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01.12.2017 | Research | Ausgabe 1/2017 Open Access

Implementation Science 1/2017

Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses’ use of electronic medication management systems in two Australian hospitals

Implementation Science > Ausgabe 1/2017
Deborah Debono, Natalie Taylor, Wendy Lipworth, David Greenfield, Joanne Travaglia, Deborah Black, Jeffrey Braithwaite
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Electronic supplementary material

The online version of this article (doi:10.​1186/​s13012-017-0572-1) contains supplementary material, which is available to authorized users.



Medication errors harm hospitalised patients and increase health care costs. Electronic Medication Management Systems (EMMS) have been shown to reduce medication errors. However, nurses do not always use EMMS as intended, largely because implementation of such patient safety strategies requires clinicians to change their existing practices, routines and behaviour. This study uses the Theoretical Domains Framework (TDF) to identify barriers and targeted interventions to enhance nurses’ appropriate use of EMMS in two Australian hospitals.


This qualitative study draws on in-depth interviews with 19 acute care nurses who used EMMS. A convenience sampling approach was used. Nurses working on the study units (N = 6) in two hospitals were invited to participate if available during the data collection period. Interviews inductively explored nurses’ experiences of using EMMS (step 1). Data were analysed using the TDF to identify theory-derived barriers to nurses’ appropriate use of EMMS (step 2). Relevant behaviour change techniques (BCTs) were identified to overcome key barriers to using EMMS (step 3) followed by the identification of potential literature-informed targeted intervention strategies to operationalise the identified BCTs (step 4).


Barriers to nurses’ use of EMMS in acute care were represented by nine domains of the TDF. Two closely linked domains emerged as major barriers to EMMS use: Environmental Context and Resources (availability and properties of computers on wheels (COWs); technology characteristics; specific contexts; competing demands and time pressure) and Social/Professional Role and Identity (conflict between using EMMS appropriately and executing behaviours critical to nurses’ professional role and identity).
The study identified three potential BCTs to address the Environmental Context and Resources domain barrier: adding objects to the environment; restructuring the physical environment; and prompts and cues. Seven BCTs to address Social/Professional Role and Identity were identified: social process of encouragement; pressure or support; information about others’ approval; incompatible beliefs; identification of self as role model; framing/reframing; social comparison; and demonstration of behaviour. It proposes several targeted interventions to deliver these BCTs.


The TDF provides a useful approach to identify barriers to nurses’ prescribed use of EMMS, and can inform the design of targeted theory-based interventions to improve EMMS implementation.
Additional file 1: Table S6. Barrier examples and illustrative quotes by domain. Nine domains of the TDF collectively captured the major barriers to nurses’ use of EMMS: Environmental Context and Resources; Social/Professional Role and Identity; Knowledge; Beliefs about Consequences; Beliefs about Capabilities; Social Influences; Memory, Attention and Decision Processes; Emotion; and Intention domains. Descriptions of the nine domains, the component behaviours for which they are a barrier and evidence related to each from the interviews are provided in Table S6. (DOCX 49 kb)
Additional file 2: Table S7. Proposed interventions (modes of delivery of BCTs) mapped to barriers to EMMS use. Two domains of the TDF emerged more strongly than the others in capturing barriers to nurses’ use of EMMS: Environmental Context and Resources, and Social/Professional Role and Identity. In-text references to specific examples (Additional file 2: Table S7) are given in the form TableNumber_QuoteNumber (e.g. T7_Q1)]. We then identify BCTs that have been shown to be effective in influencing these two theoretical domains. For each barrier, we present an example of a BCT operationalised into a potential context-specific intervention strategy. To distinguish them from the specific targeted interventions designed to deliver them, BCTs are italicised in brackets. Additional examples are provided in (Additional file 2: Table S7). (DOCX 56 kb)
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