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Table 5 Table of findings by TDF domain

From: Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF)

Target clinical behaviour TDF domain Reported barrier Reported enabler Behaviour change technique label
Swallow assessment Environmental context and resources - Difficulty finding time to document screening results in the electronic health record [24] - Efficient processes to support swallow screen tool administration and interpretation [24] - Restructuring the physical environment
Social influences - No data available - Multidisciplinary team cooperation and support from ED administrators [24] - Social support (unspecified)
Knowledge - No data available - More education on dysphagia and evidence-based screening of swallowing [24] - Information about health consequences
Skills - Inaccurate interpretation of screening items [24]
- Inconsistent administration of the swallow screen tool [24]
- No data available - No data available
Memory, attention and decision processes - Difficulty recalling all screening items during administration of the swallow screen tool [24] - No data available - No data available
All patients to be assessed for tPA eligibility
All eligible patients receive tPA
Beliefs about capabilities - Lack of self-efficacy [27] - Informants emphasized that the rapid expansion of stroke treatment options in recent decades has contributed to work pride and improved motivation to implement guidelines [28]
- “I can” accurately identify stroke patients (93.7%) [25]
- “I can” accurately identify which stroke patients may be eligible for tPA (62.0%) [25]
- The hospital has a policy for the management of stroke patients (85.8%) [25]
- The hospital has a policy for rapid referral of suspected stroke patients from ED to stroke specialists (76.2%) [25]
- The hospital has a policy for rapid access to imaging for suspected stroke patients (87.0%) [25]
- The hospital has a policy for administration of tPA when appropriate (72.7%) [25]
- Exposure, mentoring, protocols and experience through the implementation of stroke units in rural facilities, telemedicine and stroke code protocols might be beneficial to improve physicians’ ability to confidently diagnose stroke patients eligible for tPA treatment [29]
- Confidently interpret brain imaging scans (66.9%) [25]
- Social support (practical)a
- Focus on past success
- Focus on past success
- Focus on past success
- Focus on past success
- Focus on past success
- Focus on past success
- Verbal persuasion about capability; Focus on past success; Exposurea
- Focus on past success
Intentions - Lack of motivation [27] - Taking active part in quality improvement and research programs [28] - Restructuring the social environmenta
Knowledge - Lack of guideline awareness [27]
- Lack of guideline familiarity [27]
- Lack of knowledge about and experience with thrombolytic therapy [28]
- Failure to react to guideline deviations [28]
- Uncertainty with patient selection criteria [29]
- Blood pressure control [26]
- Guideline awareness and knowledge among all staff [28]
- Knowledge and attitudes of the providers on how to offer tPA to stroke patients [27]
- Continuing professional education [28]
- Education on symptoms of stroke, tPA use, pathways and protocols, its efficacy and ICH risk [29]
- Education for physicians on the calculated risk of ICH following intravenous tPA [29]
- Information about health consequences
- Information about health consequences
- Information about health consequences
- Information about health consequences
- Information about health consequences
Environmental context and resources - Lack of agreement between guidelines [27]
- Stressful working conditions [28]
- Recruitment difficulties [28]
- Limited time, human, and financial resources [28]
- Duty schedule inhibiting training [28]
- Lack of continuity (with various dimensions) [28]
- Pre-hospital delays [29]
- Patients presenting outside the time window [26]
- ED delays [29]
- Long communication time between ED staff and neurology team [26]
- Delayed referral from GP [32]
- Not ideal setting [29]
- Administrative barriers [29]
- Lack of urgency in the ED [26]
- Formal and informal meetings [28]
- Short intra hospital distances for thrombolytic processes [28]
- “To help me follow stroke care protocol” there are checklists/decision aids to help identify and triage a possible stroke case (68.8%) [25]
- “To help me follow stroke care protocol” there are checklists/decision aids to help identify stroke patients eligible for tPA (66.7%) [25]
- “At all times I have immediate access to” advice from a senior colleague in managing stroke (76.9%) [25]
- “I have immediate access to” staff trained to interpret images (78.5%) [25]
- Restructuring the social environment
- Restructuring the physical environment
- Prompts/cues
- Prompts/cues
- Restructuring the physical environment
- Restructuring the physical environment
Beliefs about consequences - Lack of outcome expectancy [27]
- Old-fashioned views on stroke, with low expectations of therapeutic options [28]
- Physician reluctance [26]
- Undue respect for treatment [28]
- Risk of intra-cranial haemorrhage [29]
- Uncertainty about benefits of tPA [29]
- No data available - No data available
Social/professional role and identity - Insufficient recognition by peers and decision makers [28]
- Poor professional identity [28]
- Formal power structures and prestige [28]
- Close collaboration with staff outside the stroke unit [28]
- Good leadership [28]
- Restructuring the physical environmenta
- Social support (unspecified)
Optimism   - Positive staff attitudes, within and outside the stroke unit [28] - No corresponding techniqueb
Behavioural regulation - Failure to react to guideline deviations [28] - Implementation work included in routines [28]
- Feedback on success or failure [28]
- Quality assurance with continuous feedback on implementation progress [28]
- Habit formationa
- Feedback on outcome(s) of behavioura; Feedback on behavioura
- Feedback on outcome(s) of behavioura; Feedback on behavioura
Skills - Interpretation of CT [29]
- Clinical diagnostic uncertainty [29]
- Personal stroke neurology experience [29]
- Experience with tPA inclusions and exclusions [29]
- Difficulty identifying stroke in presenting patients [26]
- Exposure and experience through the implementation of stroke units in rural facilities, telemedicine and stroke code protocols might be beneficial to improve physicians’ ability to confidently diagnose stroke patients eligible for tPA treatment [29]
- Continuing professional education [28]
- “I regularly” treat acute stroke patients (91.4%) [25]
- “I regularly” have the opportunity to treat stroke cases of varying complexity (88.3%) [25]
- Trained stroke nurses available [25]
- “I have seen” tPA administered to stroke patients on several occasions (78.8%) [25]
- Behavioural practice/rehearsal
- Instruction on how to perform a behavioura
- Behavioural practice/rehearsal
- Behavioural practice/rehearsal
- Restructuring the physical environmenta
- Demonstration of the behaviora
Social influences - Lack of support [28, 29] - Involvement of all professionals in implementation work [28]
- Respected and influential members of this hospital endorse the use of tPA (67.5%) [25]
- Between-hospital benchmarking and sharing experiences with staff at other hospitals [28]
- Social support (unspecified)
- Information about others’ approval
- Social comparison
Triaged at Australian Triage Scale 1 or 2 Knowledge - Inadequate public education about stroke: including patients and GPs [30]
- Stroke not recognised as a priority [31]
- No data available - No data available
Environmental context and resources - Lack of resource : staff shortages in facilities [30]
- Competing demands in ED and staffing challenges during busy times [31]
- Having the stroke protocol for consistency [31] - Prompts/cues
Skills - Lack of training and public information [30] - No data available - No data available
Social/professional role and identity - Lack of coordination between staff [30]
- Overlong waiting times – stroke care, examinations [30]
- No data available - No data available
Beliefs about capabilities - Lack of comfort with assessing stroke patients using the National Institutes of Health Stroke Scale [31] - No data available - No data available
Transfer Environmental context and resources - Poor patient flow to the rehabilitation centre [32] - No data available - No data available
  1. CT Computed tomography, ED Emergency departments, ICH Intracerebral Haemorrhage
  2. aThis technique was not suggested by the Cane et al. matrix for the corresponding domain
  3. bIt was agreed that there was no behaviour change technique that represented this enabler. This is possibly due to the limited reporting of how the staff were influenced to develop the positive attitudes