Abstract
Context/Objective
Despite availability of clinical practice guidelines (CPGs), gaps in autonomic dysreflexia (AD) knowledge and practice persist. A free, online educational module, the “ABCs of AD”, was developed to improve knowledge of the AD-CPGs among emergency healthcare personnel. We examine short-term changes in paramedic and nurse trainees’ knowledge of, and social cognitions towards using, the AD-CPGs following module completion.
Design
Pre–post.
Methods
Thirty-four paramedic and nurse trainees from two training programs in Canada completed measures immediately before and after viewing the online “ABCs of AD” module.
Outcome measures
AD knowledge test; Theory of Planned Behavior social cognition questionnaire; module feedback survey.
Results
Paired samples t-tests revealed significant increases in participants’ AD knowledge test scores (M ± SDpre = 9.00 ± 2.46, M ± SDpost = 12.03 ± 4.07, P < 0.001; d = 0.84). Prior to viewing the module, participants reported positive social cognitions for using the AD-CPGs (all Ms ≥ 4.84 out of 7). From pre- to post-module, no significant changes were seen in participants’ social cognitions for using the AD-CPGs. Participants’ average module viewing time was 36.73 ± 24.17 minutes (range 8–90 minutes). There was a decline in viewing from the first to the last module sections, with only half of participants viewing all six sections.
Conclusion
Knowledge alone is insufficient for clinical behavior change; as such, social cognitive determinants of behavior should be explicitly targeted in future iterations of the module to increase the likelihood of increased use of the AD-CPGs. To engage viewers across all module sections, the “ABCs of AD” module should include supplementary learning strategies, such as interactive quizzes and peer-to-peer interaction.
Keywords: Autonomic dysreflexia, Clinical practice guideline, Knowledge translation, Psychological theory, Spinal cord injuries
Individuals with spinal cord injury (SCI) frequently experience autonomic dysreflexia (AD), an acute, episodic bout of hypertension characterized by a sudden, exaggerated increase in systolic and diastolic blood pressure above an individual's baseline.1 Episodes of AD are often accompanied by pounding headache, flushing of the skin, and profuse sweating above the level of injury, goose bumps above or below the level of injury, and cold pale skin below the level of injury.1,2 AD occurs frequently in up to 90% of individuals with SCI with injuries above the mid-thoracic spine (i.e. T6).1 AD events are often unpredictable, can occur daily, and depend on a number of factors, including the presence of peripheral pain.2,3 Delayed recognition and unmanaged episodes of AD can lead to myocardial infarction,4 intracranial hemorrhage,5 and even death.6 However, such outcomes are avoidable if AD is recognized and managed promptly.2,6
The Consortium for Spinal Cord Medicine has published clinical practice guidelines (CPGs) for recognizing and managing AD.7 More recently, a systematic review of research evaluating AD prevention and management strategies has been published.2 Despite the availability of these evidence-based resources and guidelines, tremendous gaps in AD knowledge and practice persist among healthcare professionals.8 For example, Krassioukov et al. (Krassioukov AV, Pak M, Craven BC, Ghotbi MH, Ethans K, Ford M, et al. Autonomic dysreflexia: translating knowledge into practice for Canadian emergency room personnel. Unpublished manuscript) evaluated knowledge of AD among 133 emergency healthcare personnel (including paramedics and emergency room physicians and nurses) in three Canadian provinces. Over 80% of respondents rated their AD knowledge as “Poor” or “Fair”, 25% of respondents failed to define AD correctly, and only 50% identified three or more associated signs and symptoms of AD. Given that paramedics and emergency room physicians and nurses are the most likely healthcare professionals to encounter a patient with AD, their lack of knowledge for diagnosing and managing AD is alarming. If AD is misdiagnosed or mismanaged, patients can spend a week or more in the hospital, suffering from unstable blood pressure and associated life-threatening complications. A targeted educational intervention to improve emergency personnel's recognition and management of AD could have a profound impact on the medical treatment of people with SCI in Canada.
In response to this gap in knowledge, a free online educational module – “ABCs of AD” (available at http://wp-dev.jibc.ca/abcofad/) – was developed as part of an integrated knowledge translation (KT) project that brought together clinicians and scientists to assess and improve knowledge and management of AD among emergency healthcare personnel. The “ABCs of AD” module is delivered by an SCI clinician-scientist (Andrei Krassioukov) with supplementary video modules featuring a discussion between clinicians and people with SCI who have experienced AD. The target audience of the module is pre-hospital emergency care workers, including paramedics and emergency room nurses and physicians, with evidence-based content focusing on defining and diagnosing AD, recognizing signs and symptoms of AD, and using the AD-CPGs.
Educational outreach methods that provide knowledge, such as courses, seminars, and e-learning modules, are generally effective at increasing knowledge, but ineffective at changing the practice, of healthcare professionals.9–11 For example, knowledge about a CPG alone does not guarantee it will be adopted and implemented; individual-level beliefs and other cognitions about the guideline, as well as environmental and organizational barriers and facilitators, can impact the translation of the knowledge contained in the guideline into healthcare practice.12,13 A theory-based process evaluation of the individual-level perceptions that may be associated with intervention effectiveness can be useful for understanding why behavior change does or does not occur following a targeted educational intervention.14
The Theory of Planned Behavior (TPB) is a psychological theory that has been used widely to predict and understand individual-level behavior,15 including healthcare professionals' behavior.16–18 The TPB states that an individual's intention, or motivation, to perform a behavior is the most proximal predictor of that behavior.19 Intention is predicted by the individual's attitude (evaluation of behavior and its consequences), subjective norm (perceived sense of pressure from others to perform behavior, and motivation to comply), and perceived behavioral control (PBC; sense of control and confidence for performing behavior). PBC also has a direct influence on behavior. Although the “ABCs of AD” module was designed to be evidence-, but not behavior change theory-, based, the module includes components that may inadvertently target users’ social cognitions for using the AD-CPGs. For example, by providing knowledge about AD and outcomes associated with using the AD-CPGs, the “ABCs of AD” module may target viewers’ attitudes towards using the guidelines. Because the module information is provided by practicing clinicians and people with SCI who have experienced AD, viewers may become aware of their professional duty to follow and increase their perceptions of subjective norms for using the AD-CPGs. Finally, the module emphasizes the use of the AD-CPGs by discussing how the guidelines are used by other professionals (e.g vicarious experiences) and encourages the use of the guidelines by all professionals (e.g. social persuasion); together these features of the module may target viewers’ PBC. Examining changes in viewers’ social cognitions would allow researchers to hone in on the module components that have the greatest potential for leading to changes in practice behavior.
While it is important to educate healthcare professionals who would use the AD-CPGs in day-to-day practice, more proximal education of paramedic and nurse trainees would ensure that future healthcare professionals are equipped with the knowledge and resources necessary to implement the guidelines as soon as they enter the workforce. Furthermore, exposure to CPGs during training may result in earlier adoption, and thus use, of the guidelines in practice. As such, the purpose of the current pilot study was to examine short-term changes in paramedic and nurse trainees’ knowledge of, and social cognitions towards using, the AD-CPGs following completion of the “ABCs of AD” module. We hypothesized that trainees would report significant increases in their knowledge of, and TPB social cognitions (e.g. attitudes, subjective norm, PBC, and intentions) towards using, the AD-CPGs immediately following completion of the “ABCs of AD” module.
Methods
Participants and recruitment
Paramedic and nurse trainees enrolled at two different training institutions, one in British Columbia and one in Ontario, were recruited to participate in the current study. Both male and female trainees at any stage of their training (e.g. first year through fourth year) were asked to participate. A member of the research team visited paramedic and nursing classes at the training institutions to provide information about the study to trainees. During recruitment, the researcher made the trainees aware of the existence of AD-CPGs without providing specific information about the content of the guidelines. Note that the regular classroom instructor was not present in the classroom during recruitment and trainees were given the opportunity to have their questions about the study answered before participating. Interested trainees anonymously provided the research team member with their email address, which was used to contact trainees for collecting informed consent and administering online study measures, as well as for providing online access to the “ABCs of AD” module. Each email address was assigned a unique study identification number so that data could be tracked anonymously. These classroom visits were done at the beginning of the school year to avoid the study measures conflicting with trainees’ mid-term and final exams.
Based on a previous report of an educational intervention about the AD-CPGs, a large-sized effect was expected for changes in AD knowledge following the completion of the “ABCs of AD” module (Krassioukov et al.). G*Power statistical software indicated a sample of 24 participants was required to have 95% power to detect a large-sized effect at α <0.05.20
The module
The module is designed to take 60–90 minutes for users to complete, with the content distributed among six module sections. The first section is an introduction by a clinician-scientist that outlines the module's objectives, target audience, and user requirements (e.g. Internet browser requirements). The second section provides recommendations for working through the remaining content, and how to navigate between sections. The definition of AD is discussed in the third section, recognizing and diagnosing AD are discussed in the fourth section, and signs and symptoms, the pathophysiology, and the etiology of AD are discussed in the fifth section. The sixth and final section is dedicated to the prevention and management of AD, including a discussion of the AD-CPGs. Sections 3–6 include optional review questions at the end of the section, and Sections 4–6 include case study videos that feature patients with SCI discussing relevant content about their experience with AD with a healthcare professional. A separate tab in the module provides links to video testimonials about experiencing AD among five patients with SCI. There is also a “Resource” tab that provides links to helpful websites, references used in the module, and the option to download the AD-CPGs.
Protocol
Ethical clearance was provided by all institutional ethics boards. Informed consent and all data were collected using Fluid Surveys. Participants were emailed a link to the letter of information and consent form. Trainees who consented were directed to an online pre-module questionnaire, which included demographic questions, TPB scales assessing participants’ social cognitions for using the AD-CPGs, and an AD knowledge test. Upon the completion of the pre-module questionnaire, participants were automatically directed to the “ABCs of AD” online module. Four days after the completion of the pre-module questionnaire, the research team emailed participants to remind them about the online module and to encourage them to view the module at their convenience. Approximately 1 week later, participants who completed the pre-module questionnaire were emailed a link to the post-module questionnaire, which included the same TPB scales and the same AD knowledge test as the pre-module questionnaire, as well as a brief module feedback survey. Participants who completed both the pre- and post-module questionnaires were sent a $10 e-gift card to thank them for their time and effort.
Measures
Demographic information
Participants were asked to report their age, sex, ethnicity, province, program, and year of study, and whether they had any previous experience with a patient with SCI. Participants were also asked to rate their current knowledge of AD as “None”, “Poor”, “Fair”, “Good”, or “Excellent”.
AD knowledge test
The AD knowledge test was written and previously used by a group of SCI physiatrists and experts in AD-CPGs (Krassioukov et al.). The AD knowledge test consisted of 11 questions of varying question types (e.g. case studies, multiple choice, matching; see Supplementary Material 1 for AD knowledge test available at http://www.maneyonline.com/doi/suppl/10.1179/2045772314Y.0000000253) that assessed participants’ current knowledge of recognizing and managing a patient with AD. Responses were scored according to the previous study that used the survey (Krassioukov et al.) with a possible maximum score of 22.
TPB cognitions for using the AD-CPGs
Participants’ attitudes, subjective norms, and PBC were assessed with items adapted from Ajzen's,21 Conner and Sparks’,22 and Francis et al.s’23 recommendations for developing a TPB questionnaire. All items were rated on a 7-point Likert-type scale. For TPB construct scales with more than two items, item scores were averaged to give an overall construct score. Table 1 lists the items, response scale, and the internal reliability or correlation of the items for each scale included in the TPB questionnaire.
Table 1 .
Questionnaire items assessing trainees’ social cognitions for using the AD CPGs
| Theory of Planned Behavior construct (# items) Items included in scale |
Response scale | Internal reliability score (α) or correlation (r) |
|---|---|---|
| Attitudes (6 items) | ||
|
1 = Strongly disagree, 7 = Strongly agree Anchors represent extremes (1/7) on 7-point Likert scale |
αs ≥ 0.94 |
| Subjective norm (3 items) | ||
Complete the statement: “_____________want me to follow the AD-CPGs”
|
1 = Strongly disagree, 7 = Strongly agree |
αs ≥ 0.76 |
| Perceived behavioral control (3 items) | αs ≥ 0.73 | |
|
1 = Strongly disagree, 7 = Strongly agree |
|
| Intention (2 items) | ||
|
1 = Strongly disagree, 7 = Strongly agree |
rs ≥ 0.64 |
AD, autonomic dysreflexia; CPGs, clinical practice guidelines; SCI, spinal cord injury.
The column indicating scale internal reliability (Cronbach's α) scores for the items on the scale and Pearson correlations between the items on the scale represent the lowest value across the two timepoints (pre- and post-module). All internal reliability scores were acceptable.
Module feedback survey
Participants were asked to report the number of minutes they spent working through the module, and indicate which module sections they viewed. Six items that assessed whether the participants felt the module information was novel, interesting, easy to understand, credible, personally important to them, and whether participants would recommend the module to a colleague, were rated on a 7-point Likert-type scale (1 = strongly disagree, 7 = strongly agree). Participants were also asked open-ended questions regarding what they found effective about the module, and additional strategies that would enhance the “ABCs of AD” module in the future.
Data analysis
All data were screened for outliers and normality using established guidelines.24 Descriptive statistics were calculated for each study measure. Paired samples t-tests were computed to identify significant changes in the TPB variables and AD knowledge test scores between pre- and post-module. Cohen's d was calculated as an index of effect size.
Results
Participants
Of the 196 trainees who provided their email addresses, 86 completed the pre-module questionnaire and 34 completed the post-module questionnaire. The majority of participants who completed the pre-module questionnaire were female (72.1%), Caucasian (89.5%), and from Ontario (77.9%), with an average age of 24.33 years (SD = 6.20). Participants were enrolled in either a nursing (53.5%) or paramedic (46.5%) program, and the majority of participants were in their second year of their program (67.4%). Less than 20% of trainees had previous experience with a patient with SCI, and most participants rated their knowledge of AD as “Poor” (43.7%) or “None” (39.1%). There were no significant differences in demographics between participants who completed only the pre- vs. both the pre- and post-module questionnaires. Please see Table 2 for complete participant demographic information.
Table 2 .
Demographic characteristics of participants who completed the pre- and post-module questionnaires
| Characteristic | Pre-module | Post-module |
|---|---|---|
| n = 86 | n = 34 | |
| Age (M ± SD in years) | 24.33 ± 6.20 | 24.68 ± 7.58 |
| Sex | ||
| Male | 24 (27.9) | 5 (14.7) |
| Female | 62 (72.1) | 29 (85.3) |
| Ethnicity | ||
| Caucasian | 77 (89.5) | 32 (94.1) |
| Other | 9 (10.5) | 2 (5.9) |
| Province | ||
| Ontario | 67 (77.9) | 27 (79.4) |
| British Columbia | 19 (22.1) | 7 (20.6) |
| Program | ||
| Primary care paramedic | 31 (36.0) | 9 (26.5) |
| Advanced care paramedic | 9 (10.5) | 2 (5.9) |
| Practical nursing | 11 (12.8) | 7 (20.6) |
| BSc nursing | 35 (40.7) | 16 (47.1) |
| Year in program | ||
| First | 27 (31.4) | 9 (26.5) |
| Second | 58 (67.4) | 25 (73.5) |
| Third | 1 (1.2) | |
| Previous experience with patient with SCI | ||
| Yes | 16 (18.6) | 4 (11.8) |
| No | 70 (81.4) | 30 (88.2) |
| Current knowledge of AD | ||
| None | 34 (39.1) | 15 (44.1) |
| Poor | 38 (43.7) | 16 (47.1) |
| Fair | 6 (6.9) | 2 (5.9) |
| Good | 2 (2.3) | 0 (0) |
| Excellent | 0 (0) | 0 (0) |
AD, autonomic dysreflexia; BSc, Bachelor of Science; SCI, spinal cord injury.
All values are n (%) unless otherwise indicated.
Knowledge of, and social cognitions towards using, the AD-CPGs
Table 3 contains the descriptive statistics, t-test results, and effect sizes for participants’ social cognitions and AD knowledge test scores. From pre- to post-module, significant increases in participants’ AD knowledge test scores were seen (P < 0.001; d = 0.84). Prior to viewing the “ABCs of AD” module, participants reported positive social cognitions for using the AD-CPGs (all Ms ≥ 4.84 out of 7). From pre- to post-module, no significant changes were seen in participants’ social cognitions for using the AD-CPGs; however, small effect sizes were seen for increases in participants’ attitudes (d = 0.22), subjective norms (d = 0.27), and PBC (d = 0.24) to use the AD-CPGs.
Table 3 .
Summary of changes in social cognitions to use AD-CPGs and AD knowledge test scores between pre- and post-module participation (n = 34)
| Construct | Module |
Paired samples t-test |
Effect size | ||
|---|---|---|---|---|---|
| Pre | Post | t-value | P-value | d | |
| Attitude | 5.43 ± 1.41 | 5.76 ± 1.14 | −1.23 | 0.23 | 0.22 |
| SN | 4.84 ± 1.09 | 5.18 ± 1.17 | −1.51 | 0.14 | 0.27 |
| PBC | 4.79 ± 1.34 | 5.13 ± 1.15 | −1.23 | 0.19 | 0.24 |
| Intention | 5.36 ± 1.38 | 5.55 ± 1.34 | −0.78 | 0.44 | 0.14 |
| AD knowledge (out of 22) | 9.00 ± 2.46 | 12.03 ± 4.07 | −4.20 | <0.001 | 0.84 |
AD, autonomic dysreflexia; CPGs, clinical practice guidelines; PBC, perceived behavioral control; SN, subjective norms.
All mean construct scores are reported as M ± SD and are out of 7, except AD knowledge test scores which are out of 22 (as noted).
Module feedback
Participants’ average module viewing time was 36.73 ± 24.17 minutes, with a range of viewing times between 8 and 90 minutes. On average, participants viewed 4.48 ± 1.89 of the six module sections, with a decline in viewing from the first to the last module sections. Of the 34 participants who completed the post-module questionnaire, the percentage of participants who self-reported completing each module section are as follows: Introduction (88.2%), Getting Started (82.4%), Defining AD (76.5%), Diagnosis of AD (67.7%), Signs and Symptoms of AD (64.7%), and Management of AD (55.9%). (Given the variability in participants' module viewing time and the number of module sections completed, repeated measures ANCOVAs controlling for these two variables on pre- to post-changes in AD knowledge test scores and TPB social cognitions would have been an appropriate analytic approach; however, the covariates violated the assumption of homogeneity of regression variance thus precluding this analytic strategy.) Participants had positive perceptions of the module – the average ranking of each of the six feedback items was >5.67 out of 7 (see Table 4 for complete module feedback items and scores). The only exception was the item asking about the module's personal importance to participants, which had an average ranking of 4.67 out of 7.
Table 4 .
Participants’ feedback about “ABCs of AD” module
| Module feedback items | Mean ± SD |
|---|---|
| I learned a lot of new information in the module | 5.87 ± 1.85 |
| The information in the module was interesting | 6.00 ± 1.29 |
| The information in the module was easy to understand | 6.17 ± 1.58 |
| The information in the module was credible | 6.33 ± 1.49 |
| The module was personally important to me | 4.67 ± 2.02 |
| I would recommend this module to a colleague | 5.67 ± 1.54 |
Scores are out of 7 (1 = strongly disagree, 7 = strongly agree).
When asked what they found particularly effective about the “ABCs of AD” module, participants listed the following: (1) valuable information (n = 8), (2) personal touch of stories of real people who have been affected by AD (n = 7), (3) clear concise information with relevant images and diagrams (n = 7), (4) organization/set up of the module (e.g. easy to navigate and follow different sections; n = 5), and (5) ability to work through the module at own pace (n = 3). Participants listed the following strategies as useful ways to enhance the “ABCs of AD” module: (1) the inclusion of online quizzes to engage the viewer (n = 1), (2) more detail about the definition and etiology of AD at the front end of the module (n = 1), and (3) more specific information to engage paramedic and nursing students (n = 1).
Discussion
Following completion of the “ABCs of AD” online module, paramedic and nurse trainees achieved statistically significant improvements in their AD knowledge test scores. Despite these increases in knowledge, no statistically significant changes were seen in trainees’ TPB social cognitions to use AD-CPGs. Participants’ feedback about the module was positive, and several participants provided suggestions for future improvements to the module to more fully engage healthcare professional trainees.
Our first hypothesis – that participants’ AD knowledge would increase following exposure to the “ABCs of AD” module – was supported. Educational outreach interventions, such as the “ABCs of AD” module, have been shown to be effective at imparting new knowledge to attendees9–11; thus, these results are not surprising. Despite these significant increases in AD knowledge test scores, trainees’ post-module AD knowledge test scores were still relatively low (mean of 12 out of 22). A possible explanation for these low knowledge scores may reflect participants’ lack of knowledge and experience with patients at their current stage of their career. Compared to practicing healthcare professionals, trainees likely have less prior theoretical and practical knowledge of SCI and pathophysiology, as well as how to manage patients and apply CPGs in general. As such, it may have been challenging for trainees to understand the relevance of the module content, as well as to integrate and apply the content when completing the post-module AD knowledge test. Trainees’ feedback supports this explanation; compared to the other feedback items, trainees had lower perceptions of the module's personal importance, and they suggested that the “ABCs of AD” module could be enhanced by including more information that specifically engages trainees. These results suggest that the module content may not have been salient to trainees at this stage in their career; that is, trainees may not recognize the personal relevance of “ABCs of AD” module when they do not yet have experience with patients with SCI or are not currently working in a capacity where they can put their new knowledge into practice. This perception of personal importance may have negatively impacted participants’ desire to view all six module sections, as well as their module viewing time.
Another explanation for the low AD knowledge test scores is the lack of exposure and engagement the participants had with the module content. Given that most participants did not have previous experience with a patient with SCI, and the majority of participants rated their pre-module AD knowledge as “Poor” or “None”, the module likely presented trainees with new information. With an average module viewing time of ∼37 minutes, it is unlikely that the trainees had adequate time to process and apply the new information. Moreover, given that participants only viewed 4.5 of 6 module sections, with just over half of participants viewing the last module section about AD management highlighting the use of the AD-CPGs, participants may not have been exposed to all the content that is evaluated on the AD knowledge test. In order to more fully engage viewers, additional learning strategies to enhance knowledge retention and application should be included in future iterations of the module. For example, enhanced interaction between the user and the module, such as through quizzes, may help to engage viewers in the content.25 Also, peer-to-peer interaction (i.e. medical roundtables, discussion of case studies) is commonly used in healthcare professional practice to facilitate learning; this concept could be applied virtually in the module by including an online discussion board or real-time webinar discussion to give users the opportunity to ask each other questions and share practical experiences.25 Including module end users during the development and/or refinement of the intervention may help ensure that the strategies included are feasible for enhancing interaction with the module content.
Despite the significant increases in AD knowledge test scores, our second hypothesis was not supported. There were no significant changes in participants’ TPB social cognitions for using the AD-CPGs between pre- and post-module. There are two possible reasons for this lack of change. First, participants’ pre-module social cognitions were already quite positive (scores were >4.79 out of 7 on the TPB measure). These initially high scores may have left little room for improvement, especially considering that the use of the guidelines is not imminent in their career; that is, most participants were at least 1 year from practicing in the field and applying the guidelines with real-life patients. Second, the “ABCs of AD” module was designed to translate evidence-based knowledge of AD and the AD-CPGs without overtly targeting viewers’ social cognitions for enacting the guidelines. Previous research suggests that providing knowledge alone is necessary, but insufficient, for behavior change,26,27 and that determinants of behavior should be explicitly targeted in interventions in order to increase individuals’ motivation for changing their behavior.10,28 While the “ABCs of AD” module may have inadvertently targeted the TPB social cognitions, the overt inclusion of behavioral techniques that target these cognitions should be considered for future iterations of the module. For example, demonstrating to module viewers that social support processes are in place for the use of AD-CPGs in practice may be effective in changing social cognitive domains that could influence viewers’ perceptions of attitudes, subjective norms, and PBC.29 Third, examining individual-level perceptions of a guideline provides an incomplete picture of why guideline use does or does not occur.12,13 Environmental and organizational barriers and facilitators that influence the translation of the knowledge contained in the guideline into healthcare practice should be examined, as these factors can impact individual-level perceptions.12,13,30 For example, the incorporation of the AD-CPG recommendations and algorithms into organizational and professional standards and policies (i.e. both the Basic and Advanced Life Support Patient Care Standards used as the standard of practice for paramedics in Ontario)31,32 would likely enhance individuals’ attitudes, subjective norms, PBC, and intentions to use the guidelines, as well as increase the reach, adoption, and implementation of the guidelines.
While this study represents a pilot test of the “ABCs of AD” module among trainees, it is nevertheless important to expose healthcare professionals to guidelines early in their training to help generate a sense of norms about using guidelines throughout their career. There is an increasing demand for evidence-based practice in healthcare,33 and healthcare professionals are inundated with ever-changing CPGs that they are expected to adopt and routinely use.12 Early exposure to guidelines, such as through educational outreach like the “ABCs of AD” module, may help create a normative culture of guideline use among trainees so that they are more open to adopting new guidelines throughout their practice (c.f. Rogers’ Diffusion of Innovations34).
Strengths and limitations
A strength of this study is the inclusion of a theory-based process evaluation for determining intervention effectiveness. Few evaluations of implementation interventions, such as educational outreach, test hypotheses based on theory.35 Theory-driven evaluations can help decipher the behavioral determinants of change when an intervention is hypothesized to be mediated by the theory's constructs.14,28 The current study's evaluation protocol can now be used to determine the impact of the “ABCs of AD” module on practicing healthcare professionals’ knowledge of, and social cognitions for using, the AD-CPGs.
Despite this strength, a number of limitations should be noted. First, the module was designed to target emergency healthcare professionals, rather than trainees who were the participants in the current study. Compared to professionals, trainees may have a different perspective with respect to adopting and implementing a specific CPG when they are several years from professional practice and unfamiliar with CPGs in general. This perspective may be reflected in the strength of their social cognitive determinants for using the AD-CPGs; thus, it is unclear whether professionals would also report a lack of significant changes TPB social cognitions following completion of the module. However, a caveat is that without designing the module to include a foundation in behavior change theory, it is unlikely that professionals’ social cognitions for using CPGs will change once the module is viewed. Nevertheless, as noted above, increasing awareness of the CPGs among trainees may be important for facilitating a normative culture of guideline use; therefore, future iterations of the “ABCs of AD” module should include an additional component targeting trainees that provides general information about the importance of adopting and using CPGs prior to trainees being asked to complete the AD-specific content. Second, the study is limited by the low response rate at follow-up; only 40% of trainees who completed the pre-module questionnaire also completed the post-module questionnaire. This response rate may have improved if we had used personalized contacts when administering links to the questionnaires and modules (e.g. using the individual's name in a reminder email)36; however, trainee anonymity was a key ethical concern of the training institutions, so personalization of emails beyond the participants’ unique study ID was not possible. A third limitation is the lack of a control group that did not receive the “ABCs of AD” module. While the control group would likely not report changes in AD knowledge test scores, simply being in a study that asks about social cognitions for adopting CPGs might prompt changes in participants’ social cognitions for using the AD-CPGs, a phenomenon referred to as the mere measurement effect.37 The use of a control group is a consideration for future research evaluating the impact of the “ABCs of AD” module on changes in social cognitions for changing behavior.
Conclusion/future directions
The “ABCs of AD” online educational module appears to be effective at increasing healthcare professional trainees’ knowledge of, but not social cognitions for using, the AD-CPGs. The results of the current study suggest that the impact of the “ABCs of AD” module has the potential to be maximized by ensuring the module has a foundation in behavior change theory and by incorporating additional learning strategies throughout the module. Explicit use of theory in the design of the module would better target the social cognitions that are more likely to lead to behavior change among users (e.g. use of the AD-CPGs by healthcare professionals and trainees). The inclusion of supplementary adult learning strategies, such as interactive quizzes and peer-to-peer interaction, and tailoring of module content to the intended audience would help to ensure that users are engaged across all module sections and processing module content. Furthermore, the module would benefit from including separate components that target trainees and professionals, with the appropriate end users being included in the intervention development process so to ensure the content is salient and acceptable to each target audience group. These suggestions are currently being considered by module developers, and would likely be facilitated by including behavior change and KT researchers in the module development process.
Disclaimer statements
Contributors KAMG and AK conceived of/designed the study and obtained funding. JRT, KAMG, WP and AK obtained ethics approval at their respective institutions. JRT and WP collected the data. JRT and KAMG analyzed and interpreted the data. JRT wrote the article in whole. KAMG, WP, and AK revised the article and approved of the final version before submission.
Funding Funding for this project was provided by the Canadian Institutes of Health Research (2011-CIHR-260877) awarded to AK and KAMG, and an Ontario Neurotrauma Foundation and Rick Hansen Institute Mentor-Trainee Capacity Building in Knowledge Mobilization award to JRT and KAMG.
Conflicts of interest None.
Ethics approval Ethical approval was received by the McMaster University Research Ethics Board, the Georgian College Research Ethics Board, and the Justice Institute of British Columbia's Research Ethics Board.
Acknowledgment
The authors would like to acknowledge Melanie Meyers for connecting the research team with trainees at the Justice Institute of British Columbia, Catherine Yang for assistance with data collection in British Columbia, and Krystn Orr for assistance with data collection in Ontario and for management of the online data.
References
- 1.Teasell RW, Arnold JA, Krassioukov AV, Delaney GA. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system following spinal cord injuries. Arch Phys Med Rehabil 2000;81(94):506–16 [DOI] [PubMed] [Google Scholar]
- 2.Krassioukov AV, Warburton DER, Teasell R, Eng JJ. A systematic review of the management of autonomic dysreflexia following spinal cord injury. Arch Phys Med Rehabil 2009;90(4):682–95 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreflexia in acute spinal cord injury: an under-recognized clinical entity. J Neurotrauma 2003;20(8):707–16 [DOI] [PubMed] [Google Scholar]
- 4.Ho CP, Krassioukov AV. Autonomic dysreflexia and myocardial ischemia. Spinal Cord 2010;48(9):714–5 [DOI] [PubMed] [Google Scholar]
- 5.Pan S-L, Wang Y-H, Lin H-L, Chang CW, Wu T, Hsieh ET. Intracerebral hemorrhage secondary to autonomic dysreflexia in a young person with incomplete C8 tetraplegia: a case report. Arch Phys Med Rehabil 2005;86(3):591–3 [DOI] [PubMed] [Google Scholar]
- 6.Eltorai I, Kim R, Vulpe M, Kasravi H, Ho W. Fatal cerebral hemorrhage due to autonomic dysreflexia in a tetraplegic patient: case report and review. Paraplegia 1992;30(5):355–60 [DOI] [PubMed] [Google Scholar]
- 7.Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health-care facilities. 2nd ed Autonomic Dysreflexia Clinical Practice Guidelines. In association with Paralyzed Veterans of America 2001 [PubMed]
- 8.Jackson CR, Acland R. Knowledge of autonomic dysreflexia in the emergency department. Emerg Med J 2011;28(10):866–9 [DOI] [PubMed] [Google Scholar]
- 9.Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009;2:CD003030. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Grimshaw JM, Eccles MP, Walker AE, Thomas RE. Changing physicians's behavior: what works and thoughts on getting more things to work. J Contin Educ Health Prof 2002;22(4):237–43 [DOI] [PubMed] [Google Scholar]
- 11.Wutoh R, Boren SA, Balas EA. elearning: a review of internet-based continuing medical education. J Contin Educ Health Prof 2004;24(1):20–30 [DOI] [PubMed] [Google Scholar]
- 12.Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don't physician follow clinical practice guidelines? A framework for improvement. JAMA 1999;282(15):1458–65 [DOI] [PubMed] [Google Scholar]
- 13.Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience, and research evidence in the adoption of clinical practice guidelines. CMAJ 1997;157(4):408. [PMC free article] [PubMed] [Google Scholar]
- 14.Ramsay CR, Thomas RE, Croal BL, Grimshaw JM, Eccles MP. Using the Theory of Planned Behavior as a process evaluation tool in randomized trials of knowledge translation strategies: a case study from UK primary care. Implement Sci 2010;5:71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Armitage CJ, Conner M. Efficacy of the Theory of Planned Behavior: a meta-analytic review. Br J Soc Psychol 2001;40(Pt 4):471–99 [DOI] [PubMed] [Google Scholar]
- 16.Eccles M, Grimshaw J, Walker A, Johnson M, Pitts N. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol 2005;58(2):107–12 [DOI] [PubMed] [Google Scholar]
- 17.Eccles MP, Grimshaw JM, MacLennan G, Bonetti D, Glidewell L, Pitts NB, et al. Explaining clinical behaviors using multiple theoretical models. Implement Sci 2012;7:99. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Godin G, Belanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals’ intentions and behaviors: a systematic review of studies based on social cognitive theories. Implement Sci 2008;3:36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Ajzen I The theory of planned behavior. Organ Behav Hum Decis Process 1991;50:179–211 [Google Scholar]
- 20.Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39(2):175–91 [DOI] [PubMed] [Google Scholar]
- 21.Ajzen I. Constructing a TPB questionnaire: conceptual and methodological considerations. 2002 [accessed 2011 Mar 10]. Available from http://www.people.umass.edu/aizen/pdf/tpb.measurement.pdf
- 22.Conner M, Sparks P. Theory of planned behavior and health behaviour. In: Conner M, Norman P, (eds.) Predicting health behavior. 2nd ed Berkshire, England: Open University Press McGraw-Hill; 2005. pp. 170–222 [Google Scholar]
- 23.Francis JJ, Eccles MP, Johnston M, Walker A, Grimshaw J, Foy R, et al. Constructing questionnaires based on the Theory of Planned Behaviour: a manual for health services researchers. UK: Centre for Health Services Research, University of Newcastle; 2004 [Google Scholar]
- 24.Tabachnick BG, Fidell LS. Using multivariate statistics. 5th ed Boston: Allyn & Bacon; 2007 [Google Scholar]
- 25.Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362(9391):1225–30 [DOI] [PubMed] [Google Scholar]
- 26.Davis DA, Thomson MA, Oxman AD, Haynes B. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274(9):700–5 [DOI] [PubMed] [Google Scholar]
- 27.Ferris FD, von Gunten CF, Emanuel LL. Knowledge: insufficient for change. J Palliat Med 2011;4(2):145–7 [DOI] [PubMed] [Google Scholar]
- 28.Tomasone JR, Martin Ginis KA, Estabrooks PA, Domenicucci L. ‘Changing Minds’: determining the effectiveness and key ingredients of an educational intervention to enhance health care professionals’ intentions to prescribe physical activity to patients with physical disabilities. Implement Sci 2014;9:30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioral determinants to behavior change techniques. Appl Psychol 2008;57(4):660–80 [Google Scholar]
- 30.Gaddis GM, Greenwald P, Huckson S. Toward improved implementation of evidence-based clinical algorithms: clinical practice guidelines, clinical decision rules, and clinical pathways. Acad Emerg Med 2007;14(11):1015–22 [DOI] [PubMed] [Google Scholar]
- 31.Ontario Ministry of Health and Long-Term Care – Emergency Health Services Branch. Basic Life Support Patient Care Standards, Version 2.0 2007
- 32.Ontario Ministry of Health and Long-Term Care – Emergency Health Services Branch. Advanced Life Support Patient Care Standards, Version 3.0 2011
- 33.Sackett D Evidence-based medicine. Semin Perinatol 1997;21(1):3–5 [DOI] [PubMed] [Google Scholar]
- 34.Rogers E Diffusion of Innovations. 5th edn New York: Free Press; 2003 [Google Scholar]
- 35.Davies P, Walker AE, Grimshaw JM. A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implement Sci 2010;5:14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Cook C, Heath F, Thompson RL. A meta-analysis of response rates in web- or internet-based surveys. Educ Psychol Meas 2000;60(6):821–36 [Google Scholar]
- 37.Godin G, Sheeran P, Conner M, Germain M. Asking questions changes behavior: mere measurement effects on frequency of blood donation. Health Psychol 2008;27(2):179–84 [DOI] [PubMed] [Google Scholar]