Table 3 Major themes and sub-themes
From: Defining barriers and enablers for clinical pathway implementation in complex clinical settings
Themes (sub-themes) and definitions | TDF domain | |
|---|---|---|
1. CP and Standardization | ||
Health Professional Level | CP quality: confidence that CP is based on best available current evidence | Beliefs about consequences |
Knowledge | ||
Awareness of and benefits of using this CP | ||
Ability to follow CP and medical directives | Skills | |
Sustained CP use: sustained CP use questioned post-study | Memory, Attention, and Decision Processes | |
Perceived value of standardization: perception that standardization is good; improves health care. CP aids decision-making and will minimize errors | Social/Professional Role and Identity | |
Memory, Attention, and Decision Processes | ||
New scoring tools: unknown scoring tools anticipated as difficult to remember components | Knowledge | |
Memory, Attention, and Decision Processes | ||
ED Team Level | Experience with other CPs/standardized tools that can help with this implementation | Knowledge |
Perceived value of evidence-based standardized practice: reception to standard work. Standardization is good; improves health care | Social/Professional Role and Identity | |
ED impact: postive and negative | Beliefs about consequences | |
General commitment to best practice and best patient outcomes: general commitment across ED team/hospital to quality and process improvement initiatives | Goals | |
Intentions | ||
External social influences: impact of non-ED members (e.g., pediatricians) on CP use | Goals | |
Reinforcement | ||
Experience for future improvement processes | Social Influences | |
Organizational Context Level | Ready access to CP Tools: accessibilty to CP tools | Behavioural Regulation |
User-friendly tools: clear, easy documentation with minimal duplication | ||
Organizational reinforcement: CP might be helpful for sites with limited resources | ||
Memory, Attention, and Decision Processes | ||
Reinforcement | ||
Hospital Impact: postive and negative | Beliefs about consequences | |
Administrators’ commitment to CP implementation | Intentions | |
2. Pediatric/Patient-Specific Issues | ||
Health Professional Level | Knowledge and (lack of) experience in pediatrics may affect comfort with using the CP; may also create interest in the CP | Knowledge |
Skills | ||
Beliefs about capabilities | ||
Fear/anxiety with pediatric patients: generalized anxiety that pediatric patients deteriorate quickly. Peds patients generally have staff “at attention” | Emotion | |
ED Team Level | Benefits to patients: positive patient benefits are motivating to staff and administrators | Reinforcement |
Parental emotions: parental emotions may heighten stress among ED team | Emotion | |
Impact on patient care: using the CP will positively impact patient care. | Beliefs about consequences | |
Organizational Context Level | Benefits to patients | Beliefs about consequences |
Pediatrics factors | Environmental Context and Resources | |
3. Professional Issues | ||
Intrinsic rewards: potential impact on job satisfaction, professional well-being | Reinforcement | |
Scope of RN vs MD practice: CP shifts roles and scope of work: RNs can do more, less for the MDs to do | Social/Professional Role and Identity | |
Workload capacity: impact of other work on ability to implement/use the CP | Beliefs about capabilities | |
Threats to autonomy or decision-making: perceived threats to autonomy/ decision-making among MDs with use of the CP; opporutnity for input on CP; MD skepticism. Potentially offensive to clinicians to assume decision-making assistance is needed | Social/Professional Role and Identity | |
Memory, Attention, and Decision Processes | ||
Behavioural Regulation | ||
Staff/physician ED experience: inexperienced RNs, part-time and locum MDs may impact ability to follow directives, CPs; may facilitate implementation since minimal practice change is required | Skills | |
Beliefs about capabilities | ||
Environmental Context and Resources | ||
Unfamiliarity with the CP: generalized concern about doing things differently, learning about a new CP | Emotion | |
Memory, Attention, and Decision Processes | ||
Cognitive demands: until CP is engrained in practice, more cognitive demand and attention required. | Memory, Attention, and Decision Processes | |
Competing priorities: many competing priorities threaten attention to CP use; CP topics not priority for EDs | ||
4. Team Dynamics | ||
Confidence in Interdisciplinary Capabilities: Perceived MD confidence in RN’s abilities; RN confidence in MD’s abilities | Beliefs about capabilities | |
Confidence in team: confidence in hospital/ ED team ability to implement/use the CP, including impact of positive past experiences | Optimism | |
Beliefs about capabilities | ||
Goals | ||
Change fatigue: frustration/burnout with change among ED teams/hospitals may impact this CP implementation | Emotion | |
Memory, Attention, and Decision Processes | ||
Competing ED priorities: many competing ED priorities threaten attention to CP use; CP topics not priority issues for EDs | Memory, Attention, and Decision Processes | |
Environmental Context and Resources | ||
Concern that CP use may decrease during busy shifts or challenging periods, which are when the CP can be most helpful. | Environmental Context and Resources | |
Memory, Attention, and Decision Processes | ||
Formal/informal champion: local champion actions influence use of CP, directly and indirectly | Reinforcement | |
Adaptability, resistance, and buy-in: adaptability or lack thereof among staff to accept and adopt the CP | Social Influences | |
Interdisciplinary influences: impact of RNs on MD practice behaviour, and vice-versa | Social Influences | |
Conformity/conflict: pressures within the ED team to conform; conflicts within team | ||
Staff size: impacts ability to introduce and adopt the CP | Environmental Context and Resources | |
Optimism | ||
5. Strategies for Success and Sustainability | ||
Strategies used to impart relevant knowledge, skills; reinforce and regulate behaviours for CP use | ||
Education strategies: -In-shift training -Web modules -Professional education credits; huddles; narratives (stories); interdisciplinary training sessions; case examples; side-by-side modelling) | Knowledge | |
Skills | ||
Reinforcement | ||
Behavioural Regulation | ||
Communication: use of communication to share knowledge, reinforce, and regulate behaviour | ||
Audit and feedback: use of audit and feedback to share knowledge, reinforce, and regulate behaviour | Behavioural Regulation | |
Reinforcement | ||
Triggers/reminders: use of triggers and reminders to reinforce appropriate CP use -Posters; pocket cards; triage triggers; site champion/ super-user(s) -Integrate into existing technologies | Reinforcement | |
Memory, Attention, and Decision | ||
Behavioural regulation | ||
Input: opportunity to provide input on CP tools is likely to affect its use among staff (esp. MDs) | Behavioural regulation | |
Recognition: recognition to highlight those appropriately using the CP | Behavioural regulation | |
6. Hospital Resources and Processes | ||
Staffing: presence of stable and committed staffing group with appropriate supports | Environmental Context and Resources | |
IT support: support for IT related aspects of CP access and functioning | ||
Organizational priorities: priority initiatives at organizational level | ||
Physical design, space: physical setup and use of space in the ED | ||
Drugs, equipment: access and availability of drugs, equipment related to the CP | ||
Approval committees: processes and delays for CP approval from various hospital committees | ||
Multi-site hospital campuses: several hospitals have multisite campuses with | ||
Setting: impact of urban vs rural setting | ||
Funding: pressures related to ED Wait Times funding incentives | ||
7. Quality and Process Improvement | ||
General commitment to best practice and best patient outcomes | Intentions | |
Goals | ||
Impact of positive past experiences | Optimism | |