title: Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses' use of electronic medication management systems in two Australian hospitals.
abstract: Medication errors harm hospitalised patients and increase health care costs. Electronic Medication Management Systems (EMMS) have been shown to reduce medication errors. However, nurses do not always use EMMS as intended, largely because implementation of such patient safety strategies requires clinicians to change their existing practices, routines and behaviour. This study uses the Theoretical Domains Framework (TDF) to identify barriers and targeted interventions to enhance nurses' appropriate use of EMMS in two Australian hospitals.
  
  
  
  This qualitative study draws on in-depth interviews with 19 acute care nurses who used EMMS. A convenience sampling approach was used. Nurses working on the study units (N = 6) in two hospitals were invited to participate if available during the data collection period. Interviews inductively explored nurses' experiences of using EMMS (step 1). Data were analysed using the TDF to identify theory-derived barriers to nurses' appropriate use of EMMS (step 2). Relevant behaviour change techniques (BCTs) were identified to overcome key barriers to using EMMS (step 3) followed by the identification of potential literature-informed targeted intervention strategies to operationalise the identified BCTs (step 4).
  
  
  
  Barriers to nurses' use of EMMS in acute care were represented by nine domains of the TDF. Two closely linked domains emerged as major barriers to EMMS use: Environmental Context and Resources (availability and properties of computers on wheels (COWs); technology characteristics; specific contexts; competing demands and time pressure) and Social/Professional Role and Identity (conflict between using EMMS appropriately and executing behaviours critical to nurses' professional role and identity). The study identified three potential BCTs to address the Environmental Context and Resources domain barrier: adding objects to the environment; restructuring the physical environment; and prompts and cues. Seven BCTs to address Social/Professional Role and Identity were identified: social process of encouragement; pressure or support; information about others' approval; incompatible beliefs; identification of self as role model; framing/reframing; social comparison; and demonstration of behaviour. It proposes several targeted interventions to deliver these BCTs.
  
  
  
  The TDF provides a useful approach to identify barriers to nurses' prescribed use of EMMS, and can inform the design of targeted theory-based interventions to improve EMMS implementation.
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia. deborah.debono@uts.edu.au.|Faculty of Health, University of Technology, Sydney, NSW, Australia. deborah.debono@uts.edu.au.
authors.forename: Deborah
authors.identifier: 0000-0002-0502-2087
authors.initials: D
authors.lastname: Debono
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.
authors.forename: Natalie
authors.initials: N
authors.lastname: Taylor
authors.affiliation: Centre for Values, Ethics and Law in Medicine, University of Sydney, Sydney, NSW, Australia.
authors.forename: Wendy
authors.initials: W
authors.lastname: Lipworth
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.|Australian Institute of Health Services Management, University of Tasmania, Sydney, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Greenfield
authors.affiliation: Faculty of Health, University of Technology, Sydney, NSW, Australia.
authors.forename: Joanne
authors.initials: J
authors.lastname: Travaglia
authors.affiliation: Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia.
authors.forename: Deborah
authors.initials: D
authors.lastname: Black
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Braithwaite
mesh_terms: D001315:Australia; D005260:Female; D006761:Hospitals; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000706:statistics & numerical data*; D024802:Nurse's Role; D009741:Nursing Staff, Hospital; D061214:Patient Safety / Q000706:statistics & numerical data*; D036301:Qualitative Research
keywords: Behaviour change; Electronic Medication Management Systems; Implementation; Medication administration; Theoretical Domains Framework; Workarounds