Table 8 Reaching agreement when coding data using TDF and identifying beliefs within domains

Study title

 Anaesthesiologists’ and Surgeons’ Perceptions about Routine Pre-operative testing in low risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests.

Rationale for changing behaviour

 Routine pre-operative tests for anaesthesia management are ordered by both anaesthesiologists and surgeons for healthy patients undergoing low-risk surgery, often without any clinical indication and the subsequent test results are rarely used. Identifying factors that influence why anaesthesiologists’ and surgeons’ order these routine tests for healthy patients undergoing low risk surgery provide more effective targets for intervention development.

Study design and materials

 Interview study–sixteen clinicians (eleven anaesthesiologists and five surgeons) throughout Ontario were recruited. An interview guide based on the TDF was developed to identify beliefs about pre-operative testing practices. Physicians’ statements were content analysed into the relevant theoretical domains. Two researchers coded interview participants’ statements into the relevant theoretical domains. The first pilot interview was coded in tandem to develop the coding strategy and the second was used to ensure the two coders were comfortable with the strategy developed from the first. Subsequent coding of the remaining interviews was completed independently and Fleiss’s Kappa (κ) was calculated for all domains and interviews to assess whether the two researchers coded the same text into the same domain. Within each domain, the primary coder wrote a belief statement that captured the core thought of each utterance. For example, the following utterances were coded under the domains Social Influences: “… if a surgeon ordered it I am somewhat reluctant to cancel one of their tests even though I don’t feel that it’s necessary” & “Sometimes they are ordered and then (we) might be reluctant to cancel some of the tests because I am not privy to their thought process….”. These 2 utterances were from 2 different respondents but reflect the same core thought: I’m reluctant to cancel tests ordered by other physicians. Identical beliefs statements were then grouped together. Statements that centred on same theme or were polar opposites of a theme were also grouped together for the ease of further analysis. For example, the following 3 belief statements from Social Influences grouped under the theme influence of colleagues: The opinions of others do not influence my decision to order routine tests. I’m reluctant to cancel test ordered by other physicians. I order tests I feel are unnecessary because my conservative colleague may be in the operating room on the day of the surgery and want to see the routine test that I would not.

Belief statements that were coded in different domains by the researchers were discussed to establish consensus. Where single domain allocation agreement could not be reached, researchers agreed that the statement could be placed in both domains.

Findings and conclusions

 Seven domains were identified as likely relevant to changing clinicians’ behaviour about pre-operative test ordering for anaesthesia management (Social/professional role and identity, Beliefs about capabilities and Social influences, Environmental context and resources, Beliefs about consequences, Behavioural regulation, Nature of the behaviour). Key beliefs identified within these domains included: conflicting comments about who was responsible for the test-ordering, inability to cancel tests ordered by fellow physicians, and the problem with tests being completed before anaesthesiologists see patients. Anaesthesiologists often ordered tests based on who may be the attending anaesthesiologist on the day of surgery while surgeons ordered tests they thought anaesthesiologists might need. There was also a range of comments about the consequences associated with reducing testing, from negative (delay or cancel patients’ surgeries), to indifference (little or no change in patient outcomes), to positive (save money, avoid unnecessary investigations).

Study outputs

 Patey et al. [28]