Background
Domain (definition) | Constructs |
---|---|
1. Knowledge (An awareness of the existence of something) | • Knowledge (including knowledge of condition/scientific rationale) • Procedural knowledge • Knowledge of task environment |
2. Skills (An ability or proficiency acquired through practice) | • Skills • Skills development • Competence • Ability • Interpersonal skills • Practice • Skill assessment |
3. Social/Professional Role and Identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting) | • Professional identity • Professional role • Social identity • Identity • Professional boundaries • Professional confidence • Group identity • Leadership • Organisational commitment |
4. Beliefs about Capabilities (Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use) | • Self-confidence • Perceived competence • Self-efficacy • Perceived behavioural control • Beliefs • Self-esteem • Empowerment • Professional confidence |
5. Optimism (The confidence that things will happen for the best or that desired goals will be attained) | • Optimism • Pessimism • Unrealistic optimism • Identity |
6. Beliefs about Consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation) | • Beliefs • Outcome expectancies • Characteristics of outcome expectancies • Anticipated regret • Consequents |
7. Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus) | • Rewards (proximal/distal, valued/not valued, probable/improbable) • Incentives • Punishment • Consequents • Reinforcement • Contingencies • Sanctions |
8. Intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way) | • Stability of intentions • Stages of change model • Transtheoretical model and stages of change |
9. Goals (Mental representations of outcomes or end states that an individual wants to achieve) | • Goals (distal/proximal) • Goal priority • Goal/target setting • Goals (autonomous/controlled) • Action planning • Implementation intention |
10. Memory, Attention and Decision Processes(The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives) | • Memory • Attention • Attention control • Decision making • Cognitive overload/tiredness |
11. Environmental Context and Resources (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) | • Environmental stressors • Resources/material resources • Organisational culture/climate • Salient events/critical incidents • Person and environment interactions • Barriers and facilitators |
12. Social Influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours) | • Social pressure • Social norms • Group conformity • Social comparisons • Group norms • Social support • Power • Intergroup conflict • Alienation • Group identity • Modelling |
13. Emotion (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event) | • Fear • Anxiety • Affect • Stress • Depression • Positive/negative affect • Burn-out |
14. Behavioural Regulation (Anything aimed at managing or changing objectively observed or measured actions) | • Self-monitoring • Breaking habit • Action planning |
Methods
Study setting
Clinical context
TDM advisory Service
Data collection materials
Recruitment
Data collection and analysis
Results
Characteristic | n (%) |
---|---|
Position | |
Prescriber | 17 (74) |
JMO | 8 (35) |
Registrar | 7 (30) |
Staff Specialist | 2 (9) |
Pharmacist | 6 (26) |
Sex | |
Male | 11 (48) |
Experience in prescribing and monitoring vancomycin | |
< 1 year | 3 (13) |
1–5 years | 12 (52) |
6–10 years | 3 (13) |
> 10 years | 4 (17) |
Unspecified | 1 (4) |
Frequency of vancomycin prescribing and monitoring | |
≥ Once per day | 2 (9) |
≥ Once per week | 3 (13) |
≥ Once per month | 6 (26) |
≥ Once per year | 6 (26) |
Variablea | 5 (22) |
Unspecified | 1 (4) |
Received dose advice from the Service | |
Yes | 13 (57) |
No | 10 (43) |
Barriers to acceptance of the pilot Service
TDF Domain | Reported barrier | Supporting participant quotes | |
---|---|---|---|
Had interacted with the Service | Had not interacted with the Service | ||
‘Knowledge’ | Lack of procedural knowledge | “… so I might know that actually it [trough concentration] was a peak, or actually it was taken before the wrong dose or I might just know that from being on the ward and realise that there was a mistake there, so if I’m given advice based on that mistake then I wouldn’t” (P03, JMO)a | “There are times when the blood is not actually taken at an appropriate time … that’s the only time I can think of, when I know there’s a problem with the test … so when there’s something I’m aware of, that the person who’s just looking at numbers on the computer is not aware of” (P13, Registrar)a |
Lack of knowledge of the existence of the Service | “I guess [a] major limitation would be people not knowing about it” (P06, Pharmacist) | “… if people are moving around from different hospitals and don’t train early on knowing that this is available...” (P09, Registrar) | |
Lack of scientific knowledge | NR | “I guess the lack of evidence, again, coming back to the same point, and perhaps even clinical guidelines … some people may prefer to refer to the guidelines because a lot of work has gone into it; a lot of evidence from other sources” (P17, Pharmacist)a | |
‘Environmental Context and Resources’ | Limited accessibility of dose advice | “The turnaround time of these reports might be a limitation … are they available when we need them?” (P21, Pharmacist) | “… the hours in which it runs … but it probably won’t be running on the weekend, so as long as there’s another something in place” (P04, JMO) |
Communication issues | NR | “… the only way of potentially complicating it I think is communication issues” (P09, Registrar) | |
Resources, person x environment | NR | “… it depends how busy the person is, I mean if they’re on the team that has a lot of patients then electronically, they may or may not forget” (P14, JMO) | |
‘Social Influences’ | The prescribing hierarchy | “… sometimes I’ve been asked to not chart the medication that is being prescribed, and that’s come from either ID or from one of our senior registrars and I think it’s because of the clinical picture of the patient that they’ve decided to go with the current dose” (P08, JMO) | “If it was a complex patient, we’d probably get an infectious diseases consult and then they could give advice as to what to do with that recommendation” (P10, JMO a |
‘Beliefs about Consequences’ | Belief that dose advice is incorrect | “… perhaps if the recommended dose was very much different to what they thought it would be and what consultants might want as well, that would be a large barrier in terms of accepting and adopting that change” (P11, Pharmacist)a | “… if it was abnormally high or there was something that didn’t make sense. If I had seen they were previously quite stable and then it suddenly said, ‘Triple the dose’, then that would be a bit odd and you’d probably want to question.” (P20, Registrar)a |
Increased workload | NR | “… the only time I guess it could be hard to accept it is if, for example, in oncology and haematology patients when they lose weight really quickly over a week or two and that might not be updated on the [hospital electronic medication management system], so it might not represent the true weight and then you’d have to sort of manually check it to make sure that it’s all fine” (P12, JMO)a | |
Belief that dose advice will not be accessed | “… there’s no guarantee that anyone will look at this So I suppose it’s on assumption that, you know, this information is available and prescribers and healthcare workers will look into it, or make use of it” (P19 Registrar) | NR | |
Concerns that dose advice is not appropriate | NR | “Broadly speaking, where I would you know have concerns it’s too high or low, their renal function’s gone off since the dose recommendation had been made but I doubt there’d be too much in it” (P23, Staff Specialist) | |
‘Social/Professional Role and Identity’ | Role of senior clinicians in prescribing decision-making | NR | “I could imagine sometimes, you know, the consultants in a certain setting might disagree with it” (P23, Staff Specialist) |
‘Skills’ | Deskilling of healthcare professionals | “I think it does take away your own learning process … I used to know by heart what the values were that I should be aiming for. Whereas now I feel like I’m becoming a bit more dependent on the system telling me what to do” (P08, JMO) | “I think the one [limitation] I foresee is that it will lead to a degree of deskilling, which is a problem you get with any process you introduce.” (P13, Registrar) |
‘Memory, Attention and Decision Processes’ | Forgetting to check dose advice | NR | “… you have to remember to actually look up the result online” (P12, JMO) |
Knowledge
Environmental context and resources
Social influences
Facilitators to acceptance of the Service
TDF Domain | Reported facilitator | Supporting participant quotes | |
---|---|---|---|
Had interacted with the Service | Had not interacted with the Service | ||
‘Beliefs about Consequences’ | Dose advice leads/will lead to better prescribing and better patient outcomes | “… you are covered by a system that’s already been put in place to protect the patients from your lack of knowledge” (P08, JMO)a | “You’d probably theoretically get better control of effective levels of vancomycin and better treatment of vancomycin-required therapies” (P05, Registrar) |
Dose advice will reduce anxiety, improve confidence, and aid prescribing decisions | “I’m certainly imagining it will be helping prescribers and especially the junior doctors, who often aren’t confident, or not even confident with antibiotics as a whole.” (P19, Pharmacist) | “… it might be useful to have them [the Service] just to provide a bit of assistance in terms of dosing, in terms of therapeutic level” (P14, JMO) | |
Prescribing is/will be easier and/or more efficient with Service involvement | “… this process seems much more efficient because we don’t really have to redo the work, we’ve already got the data there … we just thought TDM Advisory group uses that data that is available to then give a more accurate result” (P06, Pharmacist) | “… anything that makes our job smoother and faster people would think is positive” (P04, JMO) | |
Dose advice reduces workload | “It saves time for prescribers in terms of dose adjustments, whether or not to review the guidelines and ‘um’ and ‘ah’ about what to do … the Service, it’s quite straightforward.” (P11, Pharmacist) | “I think it’ll be helpful if they’re able to order the samples for me” (P14, JMO) | |
Clinical teams will accept dose advice | “… getting that information to them [prescribers], they will change it [the dose].” (P06, Pharmacist)a | “We would probably just accept it anyways” (P13, Registrar)a | |
‘Environmental Context and Resources’ | Communication | “I feel that at least a page or a phone call to the team to notify them that this vancomycin dose is way too much for this patient or way too subtherapeutic for a patient will at least help influence the time to change the dosing” (P11, Pharmacist) | “… if they wanna just adjust it, that’s fine, but it would always be good to have it communicated in some way as well, either written in the notes or someone call us …” (P04, JMO) |
Accessibility of dose advice | “… having that link [the dose report], means that not only I can access it, any one of the doctors or nurses who’re involved in the patient care have access to this information because it’s there when you sign into the patient’s results …” (P19, Pharmacist) | “… it needs to be somewhere that’s really easily accessible, otherwise it’s gonna get lost and people won’t even realise that it’s generated” (P10, JMO) | |
Resources | NR | “If it was like vastly outside of it, I’d need to look twice and I’d probably either speak to someone in clin [ical] pharm [acology] or look up like AMH or MIMS or whatever and see” (P18, Registrar) | |
‘Social Influences’ | Service operators are vancomycin prescribing experts | “… the TDM Service are experts in therapeutic drug monitoring which is really important for vancomycin and getting the dose right..” (P03, JMO) | “… the way the hospital runs is different teams with different expertise provide input, so if the team with the vancomycin expertise provides input, you’d be silly to ignore it” (P10, JMO) |
Social support | “… we had a patient that was on vancomycin. One of the doctors asked about what dose they were on, so I said, ‘It’s been modelled by the clin [ical] pharm [acology] team and they’re on this dose and that’s giving the appropriate levels’, so I said that to reassure them that it was correct, they were happy with it” (P15, Pharmacist)a | “I think something that would make me take the advice on board more willingly would be talking to the microbiologist over the phone so that at least you can flag what your concerns are and they’ll take that into consideration” (P16, Registrar) | |
‘Knowledge’ | Knowledge of the existence of the Service | “… in pharmacy we’re informed of this Service, I assume they [the Service operators] would’ve done similar education or informed the prescribers in the hospital that this is available and is of benefit and to help guide practitioners in terms of dosages. So, just getting that message, and if they are aware of that, I’m sure doctors would refer to it” (P19, Pharmacist) | “… they [prescribers] then need to know that this [Service] exists” (P09, Registrar) |
Scientific knowledge | “… if they [prescribers] understood the principles of why it’s recommended, then they would be more likely to adopt it” (P11, Pharmacist) | “I would take the opinion if it’s definitely evidence-based, 100% I would definitely do that. So if they [the Service operators] say that this is the recommended dose that you use for this person for this particular indication I’d definitely take that on board” (P16, Registrar)a | |
Procedural knowledge | NR | “I guess it’s just people knowing that that’s a change and that that’s where it is and knowing where to find it and then maybe I guess if you do that, you don’t need to speak to infectious diseases as often” (P20, Registrar) | |
‘Beliefs about Capabilities’ | Dose advice increases/will increase professional confidence and comfort with vancomycin prescribing | “… and that [the dose report] kind of put me at ease seeing this has been considered. The software’s saying this, look at the progress notes and they kind of tally up and I’m more comfortable with that sort of dose.” (P19, Pharmacist)a | “… if we’re more confident about prescribing drugs that are perceived as sort of dangerous or uncommon for us, then we would also be more comfortable and that would be a very positive thing for us” (P04, JMO) |
‘Memory, Attention and Decision Processes’ | Understanding of vancomycin prescribing decision processes | NR | “… if they just tell me “drug level is low, please adjust”, then I probably will like something like that [the dose report] that will help me decide what the next dose should be.” (P14, Registrar) |