Clinical-related behaviours of healthcare workers: Determinants of adoption and planning interventions

Prof. Gaston Godin, Ph.D.Laval University, QuebecMay 9, 2012

Introduction

Regardless of the context, we all want to see our interventions as efficient and successful

Unfortunately, too often this is not the case

Introduction

In the domain of health, the same situation prevails and it is not easy to modify behaviours of…– Individuals... as well as...– Healthcare workers

Gap between evidence-based practices and the routine clinical practices of healthcare workers (HCW)

Potential explanations

Factors influencing clinical practice– Motivational predisposition to

change– Economic factors– Political aspects– Organisational context

Partial understanding of those factors

What about the quality of our interventions? Interventions can be developed

according to...– Our feeling and beliefs– The advise of others and experience– Planned models

With and without reference to behavioural theory

Conceptual framework of intervention mapping(Bartholomew et al., 2011)

1. Needs assessment• Assess health problem,

population, determinants and context

2. Objectives• State expected changes• Specify performance and

change objectives

3. Theory and practice• Identify theoretical bases• Select program method

& practical applications

4. Program• Develop program• Produce material• Identify partners

6. Evaluation• Describe program

outcomes and research questions

• Specify evaluation design

5. Implementation• Identify implementation

and adoption conditions

Degree of planning of interventions on HIV (Godin et al., 2007)

Introduction (4)

Usefulness of psychosocial theories– Few studies reviewed existing

literature

Mechanisms of adoption of behaviour– Understand and predict intention

and behaviours of HCW– Ultimately, change their behaviours

Clinical-related behaviours of healthcare workers: Determinants of adoption

Godin, G., Bélanger-Gravel, A., Eccles, M., Grimshaw, J. (2008). Healthcare professionals’ intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Science. 3: 36.

Studies included in the review (n =76) Longitudinal studies (n = 16)

– Nurses (n = 7)– Physicians (n = 6)– Pharmacists (n = 2)– Other HCW (n = 1)

Cross-sectional studies (n = 72)– Nurses (n = 29)– Physicians (n = 29)– Pharmacists (n = 4)– Dentists (n = 2)– Other HCW (n = 8)

Clinical-related behaviours Nurses

– Clinical practice (e.g., professional support for labour, pain management, providing care to patients, etc.)

– Compliance with guidelines (e.g., hand hygiene and wearing gloves)

– Documentation

Physicians– Clinical practice (e.g., prescribing, performing an

examination, referring patients to specialists, etc.)– Compliance with guidelines (e.g., hand hygiene

and wearing gloves)– Counselling

Determinants of behaviourVariables Number of times

Assessed p < .05 (%)

Beliefs about capabilities

8 5 (62.5)

Intention 12 6 (50.0)

Beliefs about consequences

9 4 (44.4)

Social influences 6 2 (33.3)

Past behaviour 5 1 (20.0)

Knowledge 2 1 (N/A)

Other beliefs 4 0 (N/A)

Personal characteristics 1 1 (N/A)

Environmental factors 1 1 (N/A)

Determinants of intentionVariables Number of times

Assessed p < .05 (%)

Beliefs about capabilities

65 51 (78.5)

Beliefs about consequences

79 58 (73.4)

Moral norm 14 10 (71.4)

Social influences 75 47 (62.3)

Role & identity 14 8 (57.1)

Past behaviour 31 14 (45.2)

Other beliefs 17 4 (4.3)

Personal characteristics 29 11 (37.9)

Environmental factors 4 1 (25.0)

Model efficacy for behaviour (n = 2 112; R2 = 0.31)HCW Type of behaviours Nb. HCW

(studies)Weighte

d R2

Nurses Clinical practiceCompliance - guidelinesDocumentation

220 (3)225 (2)158 (2)

0.410.190.09

Total 603 (7) 0.24

Physicians

Clinical practiceCompliance - guidelinesCounselling

387 (4)33 (1)

765 (1)

0.110.0010.40

Total 1 185 (6) 0.28

Other Clinical practiceCounselling

284 (1)40 (1)

0.580.33

Total 324 (2) 0.55

Model efficacy for intention (n = 14 986; R2 = 0.59)HCW Type of behaviours Nb. HCW

(studies)Weighte

d R2

Nurses Clinical practiceTechnologies acceptanceCompliance - guidelinesDocumentation

4 443 (21)151 (1)

1 181 (5)108 (1)

0.680.770.620.46

Total 5 883 (28) 0.66

Physicians

Clinical practiceTechnologies acceptanceCompliance - guidelinesCounsellingDocumentation

2 185 (11)1 150 (4)762 (4)

1 146 (3)180 (2)

0.540.680.500.280.19

Total 5 423 (24) 0.51

Model efficacy for intention (continued)

HCW Type of behaviours Nb. HCW (studies)

Weighted R2

Other Clinical practiceCompliance - guidelinesCounselling

2 042 (6)527 (1)

1 111 (5)

0.530.730.62

Total 3 680 (12) 0.59

Prediction model for clinical-related behaviours of HCW

Beliefs about consequences

Moral norm

Social influences

Role & identity

Beliefs about capabilities

INTENTION BEHAVIOUR

Habit / pastbehaviour

Characteristics of HCW

Designing interventions Prediction model presented can

guide the development of interventions with a high potential for effectiveness

Should be done and planned appropriately and according to the behavioural determinants and cognitive profile of HCW

Conceptual framework of intervention mapping(Bartholomew et al., 2011)

1. Needs assessment• Assess health problem,

population, determinants and context

2. Objectives• State expected changes• Specify performance and

change objectives

3. Theory and practice• Identify theoretical bases• Select program method

& practical applications

4. Program• Develop program• Produce material• Identify partners

6. Evaluation• Describe program

outcomes and research questions

• Specify evaluation design

5. Implementation• Identify implementation

and adoption conditions

Performance ObjectiveDeterminants

Behaviour-1

Behaviour-2

Behaviour-3

Performance objectives and the determinants to be targeted

Type of intervention

Motivational vs. Volitional (post-motivational)– Level of intention at baseline of

participants

Interventions are mainly evaluated using motivated volunteers

Outcome expectancies Intention

MaintenanceSelf-efficacy

RecoverySelf-efficacy

Action planning

Coping planning

Action control

Action

Barriers and resources (e.g., social support)

Dis

engag

em

ent

Motivational phase

Volitional phase

Task self-efficacy

Riskperception

Health action process approach

Behaviour

No Yes

Motivated to adopt

Yes No

Motivational intervention

Volitional intervention

Etc… Settings

Community

Clinical

Theory A or ? Theory B or ?

Techniques A, B, C

or ?

Techniques B, D, E

or ?

Gender

Women Men

Techniques F, G, H

or ?

Techniques G, H, I or

?

Intervention to maintain adherence

Mode of delivery

Telephone counsellin

g

Mass media

Etc…

Performance Objective

Determinants Behaviour change techniques

Behaviour-1

Behaviour-2

Behaviour-3

Performance objectives, determinants to be targeted and behavior change technique

Which behaviour change techniques can be used to target the determinants? BCT group (Michie et al.)

developed taxonomies of behaviour change techniques for different behaviours

– Physical activity and healthy eating– Smoking cessation– Reducing excessive alcohol

consumption– Condom use

The taxonomy (Michie et al., 2011) Contains 40 behaviour change

techniques (BCT)

These techniques can be grouped according to the 12 theoretical domains of Michie et al. (2005)

Theoretical domains (Michie et al., 2005)1. Knowledge2. Skills3. Social/professional role & identity4. Beliefs about capabilities (self-efficacy, PBC)5. Beliefs about consequences (attitude)6. Motivation & goals (intention)7. Memory, attention & decision processes8. Environmental context & resources9. Social influences (subjective norm, social support)10. Emotion (anticipated regret, fear)11. Behavioural regulation (action planning, coping

planning)12. Nature of behaviours (past behaviour)

A C

B D

IntentionLow High

Cap

abili

ties

Low

Hig

h

Cognitive profiles of HCW

BCT for low intention & low capabilities

A C

B D

Theoretical domains Techniques

Motivation & goals (intention)

Motivational interviewing

Beliefs about consequences Provide information on consequences of behaviour

Social influences Provide normative information about others’ behaviour

Role & identity Prompt identification as role model / position advocate

Beliefs about capabilities Set graded tasks

BCT for low intention & high capabilities

A C

B D

Theoretical domains Techniques

Motivation & goals (intention)

Motivational interviewing / Goal setting (e.g., I will wash my hands before examining a patient)

Beliefs about consequences Provide information on consequences of behaviour

Social influences Provide normative information about others’ approval

Role & identity Prompt identification as role model / position advocate

BCT for high intention & low capabilities

A C

B D

Theoretical domains Techniques

Beliefs about capabilities Barrier identification / problem solving

Beliefs about capabilities Set graded tasks

Beliefs about capabilities Provide feedback on performance

Beliefs about capabilities Model / demonstrate the behaviour

BCT for high intention & high capabilities

Ideal situation

Action planning

A C

B D

Example of action planning

Plan #1

If…

Then, I…

Plan #2

If…

Then, I…

BCT for breaking habit

Environmental restructuring

Strategies to modify the daily routine

Behavioural regulation techniques– Coping planning

Barriers Solutions

If I do not have time to refer a potential ocular tissue donor… then I will ask a colleague to help me

refer a potential ocular tissue donor

If I am uncomfortable to approach a family…

then I will ask the nurse in charge of my department to take steps to refer a potential ocular tissue donor

If I have never approached a family of a potential ocular tissue donor…

then I will discharge the duties of referring a potential ocular tissue donor to a colleague

If I am afraid of the reaction of the families…

then I will look into the binder the

procedures for human organ and tissue donations

If I am uncertain of the eligibility criteria for an ocular tissue donation…

then I will communicate directly with someone from the organ procurement organisation for assistance

If I lack knowledge on ocular tissue donation…

then I will ask the physician who diagnoses the cause of death to help me refer a potential ocular tissue donor

If I am personally against ocular tissue donation…

then I will communicate with a nurse

to obtain assistance for ocular tissue donation

Other Other

Example of coping planning

Conclusion

Conclusion

Beliefs about capabilities and intention are the two main determinants of clinical-related behaviours of HCW

Beliefs about capabilities, beliefs about consequences, moral norm, social influences and role & identity are the main determinants of intention

Conclusion (2)

Identifying the determinants of behaviour and intention allows the development of interventions tailored to the cognitive profiles of HCW

Also important to select behaviour change techniques appropriate for the cognitive profiles of HCW

Steps to evaluate the usefulness of theory for intervention

Evaluate

1. Measurement of contructs

2. Mediation and moderation analyses

Understand

1. Selection of the theory

2. Identification of determinants

Plan

1. Selection of behavior change techniques (BCT)

2. Methodological considerations

Conclusion (3)

There is room for innovation in the techniques used to change behaviour

It is important to…– Understand before acting

Theoretical model– Plan interventions

Intervention mapping Behaviour change techniques

Clinical-related behaviours of healthcare workers: Planning interventions

Bartholomew, L. K., Parcel, G. S., Kok, G., Gottlieb, N. H. & Fernandez, M. E. (2011). Planning health promotion programs: An intervention mapping approach (3rd edition). San Francisco: Jossey-Bass.

Godin, G., Gagnon, H., Alary, M., Lewy, J. J. & Otis, J. (2007). The degree of planning: An indicator of potential success of health education programs. Promotion & Education. 14, 138-142.

Michie, S., Ashford, S., Sniehotta, F., Dombrowski, U., Bishop, A. & French, D. P. (2011). A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychology & Health, 26(11), 1479-1498.

Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, A., Walker, A. (2005). Making psychological theory useful for implementing evidence-based practice: A consensus approach. Quality & Safety in Health Care. 14, 26-33.

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