Application of the Theoretical Domains Framework to Inform a Behaviour Change Strategy: The Example of Urinary Catheter Care Management Following Spinal Cord Injury
By Peter Bragge, Director of Health Programs, Behaviour Works Australia at Monash University, and Denise Goodwin, Research Fellow, Behaviour Works Australia at Monash University
The challenge
We worked with a clinical team at the Victorian Spinal Cord Service in Australia to narrow the gap between current practice and those advised in clinical practice guidelines. Specifically, we were looking to reduce the time taken for patients with acute spinal cord injury to be transferred from an indwelling catheters to an intermittent catheter, as this has been shown to reduce the incidence of urinary tract infections. These are a common and costly complication of spinal cord injury.
What we did
We interviewed clinicians’ (medical, nursing and allied health) and local peer volunteers to explore their views on spinal cord injury urinary catheter care. Thematic analysis was guided by the Theoretical Domains Framework (TDF) (refs 1-3 below) to categorise identified behavioural drivers and barriers of spinal cord injury urinary catheter care.
What we found
Findings from the TDF analysis showed It wasn’t just a knowledge and skills gap driving behaviour, although these areas did need to be addressed. There were also ‘social influences’, ‘environmental context and resources’, ‘beliefs about capabilities’ and ‘beliefs about consequences’ were found to drive behaviour.
Behaviour change strategy
Behavioual drivers were mapped to behaviour change strategies to inform a targeted intervention. We worked in collaboration with the Victorian Spinal Cord Service, a local peer support service and people with spinal cord injury to design a multifaceted intervention. The intervention was driven by the specialist spinal cord injury urology nurse, which was invaluable in addressing context specific barriers. The components of the intervention included:
An algorithm to support best practice and help address inconsistencies. It included persuasive communication to highlight potential consequences of delayed practice to ICs.
Engagement with influential nursing staff as clinical champions to support practice. Participants were deliberately selected, applying known characteristics based on diffusion of innovations theory (Rogers 1962) i.e. ‘laggards, ‘late majority’, ‘innovators’.
A research informed peer support program where coaches were trained to present a balanced view of catheter options based upon research evidence (not their own experience).
New website to improve health literacy among acute patients with SCI: www.Mybladdermylife.com
Staff training that included 1-1 skills training on how to perform ICs and a self-learning module. Staff cover is provided during training activities to remove the time barrier.
Did it work?
After a three-month audit, the number of days to an indwelling catheter removal and the start of intermittent catheter reduced from a median of 58 days to 19.5 days. Readmittance to the acute ward from the rehabilitation unit (6 months following an acute spinal cord injury) has also significantly reduced, with only 1 case recorded since the intervention was implemented.
References
Michie, S., et al., Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care, 2005. 14.
Cane, J., D. O’Connor, and S. Michie, Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation science, 2012. 7(1): p. 37.
Atkins, L., et al., A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science, 2017. 12(1): p. 77.
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