Background
Methods
The implementation of change model
Step | Summary of activities |
---|---|
1 | Development of a concrete proposal and targets for improvement or change |
• Systematic development | |
• Involvement of target group | |
• Good ‘product’ | |
• Accessible and attractive form | |
• Opportunity for local adaptions | |
2 | Analysis of performance, target group and setting |
• Stakeholders | |
• Current practice | |
• Barriers and incentives | |
• Readiness to change of subgroups | |
3 | Development or selection of strategies and measures to change practice |
• Tailored to target group and/or setting | |
• Cost-effective mixture of techniques of proven value | |
• Strategies for implementation | |
4 | Development, testing and execution of implementation plan |
5 | Evaluate and, where necessary, adapt plan |
The theoretical domains framework
TDF Domain | Example of use of domain when assessing target group concerning a behaviour change ‘X’ |
---|---|
Knowledge | Are they aware of X? |
Skills | Do they know how to do X? |
Social/professional role and identity | Is X compatible with professional identity? |
Beliefs about capabilities | How confident are they that they can do X? |
Beliefs about consequences | What do they think will happen if they do X? |
Motivation and goals | How much do they want to do X? |
Memory, attention and decision processes | Will they remember to do X? |
Environmental context and resources | Are there physical or resource factors which will facilitate or hinder X? |
Social influences | Will they observe others doing X? |
Emotion | Does X evoke an emotional response? |
Behavioural regulation | What preparatory steps are needed to do X? |
Nature of the behaviour | How understandable is X? |
Model for mapping behaviour change techniques to the TDF domains
Adult learning theory
Applying the models
Step 1 – development of a concrete proposal for change
Step 2 – analysis of performance, target group and setting
Step 3 – development or selection of strategies and measures to change practice
Steps 4 and 5 – development, testing and execution of the implementation plan, and its evaluation
Results
Step 1 – development of a concrete proposal for change
Step 2 – analysis of performance, target group and setting
TDF domain | Aspects of domain identified in target group analysis |
---|---|
Knowledge | The epidemiology and impact of OA, the recommendations of the NICE OA Guideline, the rationale for GPs providing support for the self-management of OA and that of making the diagnosis of OA clinically, details of the MOSAIC study procedures |
Skills | The skills needed to make the diagnosis of OA clinically, and those for delivering the model OA consultation |
Social/professional role and identity | The credibility of NICE guidance in general and specifically of NICE OA guidance, and the GP’s role in providing support for self-management |
Beliefs about capabilities | The time to deliver the model OA consultation in day-to-day practice, and any previous difficulties in managing OA |
Beliefs about consequences | The GPs’ doubts about the efficacy of OA interventions recommended by NICE OA guidance |
Motivation and goals | That OA and its management was not considered a high priority by the GPs, compared with other areas of general practice |
Memory, attention and decision processes | The GPs remembering to undertake the model OA consultation in day-to-day practice, when an older adult presents with peripheral joint pain |
Step 3 – development or selection of strategies and measures to change practice
TDF domain | Behaviour change intervention content | Techniques for behaviour change chosen to address domain |
---|---|---|
Knowledge | Burden/prognosis/pathophysiology of OA, experience of patients with OA of general practice | Information provision to address gaps in knowledge about: |
● The nature and management of OA | ||
● NICE OA recommendations | ||
NICE OA guidance, efficacy OA treatments | ● The model OA consultation | |
Rationale for making the diagnosis of OA clinically and for giving the diagnosis | ||
Rationale for self-care of OA, support for self-care and patient centre consulting | ||
OA Guidebook and the model OA consultation | ||
Skills | Assessing ideas/concerns and expectations/treatment preferences | Rehearsal of relevant skills; graded task starting with easy tasks; increasing skills (problem-solving) to: |
Making a clinical diagnosis of OA | ● Enhance GP consultation skills for OA | |
Giving the diagnosis/explaining OA and its treatment (use of language) | ||
Use of NICE recommended treatments | ||
Promoting OA Guidebook and nurse follow-up appointment | ||
Social/professional role and identity | Attitudes to guidelines and NICE OA guidance | Social process of encouragement, pressure and support to: |
Attitudes to support for self-care (potential conflict between professional care and self-care) | ● Engender a positive approach to guideline implementation and support for self-care | |
Beliefs about capabilities | Time to do it | Social processes of encouragement, pressure, support to: |
Other priorities in consultation | ● Enhance perceived ability to deliver the model OA consultation | |
Discussion about problems with managing OA/what would help to better manage it | ||
Beliefs about consequences | Discussion on beliefs about consequences of OA interventions and model OA consultation | Information provision; persuasive communication to: |
● Counter perceived lack of efficacy of interventions for OA | ||
Motivation and goals | Presentation of MOSAIC study payments | Contract; rewards; persuasive communication to: |
Provision of practice nurse training and a lifestyle change intervention | ● Sign GPs up to delivering the model OA consultation | |
Memory attention and decision processes | Model OA Consultation Aide Memoire | Prompts, triggers, cues to: |
● Prompt delivery if model OA consultation in day-to-day practice |
Workshop 1 – attendees: Primary Health Care Team from a single practice (GPs, practice nurses, practice manager1, receptionists1) Duration: 2 hours | |
---|---|
Time (minutes) | Activity |
5 | Introductions – facilitators and practice attendees. |
20 | How is OA managed, in your practice? Mapping practice, and local community and secondary care, resources for OA (interactive session with discussion recorded on flip chart). |
25 | OA knowledge update on: pathophysiology, definition and diagnosis, prevalence, prognosis and patient experience of OA (didactic session with discussion). |
10 | Information on: the NICE OA Guideline, support for self-management, the OA Guidebook, the model OA consultation (didactic session with discussion). |
5 | Break and non-clinical staff leave. |
20 | Presentation and discussion of case histories (GPs previously requested to bring). Difficulties in managing OA - what do GPs and nurses want from the sessions and what would aid them in managing OA (interactive session with issues recorded on flipchart and to be addressed in workshop 3). |
25 | Details of the model OA consultation - how to deliver it in day-to-day practice - GP and practice nurse roles. Aide-memoire introduced (didactic session with discussion). |
10 | Conclusion and outline of workshops 2 and 3. GPs givenDVD of simulated patient consultation2 and asked to view in preparation for workshop 2. |
Workshop 2 – Attendees: GPs from two practices.
3
Duration: 2 hours
| |
10 | Introductions – facilitators and GPs. Reflection on, and unanswered questions from, workshop 1. |
20 | Discussion and reflection on video-recorded simulated patient OA consultations. Comparison between current practice and model OA consultation. Agenda for skills training agreed (interactive session with “agenda” recorded on flipchart). |
10 | Introduction to skills training: description of purpose and methods - the GPs were asked to work as a team trying out in turn bite-sized parts of the consultation with discussion and feedback from colleagues and facilitators (didactic session with discussion). |
10 | Break. |
60 | Skills training: working through the agenda set earlier. Particular emphasis on communication, use of language for giving and explaining the diagnosis and patient-centred approach (led by an experienced GP educator). |
10 | Reflection and conclusion. Aide-memoire discussed. Preparation for second video-recorded simulated patient consultation.4 Outline of workshop 3. |
Workshop 3 – Attendees: GPs from two practices. Duration: 2 hours
| |
40 | Knowledge update: addressing needs identified in workshop 1 and questions from GPs, and covering: diagnosing OA clinically and ‘top tips’ for managing OA (interactive session led by academic rheumatologist). |
10 | Discussion and reflection on 2nd video-recorded consultation. Agenda for skills training agreed (interactive session with “agenda” recorded on flipchart). |
10 | Break. |
50 | Skills training: as for workshop 2. |
10 | Conclusion and general reflection. Aide-memoire discussed. GPs invited to complete satisfaction questionnaires. Outline of workshop 4. |
Workshop 4 – Attendees: GPs and practice nurses from a single practice. Duration: 1 hour
| |
40 | Action planning on delivery of the model OA consultation in the practice. Final version of the aide-memoire agreed. |
10 | Presentation of baseline data on OA consultations in the practice (an OA data collection template had been installed in the practices for the six months prior to the training). |
10 | Conclusion and thanks. Attendance certificates issued. |
Steps 4 and 5 – development, testing and execution of the implementation plan, and its evaluation
Evaluation level | Method | Measure |
---|---|---|
Satisfaction with workshops (delivery of behaviour change intervention). | Questionnaire administered at the end of workshop 3. | Level 1 Kirkpatrick educational outcomes [37], such as level of enjoyment, views on content and confidence in delivering the model OA consultation. |
Intention to practise. | Questionnaire administered before and twice after (at one month and five months after) the behaviour change intervention. | Vignette of an older adult presenting with joint pain and options for assessment and management. |
Mediators of change. | Questionnaire administered before and twice after (at one month and five months after) the behaviour change intervention. | Statements based on TDF* domains identified at step 2, for example “How much do you think exercise and increasing physical activity by people with osteoarthritis will improve their pain (beliefs about consequences). |
Competency in delivering the model OA consultation. | Video-recordings of the GPs undertaking a consultation with simulated OA patients were made before and twice after (at one and five months after) the behaviour change intervention. | Videos were assessed for the presence of specific behaviours necessary for the delivery of the model OA consultation. |
Performance in delivering the model OA consultation. | Patient report: patients who attended the MOSAICS study nurse-led OA clinic were asked to report on the content of the previous GP consultation. | Four aspects of the consultation, did the GP: elicit ideas about the problem, give the diagnosis, explain the diagnosis, hand out the guidebook? |