Results
Participants: Thirty-one PTs participated in the study: 10 participants in private and public practices each, and 11 participants from the education sector.
SoC classification: Table 1 outlines the classification of study participants into their appropriate SoC and includes illustrative quotations in relation to their appropriate SoC. Some participants did not have a clear understanding of CPGs, and of those that did, not all were ready to implement CPGs into practice. Conversely, of those individuals who were unclear about CPGs, there were some who wanted to apply best evidence to their practice and were unsure about doing this. Years in practice were not an indicator to whether the person was more or less likely to implement CPGs in their practice.
>>Table 1: Classification of study participants into Stages of Change about here>>
To be classified at the Pre-contemplation stage, participants must have provided evidence that they were not ready to explore the use of CPGs in clinical practice. If participants provided evidence that they were considering the possibilities of implementing CPGs, then they were classified as in the Contemplation stage. If participants noted the benefits of using CPGs in clinical practice, or if they understood what CPGs entailed, or had previously used them, they were assigned into the Action stage. P6 and P11 did not see accessing of CPGs as a barrier to CPG uptake, but rather assisting them due to it being readily available to them via online sources. They may be classified at the Action stage of the SoC, as they can already see ways to incorporate CPGs as part of their clinical load. They will need assistance with choosing a CPG and prioritising conditions seen in practice for application of CPGs.
To be classified at the Maintenance stage, the participants must have provided evidence that they have successfully used CPGs and are continuing to use it.
However, when assigning participants into the TTM SoCs, there were complexities in the classification process. Considering the quotations related to whether “time due to workload” was an issue for CPG uptake, the answers were initially divided into “yes “, “no” and “do not know” groups. In the “yes” group there were five private, two public and two educators that indicated time as a barrier. These participants were classified in the lower SoC (Pre-contemplation (n=5) and Contemplation (n=3)), except one participant who was classified as Maintenance. One private PT, two public PTs and five educators did not think that time was a barrier to CPG uptake. All but one of the PTs that did not identify time as a barrier were classified in the higher SoC, Action (n=6) or Maintenance (n=1). The one participant (P07) that was ultimately classified as “Preparation” reflected more on the view of the public sector PT than their own position. In the “do not know” group four private, six public and four educators were identified.
When comparing the different SoC levels to the subthemes relating to the concept of “lack of time” (Figure 2), all participants identified “EBP as priority in practice” as a factor, while certain SoC levels were more likely to identify other subthemes of the “lack of time”. For example, the participants in the pre-contemplation stage, were more likely to identify “Few staff, high workload” as barriers to CPG uptake. In addition to above, participants in the contemplation stage identified “accessing CPGs” as another barrier. Whereas, participants in the preparation stage, identified “Time is money” as barrier to CPG uptake. Participants in the action stage identified “knowledge on CPG use” as a barrier. The maintenance stage had no barriers apart from “EBP as priority in practice”, being cited more as a factor influencing rather than a barrier to CPG uptake.
The authors conceptualised a model of time management for better CPG uptake (Figure 3). This model combines the barriers of time, the different SoC 17 and the six domains of healthcare quality 11. This model gives researchers a way of categorising individuals into different SoC to assist clinicians in CPG uptake to ultimately align clinical practice to evidence-informed practice. Central to the model is the barrier of time, with the first circle providing underlying challenges to the concept of “lack of time” for evidence uptake. The following circle deals with a clinician moving through the different SoC (from Pre-contemplation to Maintenance) to reaching the criteria for healthcare quality. The model is encompassed by the clinician determining the importance of the outer circle, “EBP as priority”, to their own clinical decision-making process. Each circle within the wheel model is a moving part, with the circles’ parts aligning and interacting with each other at different stages of their process toward optimum usage of evidence as part of their decision-making process.
The authors mapped the constructs of the wheel model (Figure 3) to the Theoretical Domains Framework of behaviour change (TDF) (Table 2) to support its design and applicability to addressing the lack-of-time barrier to CPG uptake 22. The updated TDF “provides a method for theoretically assessing implementation problems, as well as professional and other health-related behaviours as a basis for intervention development23. The TDF has previously been used to investigate influences on health and clinical behaviours, developing and evaluating implementation intervention designs and guiding appropriate behaviour change technique identification 22.
>>Figure 3: Wheel model of time management for better CPG-uptake about here>>
>>Table 2: Mapping of wheel model to Theoretical Domains Framework 22 about here>>