Table 2.

Barriers to change identified through PDSA cycles classified with the Theoretical Domains Framework and the COM-B model^{17 20}

Barrier	Theoretical Domain	Definition	COM-B
Lack of awareness	Environmental context and resources	Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behaviour	Opportunity Physical
Finding and completing stickers perceived as unnecessary duplication	Goals	Mental representations of outcomes or end states that an individual wants to achieve	Motivation Reflective
Bundle fatigue: 22 other bundles and checklists already in use on the AMU	Optimism	The confidence that things will happen for the best or that desired goals will be attained	Motivation Reflective
Conflict with sepsis and antibiotic policies and with guidance on renal ultrasound in AMU	Beliefs about consequences	Acceptance of the truth, reality or validity about outcomes of a behaviour in a given situation	Motivation Reflective
Compliance with some bundle elements already perceived as good	Beliefs about capabilities	Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use	Motivation Reflective
Not all bundle elements perceived as equally important	Intentions	A conscious decision to perform a behaviour or a resolve to act in a certain way	Motivation Reflective

AMU, acute medical unit; COM-B, Capability, Opportunity, Motivation-Behaviour; PDSA, Plan-Do-Study-Act.