Table 1 Summary of beliefs broken down by TDF domain
From: Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study
Domain | Specific Belief | Sample quote |
|---|---|---|
Knowledge | 25% not aware of Randomised Controlled Trials or NICE guidance | Based on Questionnaire data |
Skills | Resisting pressure of patients who want an arthroscopy | Sometimes useful as a delaying tactic when under pressure from patient with minimal change but very symptomatic. (Questionnaire Participant 1) |
Diagnosis of OA knee (WB film rather than non-WB or MRI) | “it [non-weight bearing radiographs and MRI] give you some leeway to offer what you want” (Interview participant 3) | |
Social/Professional Role and Identity | Resisting pressure of patients who want an arthroscopy (Professional confidence) | “Pressure from patients who do not want major surgery but want “something” done.’ (Questionnaire participant 6) |
“Expectation of patients to have a treatment/procedure prior to receiving arthroplasty.”(Questionnaire participant 7) | ||
Junior under pressure from seniors | “He is the boss” (interview participant 1) | |
“It’s…. Commonly instigated by a senior surgeon” Interview participant 3) | ||
Beliefs about Capabilities | Resisting pressure of patients who want an arthroscopy | “Pressure from patients who do not want major surgery but want “something” done.’ (Questionnaire participant 6) |
“Expectation of patients to have a treatment/procedure prior to receiving arthroplasty.”(Questionnaire participant 7) | ||
Belief that some surgeons better than average at arthroscopy, and will therefore have better results | “some surgeons do feel that they are better than average” (Interview participant 1) | |
Beliefs about Consequences | 10% of respondents disagreed with NICE Guidance (most common in patients with mechanical symptoms); widely held belief that arthroscopy delays the need for TKR, and improves outcome in patients with knee OA | Delay in treatment: |
“Sometimes useful as a delaying tactic when under pressure from patient with minimal change but very symptomatic.” . (Questionnaire Participant 1) | ||
“It makes it look like the knee replacement was delayed” (Interview participant 1) | ||
Subgroups of patients that may benefit: | ||
“The guidelines restrict treatment for the sub-group of patients who DO benefit from arthroscopic treatment in OA, or are unfit or do not wish to have more major interventions.” (Questionnaire participant 5) | ||
Reinforcement | Financial and regulatory factors (restrictions from commissioning groups and private insurance companies) | “I think BUPA are getting independent reviews on private patients.”(Questionnaire participant 2) |
“Diagnostic arthroscopy alone is not a sufficient indication for surgery in the trust and it is not funded by the PCT. Therefore the patient is removed from the waiting list.” (Questionnaire participant 3) | ||
Intentions | Disagreement with guidelines result in no intention to adhere to them Stable | “Patients cannot … be rigidly boxed into a protocol and clinicians, especially at consultant level, should have the freedom to assess patients on an individual basis.” (Interview participant 5) |
Goals | Returns to beliefs about outcome | “Treat patients, not NICE guidelines. NICE guidelines assume patients are similar to machines, with no emotional input.” (Questionnaire participant 4) |
Environmental Context and Resources | Financial and regulatory factors | “If all my peers stop doing it I would think twice, thrice, before offering it so yes, it would make me less likely to offer it.” (Interview participant 4) |
Enabler is if other surgeons in department are not doing it | ||
Resource issue | “We essentially cant offer anything in the intermediate stage”(Interview participant 2) | |
Time pressure | “You need more time to explain to patients what the option are if you are not doing arthroscopy”(Interview participant 1) | |
Social Influences | Enabler if other surgeons in department are not doing it | “It is harder to do a treatment none of your peers are.” (Interview participant 2) |
Financial and regulatory factors | As above | |
Emotion | Desire to help – wanting to list even though might not be best thing (wanting to do something) | “You do not want to dismiss their concerns” (Interview participant 1) |
“You want to help” (Interview participant 2) | ||
Behavioural Regulation | Just habit and learned behaviour that is driving the high arthroscopy rate | “its been an established kind of solution for a long time … that is still a bit of a problem” (Interview participant 2) |
“Different consultants have different ways of managing … it would be a treatment they still would offer” (interview participant 1) |