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Dr Georgia Fisher - Using the Theoretical Domains Framework in implementation research — Transcript

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0:00hello everyone welcome to the February
0:022024 meeting of the implementation
0:04science interest group where Dr georia
0:06Fisher will be presenting on using the
0:08theoretical domains framework in
0:10healthcare research just to note that
0:13this introduction recording was done
0:15after the fact is there were a few
0:17technical issues on the day um we have
0:20edited the technical issues out of the
0:22recording but if the audio jumps around
0:24a bit that is why hopefully it should be
0:28fairly consistent though through
0:29Georgia's presid presentation so just to
0:31fill in an acknowledgement of country
0:33for the introduction so I acknowledge
0:35the traditional custodians of the mccy
0:37University land the water mle Clan of
0:39the darag nation whose cultures and
0:41Customs have nurtured and continue to
0:43nurture this land since the dream time
0:45we pay our respects to Elders past
0:47present and
0:48future this next slide is just an
0:50overview of the committee and where you
0:52can contact us and then over to Georgia
0:56Fisher's presentation so Dr Fisher is a
1:00postdoctoral fellow at the Australian
1:01Institute of Health Innovation and we'll
1:04be presenting today on facilitating
1:06practice change using the theoretical
1:08domains framework and CB model in
1:11healthcare research it really piqued my
1:13interest um because I found that as a
1:16clinician it was really hard to assess
1:20new uh and I tried to find the best
1:23research evidence that I could for the
1:25condition and I really wasn't able to
1:28use it in practice um because lots of
1:30different things were getting it in the
1:31way so I started off doing um a PhD at
1:35the University of Technology Sydney
1:37which specifically AED to look at both
1:39prop reception and unilateral neglect
1:42after a stroke uh and the main focus of
1:45the thesis was to figure out how we
1:46could assess it better in clinical
1:48practice in ways that were suitable to
1:50clinicians and that suited the ways that
1:52they
1:53practiced um after that PhD I took a
1:57poststructural fellowship at
1:58Neuroscience research Australia in the
2:00lab of Simon gandia looking at proper
2:03exception in motor impairment uh and
2:05this was a far more lab based poster
2:07which I really enjoyed it gave me really
2:09good grounding uh in bench research um
2:12but I found that I really wanted to get
2:13back to um my clinical Roots so I've
2:16started a postto here at AI I'm
2:19currently looking at learning Health
2:20Systems but I have a broader um focus on
2:23implementation science um in my
2:26research so today as I said I'll be
2:29talking about the the Ral domains
2:30framework which is a framework that I've
2:32used uh quite a bit in my own research
2:35um I came to working with it because in
2:37my PhD I was trying to find a way to
2:40figure out um what were the barriers and
2:43enablers that kind of got in the way of
2:45assessing spatial neglect in clinical
2:47practice and because I was looking at it
2:49at the level of the clinician I really
2:51liked the way that this framework um
2:53kind of spoke to individual determinance
2:55of behavior but at the same time taking
2:57into the context that clinicians were
2:59working in
3:01so the aim today will be to give you an
3:04overview of the framework um and also
3:08map it to some practical ways that we
3:10can use it um in our
3:13research so the theoretical domains
3:15framework was developed to identify
3:18influences on Behavior particularly for
3:20health professional behavior um it
3:22brought together quite a lot of
3:24experience and knowledge in its
3:26development in that it was developed by
3:28a lot of psychological theorists Health
3:30Service researchers and health
3:31psychologists and it the good job that
3:33it did was combining a lot of theories
3:36of behavior into one framework that we
3:38can kind of use to analyze the way that
3:40behavior is
3:42driven so there was 33 theories of
3:44behavior that were brought together and
3:46from these 128 theoretical constructs
3:49were identified which is still a bit
3:50much for us to use in our day-to-day
3:52research so they clustered them into 14
3:55domains and then um underw these domains
3:58underwent quite an extensive value
3:59validation via discriminate content
4:01validation and a fuzzy cluster analysis
4:04which is just two more fancy ways of
4:05checking that um categories are in fact
4:08what they seem to
4:12be okay so the tdf has been used in
4:15countless research studies both in
4:16healthcare and also in other fields so
4:18it's broadening out um and a search of
4:20the theoretical domains framework in
4:22PubMed yields
4:251,386 results but as you can see at the
4:27graph there the number is really growing
4:29exponentially
4:30each year so its popularity is
4:32increasing um it's been used by
4:34researchers from over 80 countries
4:36including those from UCL Kings College
4:38in London the University of
4:41Edinburgh so it's a nice broad reach
4:44that the framework um is getting and
4:46it's important though to remember that
4:48this is a theoretical framework rather
4:50than a theory itself it does not propose
4:52testable relationships between elements
4:55it just kind of helps you decide what
4:56those elements might be and then it's up
4:58to you to kind of go the next step after
5:02that uh so just a little bit of an
5:05overview of a few studies that have used
5:07the tdf so it's been looked at impr
5:09professional teamwork in operating
5:11theater looking at barriers to physical
5:13activity um in pregnant
5:16women um influencing um vaccinations in
5:21the
5:21states and also um training skills in um
5:27sorry training train and trainer models
5:29to ensure that knowledge gets um put
5:31into
5:33practice so now we're going to dive into
5:36what makes up the theoretical domains
5:38framework and what are those 14
5:39determinants um that it comprises the
5:42first one is knowledge and I'm just
5:44going to go through the cut and dry
5:45definition of each of these before we
5:47get to their application so and the
5:49awareness of the existence of something
5:51the basic definition the second one is
5:54skills so an ability or proficiency
5:56acquired through practice and these can
5:58be physical skills or more emotional or
6:00psychological skills as
6:03well your social and professional role
6:05and identity which is defined as a
6:07coherent set of behaviors and personal
6:10qualities that you inhibit in your
6:12either social or work setting and it
6:14would be different between the
6:17two your beliefs about your capabilities
6:20so your acceptance of the truth reality
6:22or validity about an ability Talent or
6:26facility that you could put to a
6:27constructive use
6:31your optimism about a particular
6:33Behavior so your confidence that things
6:34will happen for the best or that your
6:36goals will be
6:38attained your beliefs about the
6:40consequences of a behavior um so the
6:43outcomes of um kind of exhibiting a
6:46behavior in a given situation and these
6:48could be positive or
6:51negative the reinforcement that the
6:54behavior provides you so the probability
6:56of a response um between the rewards
6:59that you get or the outcome of the
7:01behavior and um
7:04the uh sorry the rewards that it gives
7:08you um your intentions so your conscious
7:11decision to perform a behavior or to
7:13resolve to act in a certain way and
7:15these are similarly related to the goals
7:17that you might have so these are a
7:19little bit more concrete mental
7:21representations of outcomes or end
7:23states that uh you as an individual want
7:25to
7:28achieve something call your memory
7:30attention and decision processes so your
7:32ability to retain information to focus
7:35selectively on aspects of the
7:36environment and to choose between two or
7:38more Alternatives uh and a more concrete
7:41example of this might be kind of
7:42decision fatigue when you have too many
7:44options available and you find it hard
7:46to pick between them um that it would be
7:49fit into this category um of the
7:53tdf this is a really big one your
7:55environmental context and the resources
7:57that are available to you so any circum
7:59an of your situation that either
8:01discourages or encourages you to develop
8:04uh all the other determinants of
8:06Behavior Uh and kind of gives you the
8:08opportunity to exhibit a particular
8:11Behavior your social influences so all
8:14of the interpersonal processes that are
8:16around you um really common in
8:18healthcare because we work in teams um
8:20so the social interactions within a team
8:22will influence how the team
8:25behaves emotions um so by definition are
8:29complex reaction patterns um kind of
8:32involving many elements which you
8:35attempt to process a behavior or a
8:37matter or an
8:39event and finally the way that your
8:41behavior is regulated so this is really
8:44Broad and covers anything made aimed at
8:46managing or objectively changing um
8:49actions that you can observe or
8:52measure so that was kind of the
8:54theoretical summary of the tdf um and
8:58these 14 determinant um can kind of
9:02inform what are the barriers to a
9:04particular behavior and what are the
9:06enablers to a particular Behavior by
9:08breaking down how people are acting into
9:10these
9:13categories now as I mentioned before the
9:17theoretical domains framework is not uh
9:19kind of doesn't look at the
9:20relationships between elements but
9:22what's the nice thing about it is that
9:24it has been um mapped to um a thing
9:27called the comb model and the behavior
9:29whe and these things do give a little
9:31bit more of a an idea on how exactly
9:34people's behavior is being influenced by
9:36combining different determinants of
9:41behavior so now first a background to
9:45the comb uh similar to the tdf we're
9:47going to first look at why it was
9:49developed so it was developed because to
9:52design Behavior change interventions we
9:54need to choose strategies that will have
9:56the greatest effect particularly in
9:58healthcare we're often Limited in our
9:59resources so we really need to Target
10:01the things that we do appropriately um
10:04so the ideal way for us to do this is to
10:06base the strategies that we choose on
10:08established behavioral
10:10theories however there's a few issues
10:12with some behavioral research in that
10:14interventions commonly don't fully
10:17analyze the target behavior before they
10:19try to intervene on it um they often
10:21don't use theories to predict mechanisms
10:23of action they're often based on
10:26implicit or common sense models of
10:28behavior uh and this is through no fault
10:30of their own I think it's just a
10:31pragmatic response to not having the
10:33time and kind of having to pick the best
10:35action that seems logically good um and
10:39a lot of them use one or two theories
10:40that don't cover the entire range of
10:42possible influences on
10:44Behavior so all of these factors were
10:46recognized in 2011 by Susan mitching and
10:50her colleagues who designed the
10:55com now the combi stands for capability
10:59of opportunity motivation and how these
11:02interact with a certain Behavior it was
11:05developed via systemic search of
11:07electronic databases and consultation
11:09with behavior change experts uh and the
11:12search and consultations aim to identify
11:14Frameworks of behavior change
11:16interventions and then these Frameworks
11:18were judged against a criteria of
11:20comprehensiveness coherence and a clear
11:22link to an overarching model of
11:27behavior so this is is the resultant
11:30comb model and the black arrows on
11:33screen kind of show the interactions
11:35between its facets so you can see that
11:39your capability and your opportunity can
11:41influence your motivation and that
11:43there's kind of a biral influence
11:45between all three elements and the
11:48target Behavior itself in that it's kind
11:51of like a positive feedback loop if
11:52you're doing a behavior you're getting
11:55reinforcement and kind of experiencing
11:57the behavior which could increase your
11:59opportunity to do the behavior or your
12:01skills to exhibit the behavior so it's
12:04really just a back and forth um
12:06relationship
12:08there so if we look at the individual
12:10components um your capability can be
12:13thought of as your psychological
12:15capability to engage in the necessary
12:17thought processes to complete a behavior
12:20or your physical capability um to
12:22complete a behavior so whether you're
12:24you have the skills necessary to
12:26actually complete
12:27it next looking at your opportunity so
12:30your physical opportunity afforded from
12:32the environment around you but also your
12:35social opportunity from the culture that
12:37surrounds you and the social norms that
12:38surround you and finally your motivation
12:42so what reflective processes are you
12:45using to kind of select the behaviors
12:47that you'll exhibit involving
12:49evaluations and plans and then the more
12:52automatic motivation or AO automatic
12:54processes which are more impulsive and
12:57involve a little bit more emotion
13:02and um if you think about something
13:05slightly left a field in terms of the
13:07criminal system if we want to look at
13:09how if someone has committed a crime we
13:11often look at motive means and intent
13:14and that's kind of in a lot of criminal
13:16systems the way that we prove that
13:17someone has done a crime or done a
13:21particular behavior that we're looking
13:22at and that's actually kind of what the
13:24combi is based on so we're looking at
13:26your motivation your opportunity um um
13:30and your capability to exhibit a
13:33behavior so this kind of model of
13:36behavior is really longstanding and it's
13:37present in lots of different aspects of
13:39society here we're just taking it and
13:41applying it to behaviors for healthcare
13:43practitioners um in
13:46particular so then if we look at the
13:48combi and the tdf U map on to each other
13:52so here we've got the comb so capability
13:55opportunity and motivation broken down
13:58into the
13:59two subcomponents each and then around
14:02the edges we've got the elements of the
14:04tdf as they map on to the comb so we'll
14:07just go around the wheel uh looking at
14:09them together so you've got social
14:12influences which quite obviously link to
14:14your social
14:15opportunity got your environmental
14:17context and resources which links to
14:19your physical
14:21opportunity uh your reflective
14:23motivation comprises quite a few of the
14:25tdf determinants so your social and
14:27professional role and identity
14:29your beliefs about your capabilities
14:31your optimism towards the behavioral
14:33outcome and your intentions and your
14:35goals and also your beliefs about
14:37possible
14:39consequences whereas your automatic
14:41motivation again um more reactive is the
14:44reinforcement or the rewards that the
14:46behavior provides you and also the
14:48emotions that you might have towards the
14:52behavior next moving to capability so
14:55your psychological capability is made up
14:57of your knowledge um um your cognitive
15:00and interpersonal skills and then the
15:02way that you make decisions and also
15:05your memory and your
15:06attention and finally looking at your
15:09physical SC capability which is more
15:10your physical skills um to exhibit a
15:13particular
15:14Behavior so if we start to breake a
15:17behavior dip down first by the tdf
15:20components we can then map it on to the
15:22comb to kind of see how they're these
15:24factors are interacting and get an image
15:26of why people might be behaving in a
15:29certain
15:31way uh and then the nice thing is is
15:34that once we've identified which aspects
15:37of the comb are influencing Behavior
15:40there's been a lot of work done in
15:42evidence-based strategies to then go and
15:44change that behavior so if we're looking
15:47at capability um physical and
15:49psychological um you can see here in the
15:52table that to Target someone's
15:54psychological capability we might look
15:56at Education and Training but also
15:58enablement and empowerment strategies uh
16:01to Target someone's physical capability
16:03we'd look at training and enablement as
16:06well looking now more at motivation so
16:10your reflective motivation can be
16:12targeted through a number of means and
16:14your automatic motivation through a few
16:16more by restructuring your environment
16:19um looking at people in the environment
16:22as models for behavior and again by
16:26enablement uh and finally looking at
16:29your opportunity so your physical and
16:31social these things are much more about
16:33the environment around you and also any
16:36restrictions that we could place on that
16:37environment to kind of encourage a
16:39particular
16:43Behavior so now putting it all into
16:46practice that was a very uh brief
16:48summary of the tdf and the comi uh and
16:51I'd like to now put it into um context
16:54of a case study um a study um of how you
16:57might actually do it in um in practice
17:01so Improvement in healthcare we usually
17:03use um pdsa Cycles or for quality
17:06improvement which uh plan do study and
17:10act and the important thing is is that
17:12when we actually get to doing uh or
17:15implementing a change we often don't
17:18integrate Behavior change theory into
17:20these steps it's often as I said before
17:23quite pragmatic which is absolutely
17:25understandable but I think we can really
17:27learn a lot from integrating um these
17:29theories into our pdsa cycles and it's
17:32in particularly important as if if we're
17:34using qualitative research to gather
17:36data about our quality improvement or
17:39our research
17:40interventions if certain questions are
17:42not asked of people you may not get a
17:44good picture of all of the influences on
17:46someone's behavior and so that's kind of
17:49why the tdf is a good tool in that by
17:52designing our research studies with it
17:54in mind designing the questions that we
17:56ask people in qualitative investigation
17:59we can make sure that we've covered a
18:01lot of different possible determinants
18:03of behavior so that we can be more
18:05confident that we have a really clear
18:07picture of what's driving people to act
18:09in a certain way in clinical settings
18:11and then um change that behavior
18:16eventually so in terms of dining
18:19designing a data collection to use the
18:21tdf and the combi how to get the
18:23information you want will depend on a
18:25lot of things as it usually does in
18:27research so convenience your pragmatism
18:30the sample size that you can actually
18:32get or that you do actually want your
18:34research question and how much you
18:36currently know about the problem for
18:39example interviews might be best when
18:41you don't know a lot about the
18:43implementation factors in a particular
18:44behavior and it can provide really they
18:47can provide really rich data but once
18:49you get have done a lot of interviews or
18:51you've got some rich qualitative data
18:53and you've got a good handle on what
18:55might be influencing um factors on
18:57people's behavior
18:59you could then maybe look at surveys um
19:01once those behavioral determinants are
19:04established they can provide a quicker
19:05way to get out the things that are
19:07driving people by kind of Designing the
19:09survey questions and mapping them to the
19:11tdf as one
19:13example finally you might consider using
19:16structured observations to supplement
19:18these forms of data collections just as
19:20a good means of triangulating people's
19:22self-reported
19:24information 31 sorry if I could just get
19:27you to mute mute your mic if you're
19:29watching along at home thank
19:31you um so these are just a good way of
19:35um triangulating people self-reported
19:37information because as we know people
19:39might report things that aren't
19:40necessarily reflective of what they're
19:42doing in real
19:44life but regardless of your study or
19:47quality improvement activity design it's
19:49important that the if the tdf has being
19:51used for analysis then it's also used to
19:53inform your data collection so you're
19:56designing your um data collection in
19:58struments to map to the tdf as well as
20:01your data analysis
20:05strategies and there are lots of
20:07published studies that have used the tdf
20:09for interviews and and focus groups and
20:10when I'm designing a study I don't like
20:12to reinvent the wheel I usually just
20:14find a few published pieces of work that
20:16are similar to my own they will usually
20:18publish their question Banks and I can
20:20use them as kind of the inspiration for
20:23the questions that I'd like to
20:25ask um for example below are some
20:28interview questions um from a study that
20:30looked at pharmacist provision of
20:31self-care advice for antibiotics and the
20:34associated tdf domains are in Brackets
20:37after the question so the first one is
20:39could you tell me a bit about how the
20:41general public raise or discuss common
20:43infections with you in the pharmacy
20:46which is looking at the environmental
20:47context and resources so what's
20:49happening in the pharmacy uh in this
20:52study the second one is looking at can
20:54you tell me about situations where you
20:56decide to not give self-care advice
20:58advice um for antibiotic prescription
21:01and you could probe further by asking
21:03what makes you decide that this advice
21:05isn't required and this is really
21:06looking at um someone's memory intention
21:09but more pointedly their decision-
21:11making processes so how are they
21:13deciding to give self-care
21:15advice and finally another example is
21:18what kind of attitudes have you
21:19encountered when giving self-care advice
21:22and how satisfied our patients with the
21:24advice that you give them and this is
21:27really looking at the social influences
21:29CU we know that sometimes we don't like
21:31to rock the boat and if we're en
21:33counting lots of negative attitudes in
21:35our social settings we might be
21:36disincentivized to exhibit a particular
21:42behavior um looking now more at surveys
21:45there are a few um validated
21:46questionnaires based on the tdf most are
21:49specific to certain behaviors um but
21:51there is one generic one uh and this is
21:53just a screen grab of the study in which
21:56the questionnaire is for anyone who'd
21:58like to go and look at that after the
22:00presentation and this is just some
22:03examples from this questionnaire for the
22:05domain of Behavioral regulation uh and
22:08anything in the square brackets is what
22:11you would plug in for your own research
22:13question so the action or the behavior
22:17in a particular context at this
22:19particular time with the target is
22:22something that I do automatically and
22:24you can get people to rate it from a
22:26scale of 1 to 10 zero being being
22:28disagree on tend being completely agree
22:31or other forms of laer scales that you
22:33might like to use and by asking people
22:35survey questions in all aspects of the
22:38tdf um like these in specific to
22:41behavioral regulation you can get an
22:43idea of the determinant which are more
22:45strongly influencing behavior in a
22:47certain area particularly by using
22:49sliding scales you can see uh which ones
22:51have the strongest
22:55influence uh so now for the final bit of
22:57the presentation I'd like to look at a
22:59case study of where we've used the tdf
23:02and the comb to look at a particular uh
23:05Behavior Uh and this was really done
23:08with a lot of colleagues um but largely
23:10with um Dr Karen Hutchinson um who has
23:13put a lot of effort into this project
23:15looking at the implementation evaluation
23:18of a motor neuron Disease
23:19multidisiplinary Clinic um to inform
23:22connected and improve connected care the
23:25study was conducted um on the Central
23:28Coast
23:29um of New South Wales in Australia and
23:32just to give an overview for those who
23:34might be inter state it's quite a large
23:36area um quite a green area and there's
23:39lots of national park and um settlements
23:41small like suburbs around the national
23:44park it has a population of
23:47approximately U 350,000 people by a
23:50large area of 1,600 square
23:53kilm and Sydney is around 80 kilm to the
23:57South
24:01and just a little background on motto
24:02neuron disease as well which is a rare
24:05Progressive neurogenerative disorder
24:07with no known cure and it leads to
24:09significant disability and ultimately
24:11death on average within three years so
24:14the key for people who are diagnosed
24:16with m andd is to get them access to
24:18Services as quickly as possible so we
24:20can make sure that their last uh years
24:22or months are as a good as quality of
24:26life as we can possibly provide
24:29This is complicated by the fact that M
24:31andd progression is highly variable
24:33between individuals and different types
24:34so so one person's experience will not
24:37be the same as someone else regardless
24:39of if their diagnosis is technically the
24:41same uh and people with living with M
24:44andd and their families need access to
24:46timely and specialized person- centered
24:48care and support from their diagnosis to
24:51their end of life uh as I said to make
24:53sure that this time is as functional and
24:56as happy as we can possibly make it
25:00so our study aimed to uh look at a
25:03multi-disciplinary clinic for people
25:05with mndd uh in a regional area so in
25:08the central coast and we aim to
25:10implement this Clinic to support
25:13connected care across Health disability
25:15and aged care sectors and also to
25:18evaluate the barriers that enable us to
25:21clinician and participant engagement
25:22with the clinic and to the
25:24sustainability of the clinic so the
25:27behavior in that we were looking at here
25:29just to bring it back to the tdf is
25:31engagement with the clinic attending the
25:33clinic and um you know ongoing
25:36attendance at the clinic
25:40effectively this is a slide that um
25:43Karen Dr Karen Hutcherson has created
25:45which I think is a wonderful way to look
25:47at just how complicated the system is
25:49for people with M andd you can see that
25:51they're in the center and around them is
25:53all the different types of care that
25:55they might have to access on the left
25:58there's the more tertiary hospital and
26:00specialist mdts which requires travel
26:03and accommodation for people living with
26:05M&D moving more to the center of the
26:07picture there's local hospitals and
26:09teams GPS and a neurology team who might
26:12be working with them uh also Community
26:14groups support workers nursing staff all
26:17of Allied Health who can support people
26:19living with M andd and It's Complicated
26:22by the fact that depending on the age
26:23that you're diagnosed with M&D you will
26:25either be um kind of managed through the
26:27ndi s or through my aged care which have
26:30different um kind of system designs and
26:33different supports that are available to
26:35people through them so what we really
26:38wanted to do with this multidisiplinary
26:40Clinic was bring um Specialist Care
26:43closer to home and kind of unite all of
26:46these as many of these different
26:47Services as we could so people could get
26:49them in more of a One-Stop
26:53shop our methods were a qualitative
26:56study and we conducted semi-structured
26:58interviews with Clinic staff and also
27:00its attendees to get a really kind of
27:03holistic view of the clinic we had six
27:05Healthcare professionals two social Care
27:08Professionals four people living with M
27:10andd and two of their family carers and
27:14we did a semi- deductive analysis uh
27:16using the theoretical domains framework
27:18and the comb
27:21model and here is just a a snapshot of
27:24our results we there's quite a number of
27:26Behavioral determinants that we found
27:28but I'll just be going over a couple of
27:30the key ones
27:32today so a primary barrier that we found
27:35was a lack of knowledge about Clinic
27:37structure and and this was because the
27:40clinic was set up kind of on the fly as
27:42a it was a really great idea and put
27:44together by a wonderful neurologist but
27:47it meant that there wasn't kind of the
27:49uh structures in place to explain for
27:52example the organizational map of the
27:54clinic or uh how the clinic was
27:56structured in its actual um instance um
27:59when it occurred so that maps to the tdf
28:02domain of knowledge and the Combe um of
28:06psychological capability and so if we
28:09think back to possible ways that we
28:10could intervene to overcome this barrier
28:13we'd look at providing Education and
28:14Training and resources and ways that
28:17this could U manifest might be a formal
28:20induction to the clinic and some Clinic
28:22process manuals so that people will have
28:24the resources available to understand
28:26how the clinic works
28:30a second barrier that we found was uh
28:32poor communication networks and quite a
28:34siloed Health System um particularly
28:37between the ndis and the age care system
28:39but also the private and the public
28:41sector but interestingly an enabler was
28:45strong clinician understanding of these
28:46silos and gaps and how they could kind
28:49of get around them with
28:51workaround so these things map to first
28:55in the environmental context and
28:56resources in relation to the tdf and
28:59then to people's knowledge um as well
29:02which if we go then to the comb is
29:04looking at someone's physical
29:05opportunity but then also their
29:07psychological capability so what we
29:09found here is that people's physical
29:11opportunity was limited but then they
29:13were using their psychological
29:14capability to get around that and to
29:16make the care work for people with M
29:19andd however if we wanted to stop using
29:23so many workarounds and start kind of
29:25helping people to um
29:28officially kind of overcome the silos in
29:31the health system we'd really look at
29:33environmental restructuring and
29:35enablement so ways that we could
29:37specifically do this would be creating a
29:40formal case conference and Clinic
29:41communication forms in consultation with
29:44the M&D team and distributing those
29:46throughout kind of the healthcare
29:48Network so everyone understands what's
29:49going on at the clinic and then
29:52potentially creating an address book of
29:54all clinicians in a particular area that
29:56are assigned to a clinic participant so
29:58everyone knows who they need to contact
30:00if they need to contact
30:04someone a third uh key barrier was the
30:07cognitive overload of Clinic planning
30:09and administration in that the clinic
30:11was kind of happening out privately
30:13outside of um a lot of people's day jobs
30:17um but a key enabler was that there was
30:19a dedicated Administration staff on site
30:22there was a current Clinic reminder
30:23system and lots of written reminders and
30:25checklists so even though there was a
30:28barrier in people's memory attention and
30:30decision processes which then maps to
30:32their psychological capability um the
30:35environmental context and people's
30:36physical opportunity was kind of helping
30:39people overcome that
30:40barrier so if we wanted to intervene
30:43further and further help people to
30:44overcome this barrier we would look at
30:46environmental restructuring and also
30:48some Education and Training um some
30:51specific ways to do this for our Clinic
30:52might be creating pre and post Clinic
30:54checklists incorporating current
30:56reminders and systems into the
30:58checklists and training Administration
31:00staff in all of the clinic checklists so
31:03we just weren't handing them something
31:04and expecting them to do it without any
31:08help uh and the finally one final
31:11barrier that we found was strongly
31:13defined scopes of practice and a related
31:16excuse me reluctance to cross into other
31:18Scopes and that maps to people's
31:21professional role and identity and their
31:22reflective motivation and this has come
31:26up in all studies I've done using the
31:28tdf in that we're kind of taught how we
31:31need to act as healthc Care
31:32Professionals for safety reasons but
31:34that means that if there's overlap
31:37between our scope and someone else's
31:38scope of practice it can sometimes be
31:41difficult to decide who's going to do
31:42what uh and people sometimes need a bit
31:44of a helping hand to either step into
31:48what they perceive as another scope
31:50safely um or to kind of step back and
31:53let another profession do um something
31:55which is indeed in their scope as well
31:59so a way that we might kind of overcome
32:01this barrier would be environmental
32:03restructuring again but also some
32:05persuasion uh in a specific way might be
32:07a team discussion about what is safe
32:09crossover between clinical scopes with
32:12scenarios so that people kind of have uh
32:15an example of how they might behave if
32:17they kind of felt that they were going
32:19into someone else's scope of practice
32:21and they weren't sure whether it was
32:22appropriate them for them to do so um
32:25this one was quite key to a
32:26multi-disciplinary clinic because the
32:28definition of the clinic is you all work
32:30together and also at sometimes not all
32:32professions were available in the clinic
32:34so people sometimes needed to step up
32:37safely and within still their Scopes um
32:39into things that maybe they
32:41traditionally perceived as someone
32:42else's
32:45job so in conclusion implementing any
32:48intervention into a complex system will
32:50become with unique barriers and enablers
32:53um and if we can first map the system
32:55and understand how things fit together
32:58um then that can help us get a picture
33:00of what's going on but a formal and
33:02Theory grounded assessment of factors
33:04can compl system mapping to overcome
33:07barriers and leverage available
33:08facilitators uh in the most effective
33:10way possible um to kind of encourage
33:13behaviors that we'd like to improve
33:14healthare um for our Target
33:18populations so I'll open it up for
33:21discussion now um but I'll just pop this
33:24acknowledgement slide up to everyone
33:27who's contribut did um work to the
33:29presentation that I gave today and
33:30particularly to the m andd study team um
33:34and that's my details there
33:37so I
33:40will make sure you I can hear everyone
33:43and then yeah open the floor to any
33:56questions um
34:15so um MAA did you have your hand
34:19up yes thank you for this wonderful
34:21presentation I've enjoyed it and well
34:23done through persevering through all the
34:26troubleshooting with the technology it's
34:28not easy when you're the one presenting
34:30so just wanted to acknowledge that uh a
34:32bit of a practical question towards your
34:34example that you've um presented on were
34:38you able to apply any of the recommended
34:41changes to that clinic or was the
34:44purpose of the study just to explore
34:46what the barriers were like I guess I'm
34:48asking what the impact was of that and a
34:51second to that is perhaps a Karen
34:53question is what did she use to draw
34:55this wonderful map of all the
34:57interactions if there's a specific
34:59software or something that we should
35:00know about please do share thank you
35:03very
35:04much thank you uh a great question um
35:07I'll answer the first bit and then I
35:08might throw to Karen for the second um
35:11so Our intention for the study was just
35:14to map the barriers and enablers uh as
35:18the clinic was in its first iteration um
35:20and now it's moving into it second we're
35:23going to use the findings um to
35:26hopefully Implement some of those
35:27strategies
35:28that I outlined um but we really
35:30conscious of co-designing it so we
35:32wanted to take these results to back to
35:34the team and back to the people living
35:36with M andd to make sure that it really
35:38did match what they needed and then pick
35:40the ones that we were going to implement
35:42um so watch this space hopefully in
35:43about a year's time I'll have some more
35:45findings for you thank you because
35:47that's a very common issue that um
35:49having spent a long time within the
35:51healthcare system is there's a lot of
35:53great ideas but the implementation of
35:55something or just the very a lot of of
35:57them seem to be very basic logical
35:59things you know like provide a
36:01organizational map or instructions
36:03orientation manuals they seem to have
36:05been missed in that desire to um help
36:10people absolutely yeah and when we might
36:13we might find that the simple things
36:15themselves um they don't work and we
36:17need to go for something more complex um
36:19but yeah that'll be the next next part
36:20of the journey um Karen did you want to
36:22speak to how you made that wonderful
36:26map
36:28yes hi sorry I I I I'm at the clinic at
36:32the moment so I do need to head off but
36:33um thank you Georgia that's a great
36:35presentation and um it was great um to
36:39uh see all all your amazing slides um
36:43and yes it was just PowerPoint that I
36:45used to um do that map
36:49Miler so um yeah it it it's quite a good
36:53tool when you actually pull that all
36:54together um and it just I think
36:57sometimes visual representations really
36:59highlight some complexity that maybe is
37:01hard to you know write
37:04succinctly um and yeah the the
37:07complexity um really is hits home with
37:10that diagram
37:12so thank you and thanks again I'll have
37:15to pop off now but I appreciate it thank
37:18you Georgia Thank
37:20You Geor I don't know if you've seen
37:22there's a question in the chat from
37:25astred thank you so much for your
37:27presentation really comprehensive wonder
37:29if you could give a little bit more
37:29detail about how you underwent the uh
37:32undertook the
37:34analysis uh thank
37:36you
37:38um
37:40so okay I'll just repeat the question
37:43for the people in the room um so are you
37:46able to offer a bit more detail as to
37:48how you performed the semi- deductive
37:50analysis uh yes so what Karen and I did
37:53was we first coded all of the interview
37:57transcripts to the elements of the tdf
38:01but we left a category for other because
38:04I always find there's a chance that
38:06something will come up that doesn't fit
38:07into the framework um and we also wanted
38:11to do uh we want to look at the effects
38:15of the clinic which might not have come
38:16out um via our tdf analysis so the way
38:20that we probably did it a little bit
38:22differently in ourselves but the way
38:24that I do it is I will have one tdf
38:27component in mind for example knowledge
38:30and I'll go through all of my qual data
38:33looking for quotes that map to knowledge
38:36and then code that using um we just used
38:38Excel but I've done it before within
38:40Vivo as well um and then going through
38:44continually with all of the tdf
38:46components um and and then Karen and I
38:48came together to compare what we had
38:51pulled out for each um component of the
38:53tdf and aligned ourselves um through
38:57discussion effectively and then looked
38:59at what we' coded into that other
39:01category to see if there's you know
39:02little bits of the data that we might
39:04not have captured with the framework
39:07analysis does that answer your question
39:09asid or would you like is there any
39:11follow-up question as
39:14well I was going to pop it in the chat
39:16but I might just pop myself off mute
39:17thank you so much that's really um yes
39:19that answered my question so just to
39:21clarify um you the you were open to the
39:25potential that there were themes or or
39:26constructs that may have emerged that
39:29weren't part of the tdf and
39:31then um and so therefore kind of created
39:34an additional construct as
39:36required yeah I think the research
39:39question that Karen came Karen um
39:41completed the interviews and then came
39:43to me for help with the analysis and her
39:44questions were quite Broad in that she
39:46wanted to know about the barriers and
39:48enablers uh but she was also really
39:50interested in the like the unintended
39:52consequences of the clinic that that it
39:54might have brought about so um we felt
39:56that we wanted to make sure we didn't
39:58lose that data um and and how that the
40:03consequences may have interacted with
40:05especially the beliefs about
40:06consequences bit of the tdf to really
40:09make sure we we pulled that out so I
40:11think there is depending on your
40:13research question there is some wiggle
40:14room you know provided that you do stick
40:17to the framework but then yeah taking a
40:19a broader look at the data as well to
40:21supplement what the framework tells you
40:24yeah great thank you so
40:26much
40:30um Alan do you have a
40:32question yeah I do can you can you hear
40:35me okay yeah yeah oh fantastic great
40:38presentation I I really found it really
40:40good and neat how you plan through using
40:43the tdf to analyze your data and um
40:47guide your survey kind of the questions
40:49that you going to ask them and and those
40:52steps that I think that makes for really
40:54good compelling you know papers and plan
40:57in and and all of that I was just going
40:59to ask about the next steps because I
41:01think Karen hinted that you know this is
41:03not funded and it's you know running a
41:05lot on people's kind of generosity we do
41:09a lot of these kind of things in
41:10medicine um because they're a good idea
41:12and they seem to work um were you how
41:15are you going to use the or are you
41:17going to use the tdf for the evaluation
41:19part and answering those the kind of
41:21questions that funders need like you
41:23know cost sustainability effectiveness
41:27option all those kind of things or are
41:29you going to use a different framework
41:30for
41:31that um great question so our aim with
41:34the tdf was to analyze this data that to
41:38take to the funders to show the
41:41difficulty um of doing this and the fact
41:44that we would need more resources which
41:46it has successfully done and um I think
41:49it was a really great
41:51justification uh but as you suggest we
41:54would look at the other implementation
41:56factors um in a more formal analysis and
41:59would be broadening out um to a probably
42:03more of a systems level framework um to
42:07uh do that part of the investigation I
42:09think what we really wanted to do was
42:11look at practical Solutions at the
42:12clinician level here to help the clinic
42:15run better but also to show what these
42:17clinicians are facing as because as you
42:19say things that are great ideas in
42:21healthcare often face a lot of things uh
42:23and it's individuals who persevere
42:25through it um so yeah we will be
42:28certainly yeah looking at the things
42:30that you said in terms of particularly
42:31cost um and Effectiveness in in other
42:34ways when we do the the full Clinic
42:42evaluation
42:48yes thank you for everyone comment in
42:50the chat is there any other
42:53questions at the
42:56minute questions in the
42:59room no oh
43:02Sheamus thanks Georgia thanks for a
43:04great presentation um just following up
43:06from the last question I'm a sociologist
43:09by background although was originally a
43:11physiotherapist and worked in healthcare
43:13for a while and um yeah I thought it was
43:15really interesting the way you suggested
43:18you may move on to sort of a systems
43:19level analysis um for that next phase or
43:23stage and I was just wondering if um you
43:26had any comments or thoughts thoughts on
43:27how something like the tdf how it might
43:30best be used to try and make sure we can
43:34capture some of those more systems level
43:37or environmental influences upon
43:40individual behaviors and the sort of
43:42things that people might talk about or
43:43raise when interviewed would you have
43:45any tips for how some of those more
43:48system level um you know or macro Lev
43:51factors or miso level factors might be
43:54influencing those individual level
43:57responses and how we might um capture
44:00that yeah great question
44:03um I think there's a few ways you could
44:05do it um and they probably depend on the
44:08resources that you've got available um I
44:12do think that the tdf construct of
44:15environmental context and resources
44:16really does give you the scope to look
44:18at what's surrounding a person um and so
44:22maybe focusing on that data in
44:25particular if you were really interested
44:26in the systems level and then applying a
44:29systems thinking lens to the information
44:32that you got about someone's environment
44:34um so that you're not you know doing two
44:36analyses and you know that's a lot like
44:38resource intensive but putting your
44:41focus if you were really interested in
44:43systems level one there uh and then I
44:45know there's a number of complexity
44:48Frameworks um or systems level
44:50implementation Frameworks that probably
44:53just could be used if you didn't want to
44:54use them formally just to guide your
44:56thinking about about those factors so
44:58you're still operating within the tdf
45:00but broadening it out to make sure as
45:02you said that you don't scope uh sry you
45:05don't miss those things um the more
45:07resource intensive one would be to do
45:09that full systems map um with like
45:12systems Dynamic modeling and and if you
45:15had the resources to do that um but yeah
45:17it really would I'm not good at maths
45:19enough to do that yeah I thought I feel
45:22the same um so but yeah I mean that's a
45:25good point in um I think the systems
45:29Dynamic stuff would be really wonderful
45:31to be able to bring to our research but
45:34a lot of us aren't trained in that from
45:36the beginning and it would be yeah it
45:38would be really cool to be able to
45:39integrate those two Fields I think um
45:42particularly from a complexity
45:43perspective because that's what
45:45Healthcare is as a complex
45:48system great thank
45:53you um any other questions so if not we
45:56might
45:57wrap it up
46:01there just making sure I haven't missed
46:04anything in the
46:10chat oh all right well thank you
46:13everyone for coming apologies again for
46:15the tech issues um and hopefully we'll
46:20have fix them by next time uh and we
46:22look forward to seeing you all at um
46:24next month's group meeting and we'll be
46:26sending out out details of that shortly
46:29um and feel free to contact me via email
46:31if there's any follow-up questions that
46:33I didn't cover today thanks again thanks
46:37Georgia

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