What determines practice?

What determines practice?

Watch this animation to find out more about what we know about healthcare professional behaviour.

The animation shows how every behaviour we do is determined by our capability, opportunity and motivation. How these determinants of behaviour go together to make a behaviour happen or not happen is complicated. Many scientists and social scientists are still studying this and there are over 50 different theories (http://www.behaviourchangetheories.com). The way that we think about it is not the only way but it is the way that makes the most sense to us, as we try to understand healthcare professional practice and the influence that education and training might have on practice.

We think about two processes that combine to result in behaviour.

One process (reflective motivation), involves us thinking and reflecting and weighing up what we think about the behaviour, about the goals we have, about who we are and the situation we are in.

The other process is more automatic (automatic motivation) and involves us responding to the situation we are in, and to our impulses and urges.

Both processes are important when we are thinking about how healthcare professionals practice.  Yes, we need to make a good case for the behaviour we want to see, we need to teach people how to do it, give them confidence that they can and help them to understand that it is a good thing.  But, we also need to think about what will happen to them day to day – what pressures and impulses will they feel that will push their behaviour one way or another.  These impulses and pressures can be a negative thing – pushing people towards practices that are not ideal, but if they can be harnessed they can be powerful.

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A reason why they are powerful is that when we act in line with our impulses we feel better and the way that we feel has a strong influence on us – we don’t like to feel bad and so we tend to act in ways that make us feel good.  Another reason that they are useful is that acting like this – automatically – doesn’t involve as much energy as monitoring ourselves and thinking about how we are acting.

The effort – which we sometimes call cognitive load – of constantly monitoring what we are doing and making decisions in line with what we have decided we want to do – can become too much.  Feeling that the effort of doing a behaviour is too much can sometimes be enough to stop us doing it altogether.

By understanding what drives practice, we can make our education & training address the real issues that determine whether people practice in one way or in another.  Often we design our education and training courses with someone’s capability (competence) in mind.  We then assess whether we can increase capability.  Understanding that there are other determinants of practice – both reflective and automatic – gives us a new way to think about designing education and training to make practice more likely.

We can also think about assessing whether our education and training is good by assessing whether it changes the determinants of practice in these processes.

The many theories have studied many different determinants of practice and these can be split and summarised in many ways.  One way that these are discussed is within the Theoretical Domains Framework (TDF: https://link.springer.com/article/10.1186/1748-5908-7-37).  The TDF is a simplification and integration of 33 theories (with 128 theoretical constructs) of behaviour change.  The TDF has 12 domains. Questioning these 14 domains can help understand implementation problems.

In our work, we look at constructs from the multiple theories that have previously been used to study healthcare professional practice.  These are: Theory of Planned Behaviour; Social Cognitive Theory; Self-Regulation Model; Learning Theory; Implementation Intentions; Knowledge; Attitudes; Behaviour Model; Precaution-Adoption-Process Model; plus other models / frameworks used to study healthcare professionals and implementation: Promoting Action on Research Implementation in Health Services (PARIHS); PRIME Theory; Burnout.

What factors you look at will be determined by your hypotheses about what needs to change, your intervention (education and training) and what it is aiming to change and possibly your theoretical standpoint.

What have you learnt?

  • There are many determinants of behaviour that can be summarised as capability, opportunity and motivation.
  • There are two processes that are important in determining practice: a slower, reflective process and a quicker, automatic process.
  • Automatic processes are powerful because we feel good when we go along with our impulses and it takes less energy to do something automatically than it does when we have to think a lot about it.
1 Eccles, M., et al. (2012) Explaining clinical behaviours using multiple theoretical models. Implementation Science, 7:99
2 Kitson A, Harvey G, McCormack B: Enabling the implementation of evidence-based practice: a conceptual framework. Quality in Health Care. 1998, 7 (3): 149-158.
3 www.primetheory.com
4 Scaudeli,W.B. et al. (2009).  Burnout: 35 years of research and practice. Career Development International 14(3): 204-220
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