5. Exploring behaviours and their influences

Sometimes behaviour is measured routinely. Behaviour can be measured directly or through self-report.  There are obvious benefits to measuring directly: people might not remember what they have done and also might not want to tell you what they have done.  We find that ensuring that responses are anonymous and assuring healthcare professionals of this helps people answer more honestly about their behaviours.

Exploring behaviours and determinants

In the exploring phase, information is gathered on the behaviours: we need to know how much the behaviour is happening already, to then be able to know if this improves. Sometimes, this is useful in itself, for example a team might learn that contrary to their expectations, they were already offering ‘flu vaccinations to nearly all patients.

We also need to learn about teams’ views of their capability, opportunity and motivation towards the behaviour. In both cases there are several ways we can do this: the best option is often to adopt a combination approach.

Routinely collected data

Sometimes behaviour forms part of routinely collected service data, e.g. referrals to a service, prescriptions, or health promotion questions asked. These data can be used to measure whether behaviours are happening and to see if the number of times they happen change over time.  If available, these are useful as they don’t create much extra work for your team.

Observation

With their permission can be really useful to spend some time observing the team working. You could note down how many times they do the behaviour, such as use of certain equipment or the use of an open question at the beginning of a consultation.

You could also make factual notes about barriers and facilitators you can see in terms of capability, opportunity and motivation. Make sure to keep notes anonymous where possible and confidential, typing them up and storing them securely. Observation can be labour intensive for the observer and some teams can worry if the observer is there to judge them. Reassuring teams, making notes discretely after an observation, or even doing participant-observation, where you help out (where this is appropriate) whilst observing, could all help. Observation gives a unique insight and can also help build a good relationship with teams.

Interviews and focus groups

This involves meeting with team members one-to-one or in a group to ask them about their experience of the behaviour, barriers and facilitators. This can give an in-depth insight into individuals’ and teams’ experiences and provide rich information and team members can enjoy giving their views. You could make anonymous notes, or take an audio-recording and type this up into an anonymous transcript to analyse later. There are many ethical and design aspects involved in such qualitative research: one useful freely-available guide is available here.

Questionnaires

Questionnaires can add a quantitative view and are useful especially in a large team where it is not possible to interview everyone.

We can ask healthcare professionals if they do or don’t do certain behaviours. It might be important to reassure them of anonymity and that there is no right or wrong answer here. Also, to help forgetfulness,  you can ask people to report within a certain short time frame (perhaps in one day, if that is appropriate for the particular behaviours) and you can ask multiple times and take an average.

In general, to get a measure of behaviour we will ask two questions: a) how many times has this behaviour been indicated or possible (this is usually how many patients with a particular indication have you seen) and b) in how many of these cases did you do the specified behaviour.  For example, where the behaviour of interest is antibiotic prescription for upper respiratory tract infections you might ask: a)“how many patients did you see in the last 5 days with upper respiratory tract infections?” and then b) “for how many of these patients did you prescribe antibiotics?”.  Percentage behaviour would then be (b/a) x 100.

For understanding determinants, we may conduct a literature search to understand the likely barriers and facilitators or use those explored through interviews or focus groups, and construct a COM-B questionnaire, asking participants for their views on a likert scale, such as this question for assessing social opportunity:

If I don’t prescribe antibiotics for upper respiratory tract infections, my patients will be upset with me

Strongly disagree 1 — 2 —– 3 —– 4——5—–6—–7 Strongly agree

These would then be totalled to better understand views on capability, opportunity, and motivation. Validated questionnaires on a range of topics already exist and development follows certain scientific processes, so you may wish to get help from a statistician or a health psychologist for this.

Check your application of knowledge

If the behaviour was a nurse in an emergency department of a busy hospital using an ABCDE approach to begin to manage patients who they suspected might be becoming acutely ill, what question could you ask that would measure:

Self-report behaviour

Reveal

You could ask: a) “how many patients have you seen in the past month* that you suspected might be becoming acutely ill?” and then b) “in how many of these patients did you use an ABCDE approach?”  The self report percentage behaviour would then be (b/a)x100.

a month might not be the right time -period.  It needs to be long enough for these situations to have happened but not so long that people couldn’t possibly remember or too many that people couldn’t make a good estimate. When deciding on the time period, you should think of how many times the situation is likely to have occurred and how likely someone is to remember over that time period.

The person’s psychological capability

Reveal

You could ask the nurse to rate their view of the statement:

I have the knowledge to use an ABCDE approach to begin to manage patients who I suspect are becoming acutely ill

Strongly disagree 1 — 2 —– 3 —– 4——5—–6—–7 Strongly agree

Other ideas to explore

Reveal

You may be able to observe how the nurse works in such emergency situations, or check details in the notes of his/her assessment and management of the patient.

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