Background
The project
Current work
Methods
Participants
Interviews
Measure | Definition | Interview questions explored: |
---|---|---|
Acceptability | Cognitive and emotional responses to the project [50]. | • General perceptions of the project and whether their expectations of the project had been met. |
Appropriateness | Compatibility with the individual’s perceived role or their organisation’s culture resulting in an assessment of how relevant it is. | • Views of the activities the participants were involved with. • Inclusion or exclusion of colleagues in the teams. • Roles they were asked to play. |
Feasibility | Fit, practicality of the project. | • Fitting implementation team activities into current workload. • How useful or practical they perceived the activities to be. |
Cost | Time burden and resource cost borne by participants. Cost usually refers to monetary cost or value for money but as HCP’s individual or group effort largely drove the interventions and they gave their time in kind, here we equated cost as value for contributed time [52]. | • The amount of time and effort involved in the project. |
Adoption | Extent to which participants changed their practice, or set an intention to do so, due to the project; here strongly associated with the primary outcome of referral rate. | • How has the participant’s practice changed (personal behaviour)? • How has their colleagues’ practice changed (corporate behaviour) due to the project interventions? |
Reflections
Procedure
Analysis
Recommendations
Results
Theme | Subtheme | Subtheme definition |
---|---|---|
Challenges related to using theory underpinning the TDFI approach | Accessibility of theory | Ease of which the theory can be understood and applied; access to support from theory experts. |
Commitment to theory | Issues relating to participants’ understanding of the value of theory in eliciting behaviour change, and subsequent adherence to the use of theory at the prescribed stages of the research project. | |
Problem complexity | Issues around the processes leading to the outcome, here the processes leading to identification and referral of patients flagged at high risk of Lynch syndrome. | |
Practical (or context) challenges | Navigating the system (and system changes) | Issues around governance and ethical regulatory requirements; understanding of local politics and tacit behaviours/cultural factors Constant changes affecting teams and processes, such as introduction of new IT systems. |
Stakeholder management | Issues related to multiple stakeholders across different disciplines and departments. | |
Perceptions of the problem | Issues around the perceived effort one should invest in the identified problem; lack of awareness about generalisability of solutions across contexts. |
Theory underpinning TDFI approach
Complexity of the behaviour
I think that (the process map) it’s just too complicated. You need extremely simple triggers and to have so many different permutations and so many different avenues, you look at something like this and you just go, it’s too complicated. [Surgeon #2].
So, with some of the early process maps from Hospital A, there were a lot of revisions, or additions…it did obviously take a long time to eventually get to the final process maps…a lot of that had to do with the fact that once you start looking at this, and having enough people in the room and enough people arguing over, “No, no, no. This is what actually happens,” “No, no, no. That’s what actually happens,” …I don’t think I would necessarily have the time to apply it to every other problem, if you get my meaning. [Surgeon #1].
The complex nature of the process was only realised fully after this [process mapping] exercise, making the areas to be selected for change difficult to agree on, and the process map itself seemed quite convoluted, which could have frustrated clinicians, particularly those who were not involved in creating it. [Researcher#2_structure reflection].
I think [the process map] is brilliant. Yeah… I definitely think it’s very useful. I think it’s clear. I mean everyone responds differently to images compared to text… It’s a nice flow, you can see exactly where a particular patient or specimen fits in. So yes, I’m all for process mapping. [Pathologist #1].
Accessibility of TDF
I don’t know. It’s hard for me to comment, I just don’t know enough on the literature of behavioural change…[Surgeon#2].
I probably have [heard of the Theoretical Domains Framework Approach] but I probably couldn’t articulate what it is to you. [Oncologist#2].
I think it needs to be a parallel systems approach rather not just a focus on behaviour…And I don’t think just having the attitudinal change or awareness is sufficient to produce the actual behavioural change. [Oncologist#2].
Commitment to theory
What was interesting was that it [the process mapping exercise] would almost give people a taste of, potentially, what could be fixed. And they were coming up with their solutions and implementing the change before they’d even worked through the system, which you can’t discredit it but I can see how it’s going to be frustrating for the psychological researchers who were trying to map this and how it all worked. It just adds a complex layer for you. [Genetics#1].
I reckon I could still sit down in a few hours and implement the strategies and just fix the problem just like that and not rely on anyone’s behavioural change, or whatever, just have just automatic triggers. [Surgeon#2].
Yeah, because you [the healthcare professionals] are not pure enough, you’re not – because you guys [the research team] are looking at it from a very pure point of view. [Oncologist#3].
[The behaviour change approach does make sense for a project like this] apart from us jumping the gun and coming up with implementations before we should’ve. [Genetics#1].
Practical challenges
Navigating the system
…come through more roadblocks so it’s like you [the researchers] arrive like a tourist and you don’t speak the language and you just have some basic things and you say, well, you have to go to something 100 km away and you don’t know how the system works. [Oncologist#3].
Initially there was a lot of delays with getting approval to go ahead with the project, I believe. [Pathology#1].
So the investment for a while was - the time was just ticking on being wasted. You have this whole group of people employed ready to go and you had no – you couldn’t do anything, you’re sitting on your hands just waiting for the approval of things and that came quite late and it was a long time from the approval to the governance kick off…even [the research team] all twiddling their thumbs or when can we start, when can we start? Had lined everything up, all ready to go, I was just waiting to start and then it was just waiting and waiting and waiting. And then when it mattered then they had to, kind of, almost do it out of volunteer time because we, because it, rolled on; you’re collecting the data but, oh, our funding’s stopped. [Oncologist#3].
Great concept of implementation science project. However, there were some problems in terms of the recruitment of the colorectal team members being organised and notified late. They have no idea what is happening, who to approach, who are exactly in the team and who are the research team. [Oncologist#1].
It was interesting to see the dynamics of the Hospital B team and how they had to form two groups as there was no common time at which they could meet. It was endlessly frustrating trying to pin down a time to meet. [Researcher#1_structured reflection].
We had hoped for a letter with a clear section for genetics and a clear section for medical oncology, one for surgery and one for radiation to be generated on each patient. That we still haven’t moved very far forward with, and, unfortunately, I think, part of it just has to do with the politics of the [multidisciplinary team meeting] and the politics of letters at the moment. The second intervention was some type of failsafe in the rooms, and in our clinics, where, again, we could see that there’d been a flag from genetics, but a deliberate decision to bring it up at a later date, and, again, we haven’t, unfortunately, put that into practice yet either…it just reinforces to me that there’s still a few things that we need to do. [Surgeon#1].
I’ve got on the to do list to try and get this [electronic] referral in place, but unfortunately, it’s having to take a back seat to other… Well it’s key people are involved in other major, like not just one project, they’ve got major other projects with burning deadlines. [Genetics#1].
So very frustrating hearing what people planned to do but being unable to do it for them and watching the idea fade. Not having access to things like [the patient management software] to see how they work and what is visible to clinicians and what not would have been very helpful. [Researcher#1_structured reflection].
Stakeholder management
The main limitation comes predominantly because of the fact that there is such a large network of people that are involved in this process, there’s a lot of stakeholders, and it’s obviously quite difficult getting hold of the stakeholders in the same room, it’s difficult having people bounce ideas off each other, feeling safe bouncing those ideas in that kind of environment, there’s a lot of other agendas between clinicians, political, which are outside of, I guess, the project itself. [Surgeon#1].
I didn’t expect quite so much professional territory marking. The flat refusal to allow a senior nurse to refer to genetics seems purely political; slightly more understandable is the pathologists not wanting to make referrals themselves which sadly translated into “we won’t even make a recommendation”. [Researcher#1].
And so it’s kind of, you can get lost in the stronger personalities within that, so it’s having to keep being vocal about it within those meetings. [Genetics#1].
Your collaborators and your facilitators might be the target of your improvement itself which you don’t really know when you first start until a lot later then – and then you potentially you could feel used at that time because you have now gone from an insider to an outsider. So how do you handle that? And what your disclosures are when you collaborate with people in that sense that you might be the problem we might need to fix; how do you express that with a way that does not make people not want to deal with you? [Oncologist#3].
Perceptions of the problem
I think it’s got a huge public health implication and highly relevant…but trying to improve their awareness of more than just Lynch Syndrome, I think they (surgeons, oncologists) often just think, oh Lynch Syndrome and FAP are the kind of key things that we’d (genetic specialists) be interested in, but, you know, trying to link in personal history of breast cancer with a pancreatic cancer, or you could think of a different, on the BRCA gene and things like that. [Genetics#1].
It was probably a lot of energy spent over a real problem but probably not the most important problem if - so to speak, so I don’t – to those people whose Lynch referrals increased it makes a big difference to them but overall the numbers were small and this is a large effort that required a lot of involvement of – there was a lot of energy that was put into it and it almost – you wish that it was being attached to something a little bit bigger. [Oncologist#3].
There are, certainly in my practice, there are a lot more urgent priorities that could be improved, whereas – and this is pretty small print stuff… will it make a lot of change? It might do for an individual too, but probably not a great amount of change, certainly for my practice and colorectal cancer in general. [Surgeon#1].
Discussion
Possible solutions for overcoming reluctance to use theory, and practical challenges
Subtheme | Implementation Outcomes | Suggested solutions |
---|---|---|
Accessibility of theory underpinning TDFI | Appropriateness | • Internal healthcare professional facilitators trained and supported by external TDFI experts |
Commitment to use of theory | Acceptability Appropriateness | • Addressing more focussed behaviours • Internal healthcare professional facilitators trained and supported by external TDFI experts • Flexibility around quantitative and qualitative assessment of barriers • Rigorous research designs and process evaluations to assess application of theory and intervention fidelity |
Problem complexity | Acceptability Appropriateness Cost | • Unpick complex processes to define behaviours specific to different roles |
Navigating the system and system changes | Appropriateness Feasibility | • Internal facilitators trained and supported by outside TDFI experts • Understanding of the health system as a complex adaptive system • Process evaluations to unpick context based factors influences on intervention effects |
Stakeholder management | Acceptability Appropriateness | • Internal facilitators trained and supported by outside TDFI experts |
Perceptions of the problem | Acceptability Appropriateness | • Addressing more focussed behaviours • Internal facilitators trained and supported by external TDFI experts |