Table 4.

Key content relating to the Theoretical Domains Framework for each indicator

	Risky prescribing	Treatment targets in type 2 diabetes	Anticoagulation in atrial fibrillation	Blood pressure targets in treated hypertension
Knowledge	GPs more knowledgeable compared to other staff Awareness of drug interactions and patient history	Variable awareness of recommended HbA1c levels Important to know the rationale and evidence behind recommendations Guidance generally familiar as standard practice	Indicators familiar because of QOF Important to have access to specialist knowledge Treatment often initiated in secondary care Lack of staff experience in starting treatment given relatively infrequent clinical presentation in primary care	Indicators familiar because of QOF Indicators ingrained as ‘bread and butter’ of general practice
Skills	Communication skills for effective patient counselling Limited time to use skills (e.g. communication)	Communication skills for effective patient counselling Having technical skills such as medication titration Skills for monitoring and managing blood pressure more common than those for HbA1c	Communication skills for effective patient counselling	Communication skills for effective patient counselling Technical skills such as using blood pressure machines, obtaining reliable readings and titrating treatment
Social professional role and identity	Prescribing perceived to be mainly the role of GPs. Practice nurses viewed their input as restricted to reviewing medication if required GP autonomy to deviate from guidance Threat of litigation reinforces nurse prescribers’ adherence to guidance Recognition of role of pharmacist Prescribing practice driven by perceived patient needs and professional ethos rather than guidance	Refer to diabetic lead if patient taking multiple medications Clarity of roles and responsibilities Tailoring care to patient needs and professional ethos more important than achieving strict targets	Tailored patient care can both help and hinder adherence (e.g. in elderly patients and patients with multiple conditions) Role more focused on long-term rather than acute care as atrial fibrillation often initially presents to secondary care Hospitals not always as up to date with guidance as they should be, resulting in wrong or contradictory advice for primary care Clinicians with more cardiac expertise tend to be responsible for most patients Practice nurses viewed their input as restricted to reviewing medication if required	Clarity of roles and responsibilities Professional ethics and threat of litigation promote adherence Tailoring care to patient needs and professional ethos more important than achieving strict targets
Beliefs about capabilities	Clear guidance and access to specialist knowledge and training Adequacy of information technology system support	Confidence in ability to achieve targets depends on patient factors such as attendance and motivation Many clinicians confident with blood pressure and cholesterol but less so with HbA1c and any associated medication changes Organised links between primary and secondary care Confidence in diabetes lead Information technology capability to identify patients not achieving targets	Confidence related to availability of specialist staff, training and updates Supportive, organised links between primary and secondary care	Confidence helped by relative simplicity of guidance and decision support Confidence hindered by patient factors and limited resources for referrals
Beliefs about consequences	Ensuring quality of care, patient health and patient safety Reputation for following guidance reflects well on practice and professional Perceived threat of litigation to nurse prescribers if guidance not followed Immediate financial and time costs (prescribing budget, increased appointments, auditing) outweighed by the potential longer term NHS cost reduction	Achieving targets linked to quality of care and better patient outcomes Achieving targets associated with short term gains in QOF income and longer term NHS savings Job satisfaction in achieving targets Perceived pressure to achieve targets undermines rapport with patients Achieving targets requires time and increases workload Costs for patients and side effects from additional prescribing to achieve targets	Ensuring quality of care, patient health and patient safety Achieving targets associated with short term gains in QOF income and longer term NHS savings Strict adherence to guidance inappropriate for some patients (e.g. elderly and those on multiple medications)	Ensuring quality of care and patient health Achieving targets associated with short term gains in QOF income and longer term NHS savings Perceived increased workload associated with following guidance (e.g. consultation length)
Motivation and goals	Adherence ensures quality of care, patient health and patient safety Promoting a positive reputation for the practice Guarding against litigation Incentivisation of good prescribing Generally high motivation to follow guidance	Achieving targets associated with short term gains in QOF income and longer term NHS savings Achieving targets linked to quality of care, better patient outcomes and job satisfaction	Ensuring quality of care, patient health, and patient safety Achieving targets associated with short term gains in QOF income and longer term NHS savings	Ensuring quality of care, better patient health and job satisfaction Achieving targets associated with short term gains in QOF income and longer term NHS savings Generally high motivation to follow guidance
Memory, attention and decision processes	Information technology systems often not in line with intuitive cognitive processes Decision aids and prompts for drug interactions Patient history provides important information for decision making Automatic cognitive processes useful in high-risk situations	Awareness of patient characteristics such as older age can influence decision of whether or not to aim for targets System prompts useful for embedding targets into memory	Relatively infrequent presentation of atrial fibrillation hinders commitment of guidance to memory Prompts and the ability to view guidance support decision making	High prevalence of hypertension helps embed guidance into routine practice Patient characteristics (e.g. older age) can influence tailored care to meet patient’s needs Guidance considered easy to retain Prompts useful for supporting adherence to guidance
Environmental context and resources	Practice nurses pick up medication issues during reviews but lack knowledge and suitable templates sometimes impede this Prescribing policies, support and advice available from CCG medicines management teams and pharmacists Lack of time (e.g. training and education) and decision support. Inadequate information technology systems and communications with secondary care	External support from CCG, information technology systems and training opportunities Low staffing levels and high workloads Communication between primary and secondary care could be improved to support achievement of targets	Communication systems and established lines of responsibility within the practice are needed in order to identify potential issues around professionals’ adherence Inadequate communication between primary and secondary care Time and workload, especially as current information technology systems do not support easy identification of eligible patients	Established lines of responsibility, clear templates and access to training and education (e.g. motivational interviewing and titration for nurses) Limited availability of home blood pressure machines, heavy workload and short duration of consultation makes it difficult to schedule a specific time to measure blood pressure which contributes to difficulties in achieving targets
Social influences	Patient preferences General approach and support of practice team	Pressure from QOF to achieve targets Practice managers aware that achieving targets is linked to practice QOF performance Benchmarking performance against other practices Overall team approach in practice	Pressure from QOF to achieve targets General approach and support of practice team Patient preferences	Pressure from QOF to achieve targets Team factors and support within and outside the practice (e.g. network meetings Benchmarking performance against other practices Patient preferences
Emotion	Emotion generally not considered an influence Discomfort when guidance conflicts with patient-centred care Feeling constrained by guidance Feelings of caution and worry when prescribing additional medication Workload-related fatigue restricted ability to have in-depth conversations with patients	Achieving targets lead to job satisfaction Adverse impacts of fatigue on achieving targets Frustration from patient factors (e.g. resistance, low motivation) and missing targets Perceived pressure from targets which can generate tension between clinicians and patients	Frustration caused by complicated guidance making treatment difficult to explain to patients Limited time, mood and fatigue result in deferring decisions to further consultations Discomfort with pushing adherence amongst elderly patients	Emotion generally not considered an influence Achieving targets lead to job satisfaction Fatigue and workload influence whether targets were considered at every consultation Unease created by patient reactions to additional prescribing
Behavioural regulation	Computer prompts for drug interactions, templates, audit and medication reviews Problems associated with rapidly accessing and interpreting full patient records Computer prompts not always useful – can be overwhelming	Help from computer prompts, recall systems, clear protocols and templates Action sequences helpful (e.g. reviewing patient medical notes and setting electronic reminders for action to self within patient record)	Help from computer prompts, recall systems, clear protocols and templates Limited ability of current computer prompts to support adherence to guidance	Help from computer prompts, recall systems, clear protocols and templates Patient risk factors act as prompts Opportunistic reviews of patient records Computer prompts not always considered useful and potentially distract from main purpose of consultation

CCG Clinical Commissioning Group, QOF Quality Outcomes Framework