Improvement in clinicians' perceptions of inpatient urinary continence care following an implementation study: a before and after study using a questionnaire aligned to the Theoretical Domains Framework with practical methods for analysing and presenting barrier and enabler data

Abstract

Background: Although 10-50% of patients in hospital experience urinary continence issues many do not receive guideline-recommended care. We developed and tested a co-created practice-change package that improved then maintained the proportion of symptomatic inpatients receiving a urinary continence assessment, diagnosis, and management plan. In this present study we aimed to categorise clinicians' perceptions of urinary continence care as barriers or enablers, and determine any change after implementation of the package.

Methods: Overall, fifteen adult wards (acute = 3, rehabilitation = 7, acute and rehabilitation = 5) in 12 Australian hospitals (large city = 4, regional = 8) participated. All wards were to receive the practice-change package during the study. The selected implementation strategies addressed barriers identified before implementation, and targeted inpatient clinicians. These clinicians were invited to complete a web-based questionnaire before and immediately after the 6-month implementation phase. The questionnaire was aligned to 13/14 domains of the Theoretical Domains Framework. It included 57 subitems covering assessment, diagnosis, management, or general continence care. A 5-point Likert scale was used (e.g. "strongly agree" to "strongly disagree"). To categorise responses, each subitem was dichotomised as positive (e.g. "agree", "strongly agree") or neutral/ negative ("unsure", "disagree", "strongly disagree"). Subitems were classified and colour coded as barriers (< 60% positive responses, red), neutral (60-69% positive, orange) or enablers (> 69% positive, green). Changes from before to after-implementation were assessed.

Results: Clinicians from 12 hospitals participated before-implementation (n=291, 82% female, 88% nursing), and from 10/12 hospitals (n=195, 86% female, 94% nursing) after-implementation. Two hospitals withdrew as the start of their implementation phase coincided with the onset of COVID-19. After implementation substantial improvements in perceptions were observed in 7/13 TDF domains: "skills", "knowledge", "memory", "beliefs about capabilities", "emotion", "environmental context and resources", and "social and professional role". Three domains ("goals", "beliefs about consequences" and "reinforcement") were high scoring enablers at both timepoints. Three domains had limited or no change ("social influences", "intentions", "behaviour regulation").

Conclusion: Categorisation and colour-coding of perceptions can assist end-users to quickly understand the data, identify areas for improvement, and changes after-implementation. The results helped to identify and explain which implementation strategies appeared to be successful in changing practice, and which ones need refining.