Infection Control & Hospital Epidemiology
Table 2. Results of Mapping of Barriers/Facilitators to the Theoretical Domains Framework Theoretical Domains Framework (TDF)
Knowledge (an awareness of the existence of something)
27
Barriers and Facilitators to Practice Change
Antibiotic overuse: ∙ Awareness among residents, families and healthcare workers of asymptomatic bacteriuria (ASB) and that antibiotics are overused for this indication.
∙ Awareness among residents, families and healthcare workers of the risks and consequences of unnecessary use/overuse of antibiotics.
Assessment of UTIs: ∙ Knowledge among healthcare workers regarding: o Clinically relevant signs and symptoms of a urinary tract infection (UTI) o When to collect the urine culture o Use and interpretation of dipstick, urinalysis and culture results o How to manage cases where residents have communication difficulties and nonspecific symptoms
o What contributes to the contamination of urine specimens.
Skills (an ability or proficiency acquired through practice)
Urine specimen collection and analysis: ∙ Skills associated with the collection of a proper urine specimen.
UTI surveillance: ∙ Skills to support a UTI surveillance system, including data collection, management and analysis.
Environmental context and resources (any circumstance of a person’s situation or environment that discourages or encourages the development of skills and ability, independence, social competence and adaptive behavior)
Communication: ∙ The need to improve communication amongst the care team (verbal and/or documented) on resident symptoms.
Organizational culture: ∙ The existing organizational culture has supported nursing staff in sending urine cultures for testing even when a resident does not have indicated clinical signs and symptoms of a UTI.
Process and procedures: ∙ Absence of policies and procedures on recommended practices or not aligned with current best practices
∙ Urine specimens left at room temperature, which can result in false positives ∙ Absence of information on the need for change (extent to which practice is misaligned) because data is not routinely collected
Resources: ∙ Staff do not have access to adequate supports to provide education to residents/families. ∙ Lack of resources to guide UTI assessment and management practices
External services and programs: ∙ Alignment of practice recommendations with other programs is an important facilitator. A perception that existing approaches to examine behavioral changes in residents involve ruling out a UTI prompts the collect of a urine specimens in the absence of indicated clinical signs and symptoms of a UTI.
Social/professional role and identity (A coherent set of behaviours and displayed personal qualities of an individual in a social work setting.)
Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors.)
Beliefs about consequences (Acceptance of the truth, reality, or validly about outcomes of a behavior in a given situation.) Emotions (A complex reaction pattern, involving experiential, behavioral, and physiological elements, by which the individual attempts to deal with a personally significant matter or event)
Reinforcement
(Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus)
Reinforcing current practice: ∙ Some residents are labelled as having “recurrent UTIs.” When there is a change in the residents’ behavior or urine characteristics, it is assumed they have a UTI based on this label.
∙ It is common to see urine specimens being collected for culture and susceptibility in the absence of clinical signs and symptoms of a UTI. Because of the high incidence of ASB, elevated levels of bacteria in the urine are often detected. Due to the persistent belief that antibiotics are required to treat ASB, positive urine culture results can continue to reinforce the practice of collecting urine in the absence of clinical signs and symptoms of a UTI.
∙ Conflicting practices of other organizations can reinforce poor practice. A common barrier described by LTCFs to not treating ASB occurs when residents are sent to the emergency department for assessment and return with a prescription for antibiotics for a UTI in the absence of specific signs and symptoms of a UTI.
Role clarity: ∙ Lack of clarity about the roles and responsibilities of the care team around the assessment and management of UTIs
Acceptance: ∙ Lack of acceptance by front line nursing, nurse practitioners, or physician for the practice changes
Family pressure: ∙ Families influence decisions to prescribe antibiotics in the absence of indicated clinical signs and symptoms of a UTI.
Concerns about outcomes: ∙ Concerns about the consequences of not providing antibiotics to residents with nonspecific symptoms or asymptomatic bacteriuria including fears that an infection will develop or be missed
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
