. 2016 Jan 29;66(643):e114–e127. doi: 10.3399/bjgp16X683509

Table 1.

Coding of extracts to Theoretical Domains Framework²⁶ and clinical target

Domain	Clinical target	Clinician-related factors	Patient-related factors	Organisational-related factors
Environmental context and resources	General	Families not invited for lifestyle modification discussions.⁴⁸	Patients’ socioeconomic situation, occupation, carer status, comorbidities, mobility problems, polypharmacy, and self-empowerment capacity acting as barriers to care.³²^,³³^,³⁵^,³⁷^,⁴²^,⁴⁷^–⁵¹	Workload and time pressures; inadequate funding and staff numbers (clinical and administrative); role of structured management systems; access issues for patients, including to self-management education; mixed relationships and communication with specialist teams; limited services for specific patient-groups (for example, older people); role of insurance companies in driving disease-management activity; lack of public health support for prevention awareness; lack of agreed national management protocol; and continuing clinical education provision.³²^,³⁴^,³⁵^,³⁷^,⁴⁰^,⁴²^,⁴⁵^–⁴⁹^,⁵¹^,⁵²^,⁵³^–⁵⁵
	Glycaemic control	Nurses feeling isolated in role as single diabetes nurse in practice when considering converting to insulin.⁴³	Accommodating insulin therapy with patients’ lifestyles; patients’ ability to care for themselves adversely affected by physical impairments; and patients’ limited financial resources affecting decisions about starting insulin.³⁰^,³¹^,³⁹	Lack of evidence base and clear guidelines; inadequate funding for equipment; workload; time pressures; staffing levels, language skills, and roles (for example, nurse educators); patient support; availability of interpreters; lack of same-physician continuity of care; access to and communication with specialist teams; the need for protocols; and advantages of primary care management.³⁰^,³³^,³⁹^,⁴²^–⁴⁴^,⁵⁶^–⁵⁹
	Cholesterol control	–	–	Lack of structured approach to diabetes management.³⁸
	Blood pressure	–	Patients’ financial situation and occupational constraints acting as a barrier to care.³⁶	Workload and time pressures, preferences of paper-based systems, and inadequate financial compensation.³⁶^,⁶⁰

*Knowledge (extracts in Knowledge domain with ^ also coded to Skills domain)**	General	Lack of knowledge in self and among colleagues about causes, evidence base, guidelines, services, required lifestyle changes, patient self-management education and cultural beliefs; clinician-education as facilitator of care; and nurses seen as more up to date.³²^,⁴⁰^,⁴²^,⁴⁴^,⁴⁶^,⁴⁷^,⁴⁸^,⁵⁰^,⁵³^,⁶¹^	Clinician–patient education gap with patients’ knowledge deficits leading to non-compliance coupled with concern about information overload and whether education effective.³⁵^,⁴²^,⁴⁵^,⁴⁶^,⁴⁸^,⁴⁹^,⁵¹	–
	Glycaemic control	Initiating insulin seen as a simple process by some; clinician confidence and uncertainty in how to initiate insulin; inaccurate beliefs about self-monitoring; and limited familiarity/uncertainty with guideline recommendations.³²^,³³^,³⁹^,⁴¹^,⁴²^,⁴³^,⁴⁷^,⁵⁹^	Limited knowledge of: self-testing; insulin use; erectile dysfunction on insulin; age when insulin required; and long-term effects of diabetes.²⁶^,³³^,³⁹^*,⁴¹^,⁵⁸	–
	Cholesterol control	Insufficient knowledge of guideline recommendations.³⁸	Insufficient knowledge leading to discontinuation of medicine.³⁸	–
	Blood pressure	–	Level of understanding affecting amount of information given about BP control.³⁵^,³⁶	–

Social/professional role and identity	General	Need for greater team working and engagement with diabetes strategies; emphasis on nurses’ role and clarity about responsibilities; and professionalism as an internal drive.³²^,³⁴^,³⁷^,⁴²^,⁴⁵^,⁴⁹^,⁵¹^,⁵⁵^,⁶²	Taking responsibility for managing diabetes balanced with expediency of a paternalistic approach.⁴⁵^–⁴⁷	Problems of coordination between professionals’ and nurses’ existing multiple responsibilities.⁴⁰^,⁴⁸
	Glycaemic control	Nurses as complementary to physicians’ role; concern as to where responsibility lay; diabetes care as part of an ongoing relationship with the patient; closer liaison with secondary care a solution.⁴²^,⁵⁸^,⁶⁰	Sometimes reluctant but empowered by greater involvement in their diabetes care; finding insulin treatment socially embarrassing.⁴¹^,⁴⁴^,⁵⁸	–
	Cholesterol control	Lack of perceived responsibility; secondary care’s role.³⁸	–	–
	Blood pressure	Role of other primary care professionals and patients in BP target decisions.³⁵	–	–

Emotion	General	Frustration at patients’ compliance levels and prognosis uncertainty/timeframe, and using scare tactics with patients.³²^,³⁷^,⁴⁰^,⁴²^,⁴⁵^–⁴⁷^,⁵⁸^,⁶¹	Depression, anxiety, and fear barriers to self-management, although emotional response can be an opportunity for behaviour change.³²^,³⁷^,⁴⁷	Feeling overwhelmed by workload and guidelines, and frustrated when secondary care transfer patients with drugs that cannot be prescribed within primary care.³²^,⁴⁷^,⁴⁸^,⁶²
	Glycaemic control	Feeling overwhelmed by the clinical picture; preventing burnout by partnership working; fear of inducing hypoglycaemia; frustration with: the complexity of regimens, poor control of those with different ethnic backgrounds, and limited evidence base for older people.³³^,³⁹^,⁴²^,⁵⁷^,⁵⁹	Fear of needles, weight gain, and hypoglycaemia with insulin, and with the connotations of ‘drastic’ measures.³⁰^,³³^,³⁹^,⁴¹^,⁴²	–
	Cholesterol control	Frustration at patients’ non-compliance and fears about medication side effects.³⁸	–	–
	Blood pressure	Perceived reward of controlling BP.³⁶	Life stresses taking priority over diabetes control and causing anxiety when discussing BP monitoring or control.³⁵^,³⁶^,⁶⁰	–

Beliefs about consequences	General	Pros/cons of tailored medication intensification; the centrality of the clinician– patient relationship, including patient education.³⁷^,⁴⁰^,⁴²^,⁴⁶^,⁴⁷^,⁵⁰^,⁵⁶^,⁶¹	Cultural beliefs affecting treatment decisions; non-compliance due to complexity or pain; yet motivated by significant changes in management; and opportunistic diabetes care seen as a dismissal of patients’ primary complaint.³²^,⁴⁰^,⁴⁷^,⁴⁸^,⁵⁰^,⁵²	–
	Glycaemic control	Concerns around: older patients’ response to medication; urine testing; and starting insulin, although some advantages recognised; physicians’ beliefs about consequences of diabetes shaped by medical school exposure.³³^,⁴¹^–⁴³^,³⁹^,⁵⁸^,⁶¹	Lack of appreciation of effects of poor control; belief that diet and exercise changes would suffice; compliance issues with medication intensification; belief that insulin could cause complications; and faith in traditional remedies.³⁰^,³³^,³⁹^,⁵⁸^,⁶¹	–
	Cholesterol control	Concerns about side effects of medication.³⁸	Reluctance to start medication due to side effects.³⁸	–
	Blood pressure	‘Vigorous’ guidelines encourage more aggressive management.³⁶	Resistance to taking additional medication if out-of-clinic BP readings lower than in clinic.⁶⁰	–

*Skills (extracts in Knowledge domain with ^ also coded to Skills domain)**	General	Importance of interpersonal skills facilitating holistic care, good communication, and behaviour change skills, although can be a mismatch between training and real-life practice.³²^,³⁴^,³⁷^,⁴⁰^,⁴⁵^,⁴⁶^,⁵²^,⁵⁴	–	–
	Glycaemic control	Ability to maintain skills in insulin conversion.⁴³	Patients’ ability to self-care influencing clinicians’ decisions whether to initiate insulin.³¹	–
	Blood pressure	–	Those with poor technical skills could struggle with telemedicine.⁶⁰	–

Social influences	General	The ‘superior’ specialist having a different message for the patient.⁴⁵	Influence of family and cultural beliefs, and specific problems with hard-to-reach or isolated groups.³²^,³⁷^,⁴²^,⁴⁵^,⁴⁷^,⁴⁸^,⁵¹	Increased attention to diabetes in health care and the media but a lack of public health campaigns to highlight the seriousness of the condition.⁴⁰^,⁵¹
Social influences	Glycaemic control	Perceived pressure to take on the responsibility for converting patients to insulin; nurses struggling to achieve external legitimacy in insulin initiation.⁴³^,⁵⁹	Community and spiritual/religious beliefs affecting views about insulin.³⁰^,⁴⁴	–

Beliefs about capabilities	General	Variation in abilities to adopt proactive strategies to change patients’ behaviour, circumstances or diabetic control, and low levels of trust in non-physician colleagues’ abilities.³²^,³⁷^,⁴⁰^,⁴⁵^,⁴⁸^,⁵³	Reliance on medication rather than lifestyle modification.⁴⁵	–
Beliefs about capabilities	Glycaemic control	Relative inexperience and lack of confidence prescribing insulin; nurses better at guideline adherence.³⁰^,³³^,³⁹^,⁴³	Concern that those with impairments or older people could find complicated regimens difficult.³³^,⁴²	–

Reinforcement	General	Collegial support to improve treatment in difficult patients and not wanting to ‘nag’ patients.⁴⁵^,⁴⁶	Physical disability and lack of immediate response to treatment affecting engagement; patient compliance affected only by major adverse events.³²^,⁴⁰^,⁴²	–
	Glycaemic control	Reinforcement of clinical judgements by specialist colleagues and patients’ assessments; referring to specialists about whom there had been positive feedback.³³^,⁵⁷	Symptom improvement and emphasising the value of treatment to reinforce practice.³³^,⁴⁴	Incentive payments for insulin initiation.⁵⁹
	Blood pressure	Using raised BP readings to reinforce lifestyle advice.³⁵	–	–

Intentions	General	Compliance, avoidance of complications, and professional conscience as motivators.³⁴^,⁴⁹^,⁵⁰	Non-compliance with diet or treatment despite awareness of consequences.⁴²^,⁴⁷	–
	Glycaemic control	–	Non-compliance with dietary practices except before clinic visits.⁴⁸	–
	Cholesterol control	–	Medication ‘intentional non-compliance’.³⁸	–
	Blood pressure	–	Non-compliance related to personal attitude to diabetes.³⁶	–

Behavioural regulation	General	Visual prompts; self-management education; reluctance to ‘nag’; and getting used to developments in care.³²^,⁴²^,⁴⁵^,⁵¹	Challenge of being disciplined to achieve good diabetic control.⁴²	–
	Glycaemic control	–	Insulin dose changes following self-monitoring and selective timing of adherence to diet.⁴¹^,⁴⁸	–
	Blood pressure	–	–	Immediate feedback to patients with telemedicine systems.⁶⁰

Optimism	General	Feeling positive about preventing complications by early intervention.⁴⁶	Lack of a positive approach to self-care and minimising the condition, particularly if asymptomatic.³⁷^,⁴⁵^,⁴⁷	–
Optimism	Cholesterol control	Near-target lipid achievement believed to be adequate for some patients.³⁸	–	–

Memory, attention, and decision processes	General	Using memory rather than guidelines to determine care needs but problems remembering and danger of overloading patients with information.⁴⁵^,⁵²	Delayed decisions by patients to start insulin due to perceived conflicting information from peers, the media, and healthcare professionals; being unable to sustain lifestyle changes once a lifestyle programme has ended.³⁰^,⁵¹	–
Memory, attention, and decision processes	Glycaemic control	Collusion with patients to avoid starting insulin.⁴²	–	–

Goals	General	The need to prioritise care processes and individualise goals for the patient.⁴⁶^,⁵²	Patients’ lack of ambition, interest, and engagement.⁶²	–
Goals	Glycaemic control	Converting patient to insulin allowing nurses to ‘see[ing] the job through’.⁴³	–	–

BP = blood pressure. Note: clinical targets extracts coded to: general diabetes care; glycaemic control; cholesterol control; BP control; foot exam; smoking; weight management; urine albumin–creatinine ratio/equivalent.