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Table 2 Barriers identified for T3 target behaviours by Theoretical Domains Framework domain [36]

From: Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the Theoretical Domains Framework (TDF): the T3 Trial

Domain and example quotes [target behaviour]

Target behaviour

Barriers identified

Knowledge

(n a = 16)

An awareness of the existence of something

They would need intensive education. [Triage]

I think that if nurses are educated on the importance of having the temperature taken, the compliance will fit in. [Temperature management]

Triage

Possible lack of knowledge of triaging stroke patients using the Australasian Triage Scale

Delays in identifying symptoms of stroke

Thrombolysis

Not recognising importance of documenting ineligibility for rt-PA treatment

Uncertainty about use of criteria to select patients for rt-PAb

Temperature management

Lack of awareness and/or do not understand importance of monitoring temperature in stroke patients

Lack of knowledge about alternative modes of delivering paracetamol for patients with certain needs i.e. NBM

Limited or no access to IV or rectal paracetamol for patients who are NBM

Nurses reluctance to use rectal paracetamol as invasive or possibly patient refusal may result in nurse refusal to use

Nurses routinely treat at a higher temperature threshold according to hospital policies

Blood glucose management

Lack of understanding of importance of undertaking a formal BGL

Lack of understanding of importance of monitoring BGL

Lack of understanding of importance of administering insulin for all stroke patients regardless of diabetic status

Lack of knowledge about process of administering insulin infusion

Sceptism about benefits of administrating insulin for patients with a BGL > 10, e.g. risk of hypoglycemiab

Swallow management

Lack of knowledge that all patients who fail swallow screen should be assessed by a speech pathologist

Nurses reluctance to keep patients NBM due to lack of awareness of evidence that aspirin can be administered up to 48 hours post-stroke, i.e. may not need to be given immediately

Belief of lack of robust evidence for effectiveness of non-oral aspirin when patients are NBM

Skills

(n = 4)

An ability or proficiency acquired through practice

It’s the wards, there’s a lot of wards not use to running infusions [that may be commenced in ED]. [Blood glucose management]

We struggle with the skills …we have our normal competencies, we have trouble keeping up to date with [them]. [Blood glucose management]

Triage

Possible lack of experience in triaging of stroke patients

Temperature management

Lack of knowledge about alternative modes of delivering paracetamol for patients NBMb

Blood glucose management

Lack of skill in administering an insulin infusion

Swallow management

Lack of nurses trained how to conduct of swallow screening

Social/Professional Role and Identity

(n = 4)

A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting

Oh these patients they're Category 1 or 2 [Australian Triage Scale] so there's not necessarily the need for a nurse to initiate it. You can have a physician there at the bedside as well. [Thrombolysis]

I don’t have a problem with it, we certainly have spoken about this over the last few years, but it has been about getting support from speech pathology to roll it [nurse screening] out. [Swallow management]

Thrombolysis

Delays associated with securing a CT scanb

Temperature management

Nurses are unable to administer non-oral paracetamol without a written orderb

Blood glucose management

Inconsistent use or variation in protocols between between ED and stroke unit

Swallow management

Perception that role boundaries should not be blurred, i.e. traditional discipline-specific tasks should not be conducted by staff from other disciplines.

Beliefs about Capabilities

(n = 5)

Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use

So I'm just wondering whether we need some more education in terms of tPA to try and make clinicians more comfortable in the use of it for strokes. [Thrombolysis]

But the nurses having a bit more confidence to say “well no actually they haven’t had their swallow screen.” [Swallow management]

Thrombolysis

Uncertainty about use of criteria to select patients for rt-PAb

Swallow management

Nurses lack confidence to disagree with a doctor’s decision to override a patient’s NBM status b

Delays in authorisation of new protocols/forms by hospital management committeesb

Nurses’ own perception of competence in performing a swallow screen

Lack confidence in performing a swallow screen

Optimism

(n = 2)

The confidence that things will happen for the best or that desired goals will be attained

The stuff that you're talking about - doing, a temperature check and the blood sugar - it's all routine stuff anyway. That's just what they [nurses] would do. [Temperature management]

But I think getting used to just writing up for every patient with a stroke, and whether all the nurses use it. [Temperature management]

Temperature management

Perception that this action already routine practice

Attitude by nurses that changing practices about temperature management requires time

Beliefs about Consequences

(n = 9)

Acceptance of the truth, reality or validity about outcomes of a behaviour in a given situation

But with the unimpressive previous studies with stroke I don't think any of the consultants here feels that it's particularly worth pushing. I mean if it's [BGL] above 12 then we probably would do something. [Blood glucose management]

I think you're right there is a fear of hypoglycaemia, especially in stroke patients who are obviously a slightly different group who may be NBM [and] not be getting any feeding at all. So [with] a BSL of 10.1 and then putting them on insulin infusion when they're not eating anything starts to become also a little bit of a concern. [Blood glucose management]

Triage

Lack of understanding regarding importance of triaging stroke patients

Belief that triage allocation will not impact on the patient’s outcome

Temperature management

Lack of awareness of the importance of monitoring temperature in stroke patients

Nurses reluctance to use rectal paracetamol as invasive or possibly patients may refuse may result in staff reluctance to use

Blood glucose management

Belief that introducing insulin infusions will have unintended consequences i.e. prevents admission to the stroke unit or the patient is transferred to high dependency instead (many stroke unit will not accept patients with IV insulin infusions)

Perceived increase in staff workload if insulin is administered by IV infusion

Belief that there is a lack of research evidence to justify a BGL > 10 as a trigger to treat

Sceptism about benefits of administrating insulin for patients with a BGL > 10, e.g. risk of hypoglycemiab

Swallow management

Belief there is lack of robust evidence for effectiveness of non-oral medications such as aspirin

Reinforcement

(n = 1)

Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus

No, you cannot nurse-initiate PR paracetamol. [Temperature management]

At the moment we don't have direct access to IV paracetamol in ED, we have to call pharmacy to put an order in. [Temperature management]

Temperature management

Nurses are unable to administer non-oral paracetamol without a written orderb

Intentions

A conscious decision to perform a behaviour or a resolve to act in a certain way

Example quote not applicable

No barriers identified for this behaviour/domain

No barriers identified that corresponded with this domain

Goals

(n = 3)

Mental representations of outcomes or end states that an individual wants to achieve

[Name] has described how busy the ED is and it does add a layer of complexity to the patient when they are on an insulin infusion. [Blood glucose management]

Triage

Competing priorities in a busy ED environment

 

Blood glucose management

Competing priorities in a busy ED environmentb

Lack of understanding regarding the importance of administering insulin for all stroke patients regardless of diabetic status

Memory, Attention and Decision Processes

(n = 5)

The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives

The ED nurses are really good at that [taking temperature on admission], so everyone will get one on admission. It’s just how you remind people at that four hour mark to do it. [Temperature management]

It's a matter of remembering to request [the formal glucose]. [Blood glucose management]

Triage

Lack of adherence to certain care principles or pathways for stroke patientsb

Thrombolysis

Staff overlook documentation of reasons for not administrating rt-PA

Temperature management

Lack of adherence to certain care principles or pathways for stroke patientsb

Blood glucose management

Staff overlook requesting a formal BGL

Transfer

Competing priorities in a busy ED environmentb

Environmental Context and Resources

(n = 30)

Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour

I think [Name] was worried about increased workload for his department. [Blood glucose management]

That would be difficult for an infusion to run from coming to ED to ward. We have one working pump at the moment. We have another one that we use for thrombolysis on the ward. So if you're having people coming up on insulin infusions we won't have the equipment. [Blood glucose management]

Triage

Delays in identifying symptoms of stroke

Competing priorities in a busy ED environmentb

Patient’s mode of presentation at hospital influences triage categories

Inconsistent care processes between in-hours and out-of-hours

Thrombolysis

Delays associated with securing a CT scanb

No systems in place to manage stroke calls out-of-hours

Delays in authorisation of new protocols/forms by hospital management committeesb

Temperature management

Lack of thermometers in ED

Lack of knowledge about alternative modes of delivering paracetamol when patient NBMb

Hospital regulations set for drug prescribing

No hospital protocol for temperature management in stroke patients

Blood glucose management

Formal BGL testing not routine in current practice

No hospital protocol for BGL in stroke patients

Hospital initiatives prevent implementation of this care element i.e. cost saving relating to testing of bloods

Limited access to BGL machines

Lack of insulin infusion pumps

Competing priorities in a busy ED environmentb

Perceived increase in workload for staff administrating insulin to patients by IV infusion

Limited time due to competing priorities in a busy environment

No hospital protocol for use of insulin infusions in stroke patients

Inconsistent use or variation in protocols between ED and stroke unitb

Swallow management

Competing priorities in a busy ED environmentb

Difficulties with training appropriate staff due to staffing issues, out-of-hours and organisational issues

Ineffective systems of communication during staff hand-over on patient transfer from ED to the stroke unit such as lack of documentation of aspirin administration and whether swallow screen done, particularly when the patient failed the screen

No seven-day week service provided by speech pathologists

Transfer

Hospital protocols preclude the transfer of patient undergoing thrombolysis to the stroke unit

Ineffective communication between ward staff and bed managers

Availability of beds in stroke unit prevent patients from being transferred from ED

Staff shortages impacting on bed capacity of the stroke unit

Type of stroke may influence patient’s pathway to the stroke unit

Social Influences

(n = 8)

Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours

When there's a protocol and it's the same protocol it's quite easy but when it's different, which it often is … I think there's no continuity …. it falls through the cracks. [Swallow management]

Thrombolysis

Uncertainty about use of criteria to select patients for rt-PAb

Temperature management

Attitude that changing practices about temperature management requires time

Blood glucose management

Formal BGL testing is not routine in current practice

Clinical opinion overrules guidelines or protocols

Negative perception of the value and meaning of other staff roles

Swallow management

Inconsistent use or variation in protocols between ED and stroke unitb

Ineffective systems of communication during patient transfer from ED to stroke unit

Nurses lack of confidence to disagree with a doctor’s decision to override a patient’s NBM statusb

Emotion

(n = 4)

A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event

We don't want the situation where if there's no beds [in stroke unit], the patient's stuck in ED because they have an insulin infusion. [Blood glucose management]

I'm slightly concerned they may actually induce hypoglycaemia in the people [for whom] we're trying to adjust the insulin. It's very complicated. I can foresee that the risk for error is quite high. [Blood glucose management]

Thrombolysis

Uncertainty about use of criteria to select patients for rt-PAb

Blood glucose management

Belief that introducing insulin infusions will have unintended consequences i.e. prevents the admission to the stroke unit or the patient is transferred to a high dependency ward instead

Clinical opinion overrules guidelines or protocols

Swallow management

Nurses lack confidence to disagree with a doctor’s decision to override a patient’s NBM statusb

Behavioural Regulation

(n = 3)

Anything aimed at managing or changing objectively observed or measured actions

I think a lot of education needs to be provided around that [administering paracetamol at 37.5 °C] because nursing staff always think 38 °C, nothing [no paracetamol] until 38 °C. [Temperature management]

So I think this will be the most challenging because giving insulin at 10 is not something we would do. That's way outside our practice for normal… [Blood glucose management]

Temperature management

Nurses routinely and ‘automatically’ treat at a different temperature threshold

Staff perception that this action already routine practice

Blood glucose management

Nurses routinely and ‘automatically’ treat at a different threshold for BGL

  1. BGL blood glucose level, CT computed tomography, ED emergency department, IV intravenous, NBM Nil by mouth, rt-PA recombinant tissue plasminogen activator
  2. a‘n’ refers to the number of barriers identified for each domain
  3. bIndicates a barrier that was reported for more than one T3 trial behaviour