We included 10 studies in each of the five broad categories of clinical quality interventions. Additional file 1: Table S1 describes each study in terms of:
The clinical group/s involved
The country in which the study was conducted
The number of research participants
The type of clinical quality initiative being considered
The method of qualitative data collection.
Domains of the TDF as they are represented in clinical quality interventions
Here we capture how each of the domains of the TDF emerged in the qualitative studies we analysed. The references to analysed studies are given in the form [Citation number_year, category of clinical quality intervention] to facilitate finding their details in Additional file 1: Table S1.
In the TDF, “knowledge” refers to “an awareness of the existence of something.” This is believed to be important because a person’s perceived awareness of the scientific rationale, procedure(s), and task environment associated with a desired behaviour is likely to affect whether a person decides to implement it.
Knowledge emerged as a salient domain in the context of all five of our categories of clinical quality interventions. High levels of knowledge were seen to be a facilitator of change. For example, primary care practitioners believed that the uptake of clinical practice guidelines would be facilitated by their being informed about which guidelines to follow and where to find them (; EBM). In contrast, low levels of knowledge were seen to be a barrier. For example, Primary Care Organisation (PCO) leads, discussing primary care clinical quality policy in general, argued that a major barrier to implementation was the lack of guidelines on non-clinical aspects of the quality framework (; General).
According to the TDF, “skills” refer to “an ability or proficiency acquired through practice”. Skills are thought to be important determinants of behavior change because a person’s perceived sense of their own competence in performing a desired behaviour is likely to affect whether or not they are willing and able to implement it. The provision and quality of training for skill development, opportunities to practice, and opportunities to gain an understanding of an existing skill set through assessment are also likely to influence performance of the desired behaviour.
As with knowledge, the sense that one was adequately skilled was a facilitator of behavior change, while perceived lack of skill was a barrier to change. For example, hospital doctors discussing medical audit thought that a major barrier was that not all doctors are adequately trained in audit (; Audit), while senior primary care clinicians, discussing the cultural changes needed to implement clinical quality interventions in general practice, noted that a barrier was lack of necessary skill in implementing these interventions (; General).
The perception that an intervention was “user friendly” was closely related to the perception that one had the skills to perform it. In one study of allied health and management personnel’s attitudes to trans-disciplinary teamwork, for example, informal communication was seen to be a natural and fluid process for most clinicians and one that was approved of and accepted by all clinicians that were interviewed (; Structural). This was seen to facilitate implementation. In contrast, in relation to a patient safety incident management system, a significant proportion of hospital clinicians noted that they found the system confusing or difficult to use and that this impeded implementation (; Risk).
Beliefs about capabilities
In regard to “beliefs about capabilities” the TDF refers to “acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put into constructive use”. Beliefs about capabilities are relevant because the level of confidence an individual possesses about their ability to perform a particular behaviour is likely to affect whether or not they implement it.
Unlike knowledge and skills, where high levels were always facilitative, high levels of perceived self-efficacy could be both a barrier and a facilitator of behavior change. On the one hand, belief in one’s capacity to implement an intervention could be facilitator of uptake of the intervention, while lack of belief in one’s capacity was a barrier. For example, primary care doctors expressed concern about their capabilities to apply clinical practice guidelines for the management of chronic diseases (; EBM), while a perceived facilitator of use of an electronic prescribing system in primary care was that primary care doctors and other primary care staff who had a solid background in computer use had confidence in their abilities (; Risk).
On the other hand, beliefs in one’s own capabilities to perform well without the clinical quality intervention could, somewhat paradoxically, be a barrier to uptake of the intervention. For example, reflecting on the use of decision aid software programs in tele-nursing, nurses believed that they were competent enough to handle the common practice without using software programs. In this context, belief in one’s own capabilities was a barrier to implementation of a clinical quality intervention (; EBM).
Beliefs about consequences
In the TDF, “beliefs about consequences” refer to an “acceptance of the truth, reality, or validity about the outcomes of a behaviour in a given situation.” The beliefs a person holds about the outcomes of particular behavior will affect whether or not they decide to comply.
Beliefs about consequences fell into two categories in our data. First, there were beliefs about whether a needed intervention would be effective in achieving its clinical or organisational aims. Belief in effectiveness was a facilitator, whereas belief in ineffectiveness was a barrier. For example, hospital and primary care clinicians reflecting on their use of clinical practice guidelines for chronic obstructive pulmonary disease acknowledged that they were much more likely to adhere to a recommendation to communicate with patients about smoking cessation than they were to follow a recommendation to educate patients about medication self-management. This was because of their stronger belief in the health benefits of smoking cessation for their patients (; EBM).
Second, were beliefs about whether an intervention would cause any predictable or unexpected clinical or organisational harm. For example, primary care doctors indicated that public information about performance indicators could work negatively. They were greatly concerned that patients could misconstrue, misinterpret, or not have enough medical knowledge to assess published information on physicians’ performance. This was seen as a barrier to implementation (; Audit).
Of relevance to beliefs about consequences, clinicians often referred to the internal and external validity of the clinical quality instrument in question. Not surprisingly, interventions with high levels of validity were expected to work, and be relevant to specific contexts, and were more likely to be taken up than interventions that were perceived to be lacking in internal or external validity. For example, primary care clinicians argued that performance indicators were more likely to be used if clinicians saw these indicators as being “evidence-based” (; Audit), while clinical practice guidelines were less likely to be used if primary care doctors saw the evidence upon which guidelines were based as being uncertain, inconsistent, limited and/or complex (; EBM).
In this regard it is noteworthy that while clinicians were often concerned about the internal and external validity of specific clinical quality instruments, they did not often comment of the presence or absence of a research evidence base for the general type of intervention in question. For example, while clinicians might have been concerned about whether a particular performance indicator or clinical practice guideline was based on solid and contextually relevant clinical evidence, they did not express much interest in whether indicators or guidelines in general had been demonstrated through research to be effective types of interventions. A few possible exceptions to this were the finding that some clinicians (throughout the health system) believed that there is no clear evidence to suggest that clinical governance contributes to the quality improvement of clinical care (;General) and, more specifically, the finding that some hospital clinicians were skeptical about applying evidence during a ward round in part because of a general lack of faith in the “evidence-based approach” to health care (;EBM).
Social/professional role and identity
According to the TDF, “social and professional role and identity” refers to a “coherent set of behaviours and displayed personal qualities of an individual in a social or work setting”. The extent to which someone believes that a particular behaviour aligns with their social/professional identity is likely to influence whether or not they will implement it.
Uptake of interventions was facilitated by the perception that an intervention was or would be consistent with, or strengthen, a clinician’s social/professional role or identity. Threats to role and identity, on the other hand, could be barriers to uptake. For example, hospital doctors in one study felt that improving quality of health care was integral to their role. Reviewing clinical care against defined standards, monitoring and improving patient outcomes and comparing performance with peers were seen as legitimate activities, and this encouraged implementation (; General). In contrast, hospital doctors and nurses in another study expressed uncertainty as to their responsibility for completing a new drug prescribing sheets (nurses vs. doctors), and thus made them reluctant to comply (; Risk).
The perceived effect of a clinical quality intervention on clinician autonomy and leadership was an important subcategory of this domain of the TDF. For example, reflecting on an “evidence-based ward round” on a delivery suite, some hospital clinicians expressed their reservations about conducting a ward round that would allow all members of staff to question decision making by the lead clinician on the labour ward. It was argued that this reluctance might be related to the fear of loss of autonomy by various groups of clinicians on delivery suite (; EBM).
A number of clinicians also observed that an intervention was more likely to be implemented if it was consistent with the current organizational and professional “culture” (and vice versa). Senior primary care doctors noted, for example, that if clinical quality interventions are to be accepted by clinicians, there is a need to change the culture of general practice to one that is more focused on accountability, collaboration between practices, and reflective learning (; General).
In the TDF schema, “social influences” refer to “those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours”. Factors such as pressure, encouragement, or support from others can often influence the performance of a desired behaviour.
Social influences could be both facilitators of, and barriers to, uptake of clinical quality interventions. For example, primary care clinicians argued that practices were more likely to develop plans to act on performance indicators if there was agreement amongst the team on the purpose, benefits and importance of indicators (; Audit). In contrast, members of mental health teams, reflecting on accountability in the establishment of interdisciplinary mental health teams, were concerned about lack of responsiveness on the part of the steering group charged with responding to clinicians’ concerns (; Structural).
Environmental context and resources
In the TDF, “environmental context and resources” refer to “circumstances of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour”. It is held that the nature of the environment in which a person is required to perform a specific behaviour is likely to affect whether or not a person is able or willing to perform it.
Not surprisingly, a barrier to implementation was the perception that there were inadequate resources to implement an intervention, or an environment that was not conducive to change. In one instance, lack of assessors was a major concern to primary care staff being asked to implement a “Quality Team Development Programme” (; Structural). Concerns about resources were often expressed in terms of too many demands being made too quickly. For example, some primary care clinicians felt that evidence-based healthcare, and the associated practical requirements, represents one aspect of rapid and unwanted change in the workplace (; EBM). Related to this was the sense of whether the intervention was compatible with current work practices. For example, inter-professional teamwork was seen by hospital staff to be hindered by the fact of doctors being spread through hospital, and facilitated by multidisciplinary team meetings (; Structural).
According to the TDF, “optimism” refers to “the confidence that things will happen for the best or that desired goals will be attained”. This argument suggests that the extent to which a person believes a goal will be achieved will affect the likelihood of them performing the behaviour(s) that will lead to that goal.
Optimism could facilitate the uptake of clinical quality interventions. For example, primary care staff were largely enthusiastic about the benefits of computing for general practice and were optimistic about the potential for computers to present guidelines in a manageable format (; EBM). In contrast, primary care doctors and practice nurses reflecting on a “Quality Team Development Programme” worried that once the assessment visit was over, QTD would be forgotten until the next visit (; Structural).
For the purposes of the TDF, “emotion” refers to “a complex reaction pattern, involving experiential, behavioural, and physiological elements, by which an individual attempts to deal with a personally significant matter or event”. It is thought that negative emotions such as fear and anxiety, and positive emotions such as joy and pride, associated with a desired behaviour, are likely to affect whether or not a person decides to perform it.
The belief that one would have a positive emotional experience—such as pride, satisfaction, catharsis or enjoyment could facilitate uptake of clinical quality interventions, while the belief that the experience would be frightening, exposing, humiliating, guilt-inducing, demoralizing, confusing, or boring was a barrier. For example, reflecting on their preferences as to whether clinical quality interventions in primary care should be locally or centrally managed, many of the proponents of a local approach stated that they found the process enjoyable (; Structural). In contrast, hospital clinicians discussing the introduction of a computerized provider order entry system noted the potential for exposing knowledge deficits and increasing conflict, and concern about “computerphobia”. The implementation period was therefore recognized as a time of potential stress and errors (; Risk).
In the TDF, “reinforcement” means “increasing the probability of a response through a dependent relationship, or contingency, between the response and a given situation”. Reinforcement is believed to be important because the perceived rewards and punishments associated with performance or non-performance of a particular behaviour are likely to affect whether or not someone decides to implement it.
Expectation of reward was seen to be a facilitator of compliance with clinical quality interventions. For example, primary care doctors noted that the benefits of participating in significant event analyses included appraisal, training practice accreditation, and gaining the RCGP Practice Accreditation Award (; Risk). On the other hand, expectations of punishment, or lack of reward, resulting from implementation of an intervention, could be a barrier. For example few primary care doctors considered that performance indicators could be used in a positive manner to enhance their clinical practice or to reward them (; Audit). Of course, the expectation that one would be punished for not implementing an intervention could motivate compliance. Reflecting on clinical quality interventions in general, occupational therapists noted that avoiding censure—e.g. through thorough documentation—was an important incentive for complying with these interventions (; General).
The TDF sees “intention” as referring to “a conscious decision to perform a behaviour or a resolve to act in a certain way” (e.g., I intend to check the vital signs of my post-surgical patients more frequently). It is held that the level of motivation a person has or commitment that they make to act in a particular way is likely to affect whether or not they do so.
Uptake of clinical quality interventions was seen to be facilitated by the strength and stability of clinicians’ intention, or readiness to change. Hospital nurses contemplating consumer participation in acute care, for example, expressed a commitment to working towards this model (; Structural). On the other hand, lack of intention or commitment could be a barrier. For instance, reflecting on the use of clinical practice guidelines for chronic disease, it was noted that primary care doctors could lack the motivation to apply evidence, irrespective of its quality (; EBM).
“Goals” in TDF parlance refer to “mental representations of outcomes or end states than an individual wants to achieve” (e.g., my goal is to monitor my patients every 15 minutes for the first four hours after surgery). The existence of a goal and the value placed on it in relation to a particular behaviour is likely to influence whether or not someone decides to activate that behavior.
Uptake of clinical quality interventions could be facilitated by consistency of the intervention with clinicians’ goals and priorities. In a study, occupational therapists argued that, in the face of various “accountability dilemmas”, professionals had to choose about how to enact their various obligations. This involved setting “accountability priorities” (; General). On the other hand, lack of consistency of clinical quality interventions with clinicians’ goals and priorities could be a barrier to the implementation of these interventions. For example, hospital doctors argued that they often had to prioritise urgent clinical assignments over nurses’ requests to clear up ambiguous drug prescriptions in a new drug record system (; Risk).
Memory, attention and decision processes
In the TDF, “memory, attention and decision processes” refer to “the ability to retain information, focus selectively on aspects of the environment, and choose between one or more alternatives”. Remembering to enact a particular behavior, or remaining focused on it, is likely to affect whether or not the behaviour is implemented.
Uptake of clinical quality interventions was seen to be easier if the intervention was designed in such a way that clinicians would pay attention to it, remember to implement it and make the necessary decision. Primary care doctors argued, for example, that persistent, non-conflicting and repeated exposure to recommendations was an important facilitator of uptake of clinical prescribing guidelines in primary care (; EBM). In contrast, if clinicians were unable to focus on an intervention, this could be a barrier to behavior change. For example, primary care doctors reflecting on clinical decision support alerts were aware of the potential for “alert fatigue,” and expressed a desire for alerts to be relevant (; Risk).
In the TDF, “behavioural regulation” refers to “anything aimed at managing or changing objectively observed or measured actions”. This is held to be important because the existence of an action plan, or monitoring progress towards a behaviour, is likely to influence whether or not a behaviour is performed or an outcome is achieved.
In the articles we analysed, willingness to comply with clinical quality interventions was associated with clinicians’ ability to self-monitor, plan their actions and break habits. For example, reflecting on establishing a “Quality Team Development Programme,” clinicians from multiple groups argued that uptake could be facilitated by acknowledging the attitudes of those whose behaviour was being audited and modifying the audit process to accommodate them, and by allowing clinicians to control the process (; Audit). Of course, leaving primary care clinicians to monitor their own performance could also allow them to game it by distorting their behavior to improve their repeated performance in audits (; Audit).
Trustworthiness and justice
Two particularly interesting categories to emerge from our data, which did not fit easily into any single domain of the TDF, were those of “perceived justice” and the “perceived trustworthiness” of the managers and policymakers asking for behavior change. With respect to justice, some clinicians saw the demands made by those promoting clinical quality initiatives as appropriate, fair and legitimate, while others perceived the demands as being fundamentally unjust. For example, junior hospital doctors expressed resentment about the fact that, since they carry out the day to day duties of clerking and managing patients, it was primarily their work that was being monitored through audit processes (; Audit).
Perceived trustworthiness had two components: 1) perceived technical competence and objectivity and 2) perceived benevolence—the motivation to do good for others. First, some clinicians spoke of being more willing to implement interventions if they saw those involved as technically competent. For example, primary care doctors had varying perceptions of the professional status of peer reviewers who were giving feedback on significant event analyses. When it emerged that reviewers were largely ‘frontline’ primary care doctors who were trained and experienced in giving peer feedback, skeptical participants found this encouraging and reassuring (; Risk). Second, beliefs about the goodwill, or otherwise, of those promoting clinical quality interventions also featured strongly in the studies. For instance, some hospital doctors felt that they shared a common goal with management related to improving the quality of care for patients. For others, however, the hospital was also seen as prioritizing financial objectives and government performance targets over quality improvement (; General).