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Table 1 COM-B Theoretical Domains Framework for barriers to adoption of guideline-based clinical practice at ORCI

From: Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa

Domain

Barriers

Physical capability

• Lack of updated context-specific clinical practice guidelines to date

• Existing resource-stratified guidelines (e.g., NCCN Framework™) are not easily accessible

• Limited and/or inconsistent resources may affect the ability to follow guidelines

Psychological capability

• Providers are not very familiar with existing guidelines

• Providers are not accustomed to guideline-based practice

• Providers do not necessarily believe that they should be following guidelines

• More effort is required to reference guidelines than seek (or make) an experience-based decision

Physical opportunity

• Guidelines are not part of didactic education or ongoing case-based training

• The oncologist, resident, and nurse responsible for a patient may not typically be together when a treatment plan is made or changed

• Multiple consultants may sequentially assume responsibility for a patient during the treatment course, leading to lack of accountability in patient management

• Inefficiencies in clinical systems impede timely completion of standard treatment

• Poor communication and coordination among multidisciplinary providers at different institutions

Social opportunity

• Clinical norms favor decision-making based on expert opinion and individualized experiences

• Little professional or organizational value is placed on guideline concordance

• Nurses often do not participate in management decision-making

• The organizational culture is hierarchical

Reflective motivation

• Predominant belief that expertise-based decisions are superior to guidelines

• Lack of awareness of the clinical benefit of guideline-based practice

• Perception that guidelines do not apply to local ORCI setting

• Consultants feel that using guidelines stifles professional authority and intellect

• Residents and nurses do not feel empowered to question guideline concordance

Automatic motivation

• Consultants take pride in expertise and expert-based decisions

• Residents defer to consultant expertise

• Nurses do not routinely evaluate guideline concordance of management decisions

• Residents and nurses may fear questioning of management decisions made by consultants

• Gap between institutional vision/mission and available resources impacts morale