Defining barriers and enablers for clinical pathway implementation in complex clinical settings

Abstract Background While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency...

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Main Authors: Mona Jabbour, Amanda S. Newton, David Johnson, Janet A. Curran
Format: Article
Language:English
Published: BMC 2018-11-01
Series:Implementation Science
Subjects:
Online Access:http://link.springer.com/article/10.1186/s13012-018-0832-8
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spelling doaj-2c5ef46173c64564a86da11014f42b2d2020-11-25T02:16:00ZengBMCImplementation Science1748-59082018-11-0113111310.1186/s13012-018-0832-8Defining barriers and enablers for clinical pathway implementation in complex clinical settingsMona Jabbour0Amanda S. Newton1David Johnson2Janet A. Curran3Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern OntarioDepartment of Pediatrics, Division of General Pediatrics, Faculty of Medicine and Dentistry, University of AlbertaDepartments of Pediatrics and Emergency Medicine, University of CalgarySchool of Nursing, Faculty of Health Professions, Dalhousie UniversityAbstract Background While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. Methods This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model—capability, opportunity, and motivation—of the Behaviour Change Wheel. Results Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. Conclusions Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. Trial registration ClinicalTrials.gov, NCT01815710.http://link.springer.com/article/10.1186/s13012-018-0832-8ImplementationClinical pathwaysBarriers and enablersTheoretical domains frameworkEmergency medicine
collection DOAJ
language English
format Article
sources DOAJ
author Mona Jabbour
Amanda S. Newton
David Johnson
Janet A. Curran
spellingShingle Mona Jabbour
Amanda S. Newton
David Johnson
Janet A. Curran
Defining barriers and enablers for clinical pathway implementation in complex clinical settings
Implementation Science
Implementation
Clinical pathways
Barriers and enablers
Theoretical domains framework
Emergency medicine
author_facet Mona Jabbour
Amanda S. Newton
David Johnson
Janet A. Curran
author_sort Mona Jabbour
title Defining barriers and enablers for clinical pathway implementation in complex clinical settings
title_short Defining barriers and enablers for clinical pathway implementation in complex clinical settings
title_full Defining barriers and enablers for clinical pathway implementation in complex clinical settings
title_fullStr Defining barriers and enablers for clinical pathway implementation in complex clinical settings
title_full_unstemmed Defining barriers and enablers for clinical pathway implementation in complex clinical settings
title_sort defining barriers and enablers for clinical pathway implementation in complex clinical settings
publisher BMC
series Implementation Science
issn 1748-5908
publishDate 2018-11-01
description Abstract Background While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. Methods This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model—capability, opportunity, and motivation—of the Behaviour Change Wheel. Results Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. Conclusions Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. Trial registration ClinicalTrials.gov, NCT01815710.
topic Implementation
Clinical pathways
Barriers and enablers
Theoretical domains framework
Emergency medicine
url http://link.springer.com/article/10.1186/s13012-018-0832-8
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