1224
Table 1. Links Between Components of the ‘COM-B’ Model of Behavior and Intervention Functionsa Intervention functions
Source of Behavior Education Persuasion Incentivization Coercion Training Restriction Environmental Restructuring Modeling Enablement
Physical capabilityb √√ Psychological capabilityc√√ √ Reflective motivationd √√ √
√
Automatic motivatione √√ √ Physical opportunityf Social opportunityf
√ √ √
√√ √ √√ √
aTable reproduced with permission from Michie et al.32 bPhysical capability can be achieved through physical skill development, which is the focus of training, or potentially through enabling interventions such as medication, surgery or
prostheses. cPsychological capability can be achieved through imparting knowledge or understanding; training emotional, cognitive, and/or behavioral skills; or through enabling interventions such as
medication. dReflective motivation can be achieved through increasing knowledge and understanding or through eliciting positive (or negative) feelings about behavioral target. eAutomatic motivation can be achieved through associative learning that elicits positive (or negative) feelings and impulses and counterimpulses relating to the behavioral target, imitative
learning, or habit formation that directly influences automatic motivational processes (eg, via medication). fPhysical and social opportunity can be achieved through environmental change.
Table 2. Semi-Structured Interview Guide Introducing Question
1. What crosses your mind when you hear the term VAP?
3. Do you know the elements of the VAP bundle in this hospital?
4. For which bundle elements is adherence good or poor?
Note. VAP, ventilator-associated pneumonia.
of patients did not have a tube with a suction port for subglottic suctioning.
Focus group interviews
Overall, 42 nurses and 4 physicians participated in the interviews (Table 4); of these, 17 were male (37%). One participant withdrew consent because the interview was audiotaped. The interviews lasted between 35 and 45 minutes. We determined that data saturation was achieved (ie, no new barriers and facilitators were being identified35 after the fourth focus group), but we continued data collection based on our criterion sampling strategy until all ICUs had been included.
Barriers and facilitators for adherence to the VAP bundle according to the BCW sources of behavior
At the center of the BCW framework lie the ‘sources of behavior’,6 essential components that shape behavior: physical and psycholo- gical capability, reflective and automatic motivation, and physical and social opportunity.32 The interviewee’sstatementsabout bar- riers and facilitators for adherence to the prevention measures were coded according to these components (Table 5). A total of 104 statements were coded: 79 (76%) referred to barriers and 25 (24%) to facilitators. The most commonly coded components were
What do you perceive as facilitators and barriers to adherence with the bundle elements?
Deepening Question
How many patients do you estimate, suffer from VAP on your ICU?
2. Do you think VAP is preventable? To what extent VAP is preventable?
‘physical opportunity’ with 49% of statements (n=51: 47 barriers and 4 facilitators), followed by ‘reflective motivation’ with 21% (n=22: 9 barriers and 13 facilitators), ‘automatic motivation’ with 12% (n=12: 11 barriers and 1 facilitator), and ‘psychological cap- ability’ with 10% (n=10: 5 barriers and 5 facilitators) of statements, respectively. ‘Social opportunity’ and ‘physical capability’ appeared rarely, in 7% (n=7) and 2% (n=2), respectively.
Physical and psychological capability ‘Physical capability’, which is defined as the individual’s physical capacity to engage in the activity, was brought up as a barrier once, referring to the inability to estimate the correct angle of head of bed elevation by eye. ‘Psychological capability,’ like self- discipline, was mentioned as a facilitator. Lack of knowledge and forgetfulness were brought up as barriers several times.
Reflective and automatic motivation Most facilitators were related to the ‘reflective motivation’ BCW component, defined as ‘evaluations and plans that energize and direct behavior.’ Interviewees were aware of the frequency and consequences of VAP and generally considered prevention measures useful to lower VAP rates. Some HCPs, however, mentioned doubts about the effec- tiveness of certain prevention measures like head of bed elevation and noninvasive ventilation, which may have presented a barrier to adherence. Numerous barriers belonged to the ‘automatic motivation’ component, that is, emotions and impulses that direct behavior. HCPs were concerned about preventionmeasures affecting the patient’s well- being, such as disturbance by the noise of the subglottic suctioning device, uncomfortable body position due to head of bed elevation, and unpleasant taste of the chlorhexidine mouth wash.
Physical and social opportunity Most barriers were assigned to the group of ‘physical opportunity’ and, less commonly, ‘social opportunity’—factors that lie outside the individual HCP. Three points emerged as being most important: (1) lack of equipment (eg, tracheal tubes with suction port for subglottic suctioning, chlorhexidine gel instead of mouth wash, beds with appropriate angle measurement devices), (2) lack of adequate staffing or time for patient care, and (3) competing priorities of
Aline Wolfensberger et al
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144