
Achieving targets lead to job satisfaction
Adverse impacts of fatigue on achieving targets
Frustration from patient factors (e.g. resistance, low motivation) and missing targets
Perceived pressure from targets which can generate tension between clinicians and patients
Frustration caused by complicated guidance making treatment difficult to explain to patients
Limited time, mood and fatigue result in deferring decisions to further consultations
Discomfort with pushing adherence amongst elderly patients
Emotion generally not considered an influence
Achieving targets lead to job satisfaction
Fatigue and workload influence whether targets were considered at every consultation
Unease created by patient reactions to additional prescribing
Behavioural regulation Computer prompts for drug interactions, templates, audit and medication reviews
Problems associated with rapidly accessing and interpreting full patient records
Computer prompts not always useful – can be overwhelming
Help from computer prompts, recall systems, clear protocols and templates
Action sequences helpful (e.g. reviewing patient medical notes and setting electronic reminders for action to self within patient record)
Help from computer prompts, recall systems, clear protocols and templates
Limited ability of current computer prompts to support adherence to guidance
Help from computer prompts, recall systems, clear protocols and templates
Patient risk factors act as prompts
Opportunistic reviews of patient records
Computer prompts not always considered useful and potentially distract from main purpose of consultation
  1. CCG Clinical Commissioning Group, QOF Quality Outcomes Framework