Part 1
For the case studys reading (Foy), please describe the following:
1. How did the authors use theory? The authors used the theory of planned behavior to frame subject questionnaires and interviews. Where would you place it on a continuum of uses of theory we discussed? Testing theory. They were able to attribute to what degree perceived behavioural control explained intention.
2. How did it relate to the uses of theory as described by Bartholemew and Mullen? They used theory to define a logic model of determinants of behavior. They used surveys to identify barriers and facilitators. There was no intervention aimed at increasing compliance in this retrospective observational study.
3. In you view of the work, how much did their explanation of the data ‘fit’ the theoretical components? The results seemed to support the theory because there was higher compliance to the recommendations where providers had higher perceived control (contraception supplies) compared to the recommendation (to see patients in 5 days) where they perceived they had lower control – yet there was strong agreement with the recommendations 6/7.
Part 2
The intervention I am working on is the implementation of a preprocedural anesthesia checklist at upto 10 sites. We plan to have the Chief of the Anesthesia service to choose among 4 modalities (paper, anesthesia computer software, hospital electronic health record, a checklist software that we have developed) for implementing the checklist. The outcome that we will measure is the % of cases where the checklist is documented. It is likely that all institutions have some sort of checklist; Another aspect of this project that will be interesting to track is to what extent aspects of the Anesthesia Patient Safety Foundations’ checklist (grant solicitor) have been incorporated into the checklist.
1. Select a behavior that is relevant to your area of interest. 1a.Which levels (individual, social, institutional, environmental) are most likely to have a significant role? My initial expectation is that environmental factors will have the most significant impact on the measured outcome. Because there is no “top down” pressure to implement the APSF checklist, implementation rates might be highest where staff is not overly busy and where providers have time to consider research initiatives. Alternatively there may be “checklist fatigue” and staff may welcome the use of paper instead of a cumbersome computer system to document their work. It is also possible that those institutions with academic affiliations will more likely be the highest adoptors. Or social factors, if site champions or team dynamics lead to the greatest diffusion. 1b.Who would you engage to develop a formative project to understand more about this behavior? We plan to initially engage the Chief of Anesthesia at each institution to gain participation in the trial; but the Foy and Francis articles provide a framework for provider surveys to define a logic model for determinants of behavior and testing theory constructs.
The intervention is to implement the PIPS checklist using the 4 modalities described above; and after a year, we will correlate implementation rates (the % of cases where completion of the checklist was documented) with provider survey results:
APSF Pre-anesthetic Induction Patient Safety (PIPS) Checklist
- Suction is working.
- Anesthesia workstation can provide ventilation with 100% oxygen under positive pressure.
- Upper airway status has been evaluated.
- Backup airway devices are immediately available.
- Patient’s significant drug allergies and possible drug interactions noted.
- NPO status and aspiration risk confirmed.
- Monitors are functioning with appropriate waveforms.
- Audible and visual alarms are set appropriately.
- Appropriate medications including resuscitation drugs are available.
- Intravenous access (if indicated) is appropriate and functioning.
- Special considerations for this patient confirmed (may include but not limited to):
- Increased risk for operating room fire.
- Surgical positioning requirements.
- Goals for blood pressure and/or heart rate management.
2. For one of the behaviors relevant to your outcome, complete a table relating variables relevant to your behavior to theories presented in class and in the readings. Can you expand on these individual factors, to include other factors at the social, institutional and environmental levels? I’m choosing a slightly different approach to complete this homework assignment to solicit feedback for a survey to be included in a grant I am preparing. The specific aim is to determine whether an intervention targeting individual, social, institutional or environmental factors would be most effective for optimizing implementation. For each question, respondents will be asked to provide an answer of 1 if they strongly disagree and 7 if they strongly agree.
Survey questions supporting the Theory of Planned Behavior as a concept model
- Behavioural Intention: I want to do all I can to protect my patients
- Attitude: I'm too busy to fill in another checklist
Certain cases are so simple that a checklist is unnecessary
- Subjective norm: I don't want to be the poorest performer
- Percieved control: Having to use the computer to document cases reduces efficiency
Implementation will be easy
Survey questions that support the Social Cognitive Theory as a concept model
- Reciprocal determinism: Which of the four implementation options work best for me?
- Behavioral capability: It would help if more information about how to complete certain checklist items were provided.
- Expectations: Taking the time to document completion of the checklist will improve patient safety at my institution.
- Self-efficacy: Completing the checklist will make me more effective.
- Observational learning: It would help to see how others have optimized checklist compliance.
- Reinforcements: We should periodically review how well our team is completing the checklist.