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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

DomainBarriers
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