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01.12.2018 | Research | Ausgabe 1/2018 Open Access

Implementation Science 1/2018

Health professionals’ perceptions about their clinical performance and the influence of audit and feedback on their intentions to improve practice: a theory-based study in Dutch intensive care units

Implementation Science > Ausgabe 1/2018
Wouter T. Gude, Marie-José Roos-Blom, Sabine N. van der Veer, Dave A. Dongelmans, Evert de Jonge, Jill J. Francis, Niels Peek, Nicolette F. de Keizer
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s13012-018-0727-8) contains supplementary material, which is available to authorized users.



Audit and feedback aims to guide health professionals in improving aspects of their practice that need it most. Evidence suggests that feedback fails to increase accuracy of professional perceptions about clinical performance, which likely reduces audit and feedback effectiveness. This study investigates health professionals’ perceptions about their clinical performance and the influence of feedback on their intentions to change practice.


We conducted an online laboratory experiment guided by Control Theory with 72 intensive care professionals from 21 units. For each of four new pain management indicators, we collected professionals’ perceptions about their clinical performance; peer performance; targets; and improvement intentions before and after receiving first-time feedback. An electronic audit and feedback dashboard provided ICU’s own performance, median and top 10% peer performance, and improvement recommendations. The experiment took place approximately 1 month before units enrolled into a cluster-randomised trial assessing the impact of adding a toolbox with suggested actions and materials to improve intensive care pain management. During the experiment, the toolbox was inaccessible; all participants accessed the same version of the dashboard.


We analysed 288 observations. In 53.8%, intensive care professionals overestimated their clinical performance; but in only 13.5%, they underestimated it. On average, performance was overestimated by 22.9% (on a 0–100% scale). Professionals similarly overestimated peer performance, and set targets 20.3% higher than the top performance benchmarks. In 68.4% of cases, intentions to improve practice were consistent with actual gaps in performance, even before professionals had received feedback; which increased to 79.9% after receiving feedback (odds ratio, 2.41; 95% CI, 1.53 to 3.78). However, in 56.3% of cases, professionals still wanted to improve care aspects at which they were already top performers. Alternatively, in 8.3% of cases, they lacked improvement intentions because they did not consider indicators important; did not trust the data; or deemed benchmarks unrealistic.


Audit and feedback helps health professionals to work on aspects for which improvement is recommended. Given the abundance of professionals’ prior good improvement intentions, the limited effects typically found by audit and feedback studies are likely predominantly caused by barriers to translation of intentions into actual change in clinical practice.

Trial registration

ClinicalTrials.​gov NCT02922101. Registered 26 September 2016.
Additional file 1: Screenshot dashboard (translated from Dutch). (PDF 137 kb)
Additional file 2: Predefined reasons to be asked if hypotheses posed by Control Theory are violated. (PDF 37 kb)
Additional file 3: Linear (for perceived clinical performance and targets) and logistic (for intention to improve) regression analysis results assessing differences between different professional roles for each quality indicator. The reason to explore this is that response might be affected by the level of control participants have over specific quality indicators. For example, nurses might have more control over measuring pain than intensivists and therefore estimate performance or set targets more realistically than others, or develop different intentions to improve. The analyses show that this is however not the case; which might be explained by the shared responsibility for patient care and close collaboration in quality teams in intensive care units in comparison to general wards. (PDF 68 kb)
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