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