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Table 2 The facilitators and barriers identified linked to their TDF domains, with quantitative and qualitative results

From: Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study

TDF Domain Factor affecting implementation Facilitator (F) / Barrier (B) Survey data   Qualitative data
Knowledge Understanding of evidence-informed interventions for patient with blunt chest injury F How important are the following interventions in the management of patients with blunt chest injuries? Median [IQR]
(scale 1–5)a
Reponses (n) Sub-category: Beliefs about blunt chest injury patient needs
Example quote: “Takes an MDT [multidisciplinary team] to assess and manage these patients.”
a. Early analgesia 5 [5–5] 171
b. Regular deep breathing and coughing 5 [4–5]
c. Maintaining oxygenation 5 [4–5]
d. Early mobilisation 5 [4–5]
e. Multimodal analgesia 5 [4–5]
Understanding of term care bundle B I am familiar with the term “care bundle.” % 189
No 69.6
Yes 30.4
  Understanding of blunt chest injury risk factors F Select the risk factors you feel are most likely to lead to deterioration for patients with blunt chest injuries % 198  
Elderly 80.3
3 or more rib fractures 87.9
COPD / Chronic lung disease 81.3
Physical Skills Confidence in patient assessment skills F In patients with blunt chest injury, I am confident in my ability to accurately…. Mean [SD]
(scale 1–6)
168  
a. Assess patient’s respiratory effort 5.38 [0.5]
b. Locate chest landmarks 5.26 [0.62]
c. Monitor for deterioration 5.11 [0.77]
d. Interpret findings from assessment of respiratory function 5.09 [0.76]
e. Describe findings from assessment of respiratory function 5.03 [0.73]
f. Assess pleuritic pain 4.86 [0.95]
Physical skills (continued) Confidence in skills needed for evidence-informed management of blunt chest injury F I am confident in my ability to accurately…. Mean [SD]
(Scale 1–6)
  
a. Prescribe oral opioids (doctors/nurses) 5.35 [0.65] 130
b. Manage oral opioid analgesia (nurses) 5.33 [0.1] 64
c. Manage IV opioid analgesia 5.3 [0.7] 64
d. Prescribe appropriate analgesia 5.27 [0.77] 63
e. Monitor for deterioration 5.11 [0.77] 168
f. Set up high flow nasal cannula (HFNC) 5.33 [0.73] 54
g. Manage patient-controlled analgesia 4.91 [0.97] 64
h. Titrate flow rates for HFNC 4.88 [1.03] 130
i. Prescribe HFNC 4.84 [1.05] 55
Adequate skill in regional analgesia prescription and management B I am confident in my ability to accurately…. Mean [SD]
(Scale 1–6)
  Sub-category: Lack of experience.
Example quote:
“Skill levels for thoracic epidural/ paravertebral analgesia vary. A protocol will need to appreciate this or upskill a core group of clinicians to provide this service effectively”
a. Prescribe epidural analgesia 3.57 [1.72] 63
b. Prescribe paravertebral block 3.56 [1.61] 55
c. Manage epidural blocks 3.52 [1.44] 64
d. Manage paravertebral blocks 3.03 [1.44] 64
Memory, attention, and decision processes Remembering to use protocol B In relation to experience with clinical protocols,
I find it easy to remember when to activate new protocols
Mean [SD]
(Scale 1–6)
4.32 [0.964]
176 Sub-category: Aids for implementation.
Example quote:
“…it is not easy to remember them [protocols] and they will get remembered wrong.”
Professional/ social role and identity Identify with professional role associated with care of blunt chest injury patients F Relating to patients with blunt chest injury, it is my role to ... Median [IQR]
(Scale 1–5)
  Sub-category: Staff roles.
Example quote:
“I have advocated for admissions for this patient group many times where the medical officer has felt the patient could be discharged.”
a. Identify and escalate deterioration 5 [4–5] 153
b. Assess and recognise if need for further analgesia 5 [4–5] 153
c. Assess the patient 5 [4–5] 153
Beliefs about consequences Belief of consequences of care bundle F If a new protocol is implemented in your hospital, that activates an early multidisciplinary response (like a trauma call) and prompts evidence-based guidelines for patients with blunt chest injury. What statements reflect what impact you think it will have on you and/or your patient with blunt chest injury on the following? Mean [SD]
(Scale 1–6)
  Subcategory: Optimism
Example quote:
“My previous experience with a [chest injury] protocol has been that it is easy to remember as it is used frequently enough that it becomes second nature and less protocol more a ‘reminder’ of what needs to be done”
a. There will be overall improvement in patient care 5.18 [0.71] 148
b. The health care process will be improved overall 5.13 [0.70]
c. There will be improved time to physiotherapy review 5.05 [0.8]
d. There will be improvement in patient outcomes Median
6 [5–6]
148
e. The patient will receive analgesia earlier 5 [5–6]
f. The patient will receive earlier pain team review 5 [5–6]
g. There will be improved time to medical review 5 [4–5]
Emotion Emotions relating to commencing new protocol B When using new protocols in my practice, I feel.......... Mean
(scale 1–4)
160 Sub-category: negative feelings
Example quote:
“Doing a new task is challenging and inspiring but also anxiety producing as it is unfamiliar ground.”
Positive related feelings – means ranged 1.99–3.05 [with SD 0.7–0.9] 2.71
Negative feelings – means ranged 1.15–1.47 [with SD 0.45–0.66] 3.04
Environmental context and resources Access to protocol B How likely are the following factors going to prevent you using protocols? Mean [SD]
(Scale 1–4)
166 Subcategory: System issues.
Example quote: “…very hard to find protocols and guidelines online”
a. Can’t find protocol when needed 3.11 [0.90]
b. No access to computer 2.63 [1.04]
Provision of training F How important are the following educational supports in using a new protocol? Median [IQR]
(Scale 1–5)
164 Subcategory: Recommended methods for education
Example quote:
“More face to face educational sessions”
a. Help on the floor from senior staff 4 (4–5)
b. An educational session on the protocol 4 (4–5)
How likely is inadequate training in protocol going to prevent you using protocols? Mean
3.05 [0.91]
The protocol design F How important are the following environmental factors in helping you remember to use clinical protocols? Median {IQR]
(Scale 1–5)
171 Subcategory: Protocol design
Example quotes: “Succinct protocols are valued.”
“The protocol has to be appropriate and rigorously tested”
Simple criteria for activation of protocol 4 [4–5]
How likely is it that an unclear protocol is going to prevent you using protocols? Median [IQR]
3 [2–4]
Access to equipment B How important are the following environmental factors in helping you remember to use clinical protocols? Median [IQR]
(Scale 1–5)
  Subcategory: Equipment issues
Example quote:
“Access to PCA an issue”
Having equipment easily accessible 4 [4–5]  
Social influences Social Supports F I am more likely to follow a new protocol if I have support from......... Median [IQR]
(Scale 1–6)
164 Subcategory: Recommended issues for education
Example quote:
“All staff potentially involved in implementing a new protocol need to be included in all education for it to be successful, not just some disciplines”
My superiors 5 (5–6)
Medical staff 5 (5–6)
Nursing staff 5 (5–6)
My colleagues 5 (5–6)
The patient 5 (4–5) 155
The patient’s family 5 (4–5)
  1. aFigures represent Likert scale range
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