QUALITATIVE ANALYSIS AND CATEGORIZATION OF COMMITMENT-TO-CHANGE

QUALITATIVE ANALYSIS AND CATEGORIZATION OF COMMITMENT-TO-CHANGE STATEMENTS Heather Armson: University of Calgary Stefanie Roder: McMaster University Sarah Kinzie: McMaster University Tom Elmslie: University of Ottawa Jacqueline Wakefield: McMaster University The Foundation for Medical Practice Education SACME Spring Meeting April 22-26 in Rancho Mirage, CA Background Commitment-to-change statements (CTCs) are used in a variety of educational activities to promote and document practice changes CTCs are predictive of implementation of changes into practice The components of CTCs that contribute to implementation of new practice behaviours are not known. Background Phase I Development of practice reflection tool (PRT) to capture reflection & CTCs at the end of small group discussions The PRT encourages family physicians to:    Reflect on the application of new knowledge to their clinical practices Document the outcome of their learning session in the form of commitment-to-change (CTC) statements. Review CTC at 3 months to assess successful implementation PERSONAL PRACTICE REFLECTIONS IMPACT ON MY PRACTICE (to be completed immediately after reviewing the module) Name of Module: ________________________ __ Date:_____________________ day / month / year The most useful information for me was: This highlighted the following gap in my current practice: I will change my current practice in the following way: The barrier(s) that I am anticipating include the following:  What changes to my current practice am I considering? What would enable me to change my current practice?  What confirmed my current practice?  What supports my current practice? I am not convinced there is a need to change my current practice because: Personal Practice Reflections – Follow-up Review Name of Module: What change(s) did I make in my practice? Date: What were the barrier(s) and/or facilitator(s) to my practice change? What practice change(s) did I make that I did not anticipate? I can identify other change(s) I would like to make in my practice? These are of the following: The barrier(s) / facilitator(s) that I am anticipating are: Purpose Phase II Can CTC statements be categorized to reflect a cognitive hierarchy of increasingly complex, higher level practice changes? Is there a link between higher cognitive level of the CTC statements and the likelihood of practice change? Methods Design: Mixed Methods Participants: Family Physicians participating in PBSG / PBIL learning program Procedures /Tools: • • • Review of educational module on a specific topic Group discussion of module topic Documentation of the outcome of their learning session on a personal practice reflection tool (PRT):  “most useful information”  “gap in my practice”  Guided CTCs: “will change”, “considering change”, “confirmed practice”, “not convinced” Analysis: Principles of grounded theory including iterative coding, constant comparison, data saturation Categorization of PRT statements Categorizing PRT statements according to the Cognitive levels of Bloom’s Taxonomy Sample Coding done using Bloom’s Taxonomy Statements taken from Practice Reflection Tool: PRT question: “the most useful information for me was:” Cognitive levels of Bloom’s Taxonomy knowledge comprehension analysis / application analysis application application “variety of differential diagnosis” “complexity of diagnosing PN” PRT question: “this highlighted the following gap in my practice:” “small gaps, more detailed physical” “not doing enough investigations” PRT question: “I will change my current practice in the following way.” “ask more about FmHx” “likely order more complete blood work on these patients to R/D multiple causes” PRT question: “What confirmed my current practice?” “my treatment alone is as indicated in this module” “my treatment of PN seems reasonable and my approach to diabetic patients meets guide lines” “I do not think there is anything new” “I feel I handle this problem with the current knowledge of the disease and the treatments available” analysis analysis / evaluation PRT question: “ I am not convinced there is a need to change my current practice because:” evaluation evaluation Outcome of coding statements according to Bloom’s Taxonomy Questions on the PRT really present stimulus questions that could be considered as leading the physicians through a hierarchy of learning. PRT questions “The most useful information for me was:” “This highlighted the following gap in my current practice” CTC Section - Practice Change options: “I will change my current practice in the following way.” “The barrier(s) that I am anticipating include the following” “What changes to my current practice am I considering?” Application Synthesis Analysis / Application Cognitive levels of Bloom’s Taxonomy Knowledge and Comprehension Analysis “What would enable me to change my current practice?” “What confirmed my current practice?” “What supports my current practice?” Synthesis Application / Synthesis / Evaluation Synthesis / Evaluation “I am not convinced there is a need to change my current practice because” Analysis Categorization of CTC statements Tried linking other Models of Physician Change with Bloom’s Taxonomy and CTC statements from the PRT Models of Physician Change Rogers, 1995 Fox, Mazmanian & Putnam 1989 Mazmanian &Mazmanian 1999 Steps in the Innovation- Decision Process Stages of Change and Learning Stages of Commitment-to-Change Hierarchy of Outcomes Grol&Wensing 2004 10 step model for inducing change Categorization of CTC statements The outcome of a learning session differed depending on where the physicians started with respect to existing practice and how they assessed the relative value of a practice change. Five categories of outcomes were found in the data: unaware scattered systematize / construction fine-tuning confirmation Development of coding book Code Category Unaware Definition Unaware of the problem or with minimal information and strategies Disorganized, disconnected or discounted information is identified Useful information: “checking for investigation of +Rx of PN; hereditary nature of PN” Gap in practice: “aggressive DM control” Will change: “ask about more aggressive early intervention RX of early +Rx of early DM pt” Useful information: “at last I have a comprehensive approach to this common problem-diagnostically” Gap in practice: “I feel better able to cope with Hx/Px/Ix” Will change: “as above, more empowered; more family Hx” Useful information: Gap in practice: “higher index of suspicion for EtOh abuse; I had not been considering hereditary PN’s as a common etiology” Will change: “explore EtOH as a possible cause sooner” Example Scattered Systematize / Construction Making sense of disorganized, disconnected information; constructing a more systematic approach; comfort level not high An overall understanding and approach to the problem exists but need to clarify, enhance or improve specific aspect of practice; comfort level high Fine-tuning Confirmation Good knowledge, good approach, confirmed practice; not just given information, but also identifies an approach Useful information: “just a review of the differential diagnosis” Gap in practice: “management+work up remain the same; have been diag. What they recommended” Will change: “no, already done what has been suggested” Conclusions • PRT does capture proposed practice changes • PRT enhances the development of CTC by using questions at different levels of learning • In process: determine to what extent a hierarchy of CTCs relate to actual practice change This study was in part funded by a grant from Society for Academic Continuing Medical Education (SACME) For further information please contact armson@ucalgary.ca