Clinical-related behaviours of
healthcare workers:
Determinants of adoption and
planning interventions
Prof. Gaston Godin, Ph.D.
Laval University, Quebec
May 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
6. Evaluation
•Describe program outcomes
and research questions
•Specify evaluation design
•State expected changes
•Specify performance and
change objectives
5. Implementation
3. Theory and practice
•Identify implementation
and adoption conditions
•Identify theoretical bases
•Select program method &
practical applications
4. Program
•Develop program
•Produce material
•Identify partners
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 behaviour
Variables
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 intention
Variables
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
Nurses
Type of behaviours
Clinical practice
Compliance - guidelines
Documentation
Total
Physicians
Clinical practice
Compliance - guidelines
Counselling
Total
Other
Clinical practice
Counselling
Total
Nb. HCW
(studies)
Weighted
R2
220 (3)
225 (2)
158 (2)
0.41
0.19
0.09
603 (7)
0.24
387 (4)
33 (1)
765 (1)
0.11
0.001
0.40
1 185 (6)
0.28
284 (1)
40 (1)
0.58
0.33
324 (2)
0.55
Model efficacy for intention
(n = 14 986; R2 = 0.59)
HCW
Type of behaviours
Nb. HCW
(studies)
Weighted
R2
Nurses
Clinical practice
Technologies acceptance
Compliance - guidelines
Documentation
4 443 (21)
151 (1)
1 181 (5)
108 (1)
0.68
0.77
0.62
0.46
5 883 (28)
0.66
2 185 (11)
1 150 (4)
762 (4)
1 146 (3)
180 (2)
0.54
0.68
0.50
0.28
0.19
5 423 (24)
0.51
Total
Physicians
Clinical practice
Technologies acceptance
Compliance - guidelines
Counselling
Documentation
Total
Model efficacy for intention
(continued)
HCW
Type of behaviours
Nb. HCW
(studies)
Weighted
R2
Other
Clinical practice
Compliance - guidelines
Counselling
2 042 (6)
527 (1)
1 111 (5)
0.53
0.73
0.62
3 680 (12)
0.59
Total
Prediction model for clinicalrelated behaviours of HCW
Beliefs about
consequences
Beliefs about
capabilities
Moral norm
Social influences
INTENTION
Role & identity
Characteristics
of HCW
Habit / past
behaviour
BEHAVIOUR
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
6. Evaluation
•Describe program outcomes
and research questions
•Specify evaluation design
•State expected changes
•Specify performance and
change objectives
5. Implementation
3. Theory and practice
•Identify implementation
and adoption conditions
•Identify theoretical bases
•Select program method &
practical applications
4. Program
•Develop program
•Produce material
•Identify partners
Performance objectives and the
determinants to be targeted
Performance Objective
Behaviour-1
Behaviour-2
Behaviour-3
Determinants
Type of intervention

Motivational vs. Volitional (postmotivational)
– Level of intention at baseline of
participants

Interventions are mainly evaluated
using motivated volunteers
Health action process approach
Outcome
expectancies
Maintenance
Self-efficacy
Action planning
Recovery
Self-efficacy
Action control
Intention
Risk
perception
Motivational phase
Coping planning
Action
Barriers and resources (e.g., social support)
Volitional phase
Disengagement
Task
self-efficacy
Behaviour
No
Yes
Motivated to adopt
Intervention to maintain
adherence
Yes
No
Etc…
Volitional intervention
Motivational intervention
Etc…
Settings
Community
Clinical
Theory A or ?
Theory B or ?
Mode of delivery
Gender
Mass media
Telephone
counselling
Women
Men
Techniques
A, B, C or ?
Techniques
B, D, E or ?
Techniques
F, G, H or ?
Techniques
G, H, I or ?
Performance objectives, determinants to
be targeted and behavior change technique
Performance
Objective
Behaviour-1
Behaviour-2
Behaviour-3
Determinants
Behaviour change techniques
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Knowledge
Skills
Social/professional role & identity
Beliefs about capabilities (self-efficacy, PBC)
Beliefs about consequences (attitude)
Motivation & goals (intention)
Memory, attention & decision processes
Environmental context & resources
Social influences (subjective norm, social support)
Emotion (anticipated regret, fear)
Behavioural regulation (action planning, coping planning)
Nature of behaviours (past behaviour)
Cognitive profiles of HCW
Intention
Low
High
Capabilities
Low
High
A
C
B
D
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
Example of 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
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
Understand
1. Selection of the
theory
2. Identification of
determinants
Plan
1. Selection of
behavior change
techniques (BCT)
2. Methodological
considerations
Evaluate
1. Measurement of
contructs
2. Mediation and
moderation
analyses
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.
Thank you !
QUESTIONS ?
COMMENTS ?
www.godin.fsi.ulaval.ca