Participants (cardiac surgeons, n = 5, cardiac anaesthesiologists, n = 7, clinical perfusionists, n = 5) represented key stakeholders involved in practicing and implementing bleeding management in cardiac surgery in Australia. Participants practiced across different states and settings including public (6), private (1) and both (10). Length of interviews ranged from 27 minutes to 53 minutes. Specific participant demographics or any identifying data within the quotes were not included to protect anonymity.
Of the 14 TDF domains, nine emerged as significant to categorise clinicians’ beliefs about the barriers and facilitators to managing bleeding and implementing change to improve practice. Four TDF domains were present but rare. (Table 1)
Table 1
TDF Domains reported by occurrence and participants
COM-B | TDF | No. of Occurrences | No. of Participants | % Participants |
| Relevant Domains | | | |
Capability | Behavioural Regulation | 54 | 14 | 82% |
Knowledge | 77 | 13 | 76% |
Skills | 23 | 12 | 71% |
Opportunity | Environmental Context and Resources | 81 | 17 | 100% |
Social Influences | 109 | 16 | 94% |
Motivation | Belief about Capabilities | 34 | 14 | 82% |
| Social Professional Roles & Responsibility | 47 | 14 | 82% |
| Belief about Consequences | 25 | 12 | 71% |
| Emotion | 17 | 10 | 59% |
| Rarely Reported Domains | | | |
Capability | Memory, Attention, and Decision Making | 4 | 4 | 23% |
Motivation | Intentions | 4 | 4 | 23% |
| Goals | 5 | 3 | 18% |
| Optimism | 7 | 3 | 18% |
A number of explanatory themes (barriers and facilitators) were connected within and across domains, while remaining a specific theme (illustrated by connecting arrows in Fig. 1)
Capability
Psychological Capability, Physical Capability
‘Capability’ (COM-B) can be explained as the clinician's capacity to engage in the management of actual bleeding episodes or implement change to improve practice. Six barriers and three facilitators emerged in relation to this construct.
Behavioural Regulation (psychological capability)
These included three related to “Behavioural Regulation” (TDF) whereby clinicians described standardisation with protocols and decision support tools as useful to guide and reduce variation in practice. All quotations are followed by recognition of profession (S) for surgeon, (A) anaesthetist, (P) perfusionist.
“I think that protocol-based practice has a huge amount going for it – reproducibility of what you do, patient safety, everyone being able to be on the same page every time. I think that the answer to a lot of these problems, is having protocols to drive your practice” (A)
“So, to follow a protocol and get the majority of problems (bleeding) sorted – 95–99% of the time, is really easy” (A)
“If it’s done every time, it’s part of the vernacular…. it becomes part of the language. It has to become part of the standard practice, so it’s more habit actually, that changes” (A)
“An algorithmic guideline helps you remember things that you may have otherwise forgotten” (A)
However, there was also the belief that flexibility in decision making using experience were equally important because of locally contextual clinical and environmental issues.
“It’s a combination of evidence based and personal preference and personal experience” (S)
“It’s never going to be a rigid application of guideline for every single patient and there has to be that of course” (A)
“It’s like a mental check list but it’s dependent on the patient, the procedure, where I’m operating and who I’m working with” (S)
“One of the problems with clinical medicine is that people do tend to think dichotomously rather than continuously and that’s not helpful” (A)
Additionally, participations considered behaviours and the ability to implement improvement could be influenced by audit and feedback This was considered particularly relevant as surgeons and anaesthetists were highly driven, often competitive, and capitalising on these traits was considered an enabler for practice improvement.
“It’s about incentive, we have brought it in for them……. the de-identified data, where they all want to be like everybody else. They don’t want to be an outlier, so when you can present them with a graph with their de-identified, they take note” (A)
“It’s important to have feedback loops because you become accustomed to what you are doing whether its adequate or inadequate” (P)
“I think training, education and quality assurance provided by having dedicated CNCs’ support for blood management is essential and this feeds our knowledge and that feeds into audit data and that in turn feeds back into proving efficiencies and effectiveness” (A)
“There is a big difference between what people know and what they practice and without the collection of data your opinion can be enormously skewed to fit your own belief system” (A)
Knowledge (psychological capability) and Skills (physical capability)
Four themes emerged related to the TDF domain ‘knowledge’, two related to ‘skills’ specifically and two themes bridging both domains. (Table 1) In the first bridged theme, participants supported the concept of joint educational opportunities with relevant colleges and societies to improve both ‘knowledge’ and ‘skills’ within the multidisciplinary framework. There was a belief that this type of joint training could address the lack of a common language.
“Collaborative teaching would be helpful. It has to be multi-disciplinary though, so you can’t have the cardiac ANZSCTS (Australian & New Zealand Society of Cardiothoracic Surgeons) doing one thing for the cardiac surgeons and ANZCA’s (Australia and New Zealand College of Anaesthetists) cardiac special interest group doing something for the cardiac anaesthetists and they’re different. You’ve got to be working from the same knowledge base” (A)
“An area where both groups can get together and learn and have a combined approach. I think team management is important so that when we say to the surgeon, X and Y are ok but maybe you should consider Z, but they say to us but A, B and C. We’re both talking the same language and making a collective decision based on that” (A)
In the second bridged theme participants overwhelmingly reported ‘skills’ and ‘knowledge’ were acquired informally by clinicians with a particular interest in bleeding management, then learnings passed in an ad hoc way or, on the job discussion.
“Peripherally, there are bits of knowledge you can gain and obtain, but I’m not aware of a specific course or a specific online teaching resource for bleeding in cardiac surgery” (A)
“Currently you have knowledge that is dispensed by individuals, it is uncoordinated, based on opinion, and I think that is part of the confusion with blood management” (P)
“I do think that the bleeding that you see in cardiac surgery is unique and the patterns of coagulopathy that you see associated with cardiac surgery are unique and that trying to lump those in with other major bleeding and other surgery or trauma is a mistake” (A)
The majority (but not all) participants believed that specialist training could be improved with the inclusion of more up to date learning for example, related to the cell-based model of coagulation, viscoelastic haemostatic assays and goal directed therapy.
“I never had any formal teaching in haemostasis except those diagrams in medical school that actually mean nothing the, INR and PT and APTT. I don’t think any of those tests are useful in bleeding management” (S)
“I think it needs to get into the training programs. It needs to become second nature for people. We’re sort of attacking it from the wrong end trying to grab people by the time they're out and invested in their current practice” (A)
“I think there is probably a very variable range of knowledge among cardiac anaesthetists about management of coagulation, to be honest with you” (A)
“In my training, I got taught very little about bleeding. Not at medical school and not at surgical school, so when we started doing blood management here, I knew a bit about bleeding and haemostasis management but I didn’t know a lot and I didn’t know anything about ROTEM or TEG or any of those technologies and so I had to learn” (S)
“Every cardiac surgeon during its training is well-experienced. I think in six years they know how to control bleeding and how to manage patients with bleeding” (S)
“Anaesthetists probably have the most education on managing major haemorrhage and bleeding, we have to do major haemorrhage and critical bleeding modules for CPD” (A)
“…they are still being taught these old pathways that exist in test tubes and not being taught practical stuff in terms of bleeding management” (S)
A barrier to ‘knowledge’ was widespread acknowledgement of non-compliance with current guidelines. Deviations from recommendations were considered an accepted part of practice. It was generally believed this was due to divergent recommendations, recommendations based on low levels of evidence, and a lack of local relevance.
“I am aware of multiple sets of guidelines through my own work and research. They don’t all harmonise of course, and so that’s problematic” (A)
“They (Australian & New Zealand Society of Cardiothoracic Surgeons) would be an authority that I would turn to because they’re local, but they don’t have anything specific” (A)
“The challenge that we have for example, the European guidelines, there is a lot of factor concentrates and they have different systems, so they don’t necessarily apply to here” (A)
“The problem being of course is that they (guidelines) are disparate in some respects. On occasions, the guidelines actually contradict each other, or else they have different weightings for the level of evidence that they present and that of course is a problem” (A)
Participants felt that they often lacked the skills needed to negotiate and relate with finance/business departments when trying to introduce new equipment, testing, products, or additional clinical time to support practice improvement. It was felt that, not only the language used by clinicians, but the goals and outcomes of these different departments did not align and was a source of frustration.
“In the public hospital system, a huge barrier is that doctors and medical people are not trained in the same way in business and in budgeting and even how to interact with groups outside the medical profession” (A)
“The project management skills that you need to set up a program are quite significant, and I think many of us, not only don’t have the time to do it, but don’t have the skills unless you have them intrinsically, they are not there” (A)
“You’ve got to learn how to talk to all these other people, the funders and the bean counters, you’ve got to learn to talk to them in a way that they understand and sell yourself” (A)
Opportunity
Physical Opportunity, Social Opportunity
‘Opportunity’ (COM-B) can be explained as all the factors that lie beyond the individual, that make the management of bleeding or implementation of practice improvement, possible. These included factors in the environment that encourage or discourage these goals. These factors can be physical for example, time constraints, resources, cost, physical environmental barriers. Or they can be related to social context of practice including interpersonal, intradepartmental, or interdepartmental influences, group or individual attitudes, culture or the expectations of others. Five barriers and one enabler emerged as influencing participants within this construct. These included three related to three related to ‘Environmental context and resources’ and two related to ‘Social influences’.
Environmental Context and Resources (physical opportunity)
Participants believed that complicated administrative processes negatively influenced their ability to implement improvements in bleeding management. Compounding these barriers were a lack of organisational and/or managerial support and leadership for training/education, skill development, resources, and dedicated blood management clinicians. Participants also reported considerable time restraints due to their primary clinical responsibility with little or no time to dedicate to write business cases for funding, or develop processes, policies, tools, and educational packages required to change practice.
“We’ve got pain nurses and infection-control nurses, we’ve got joint-care nurses, we’ve got colostomy nurses, but we don’t have a blood management nurse who is here every day like those others, who can do this stuff. I’ll know that there is an issue but it’s going to take me two weeks until I can actually sit down and make an attempt to address it. A person who had the time, dedicated to this sort of thing, would really make a big difference” (A)
“Putting a business case together, no body teaches you how to do that and it takes a lot of time. We're clinicians looking after patients, who has the time?” (A)
“You need to have both support from the Chief Executive as well as the individual people in the room. I think all are very important” (S)
“Administrative bureaucracy that prevents improvements from happening. That’s one thing you have to overcome. I think that’s definitely a big barrier, it’s frustrating” (A)
“The external factors, non-clinical entities, which affect us, I don’t think that anybody would stand in the way of us delivering evidence-based care on a day to day basis but they will stand in the way of providing the resources that we need to do it over the short to medium long term” (A)
Participants agreed that differences in resourcing between private/public & regional/ metropolitan hospitals influenced bleeding management and the ability to implement practice improve initiatives.
“It’s difficult, I can’t really say, ‘let’s not give anything’ because we don’t have any evidence without a ROTEM or access to platelet function, and I am not the one who has a bleeding patient under my hands. I think we have some power, to discuss and talk but no real time information to make treatment decisions and that limits our input” (A)
“I don’t have a good answer for how it would work in the private sector, but the public sector you have a chance of getting a paid person, generally like a nurse educator type role, that works best I think in the public sector” (A)
“….. it’s less easy, for instance, simple things like getting blood. You can wait hours for blood or platelets at some hospitals” (S)
“In private it makes it more difficult because you don’t really know what the status of the patient is, because there is no ROTEM to go by” (P)
“Something like a research nurse that would enable the data collection and the day to day management and the education of people, I think, is probably the tool that is best suited to do it in the public sector” (A)
“Sometimes I can't get what I need because sometimes there are resource limitations. Sometimes specific hospitals don’t have specific products, especially the private ones that are smaller” (A)
Social Influences (social opportunity)
A very specific barrier participants discussed was the conflicting processes, goals and outcome criteria from the pathology and haematology departments that had a direct impact on clinician’s ability to make change improvements.
“Pathology and other departments who have various policies in place that make it difficult to implement change to begin with. It can be discouraging” (A)
“If I wanted to bring that in, I would have to sit with haematology, and they are concerned that I don’t get a rebate, or they don’t get paid enough to do platelet function tests. They are not interested in doing it because it will be cost for their department, without money for their department because the savings are in the blood bank which is a different department. That’s an external factor. That is a problem” (A)
“There was a resistance for a long time from haematology to basing any decisions on viscoelastic testing” (A)
“A haematologist who hasn’t quite got their head around that… we care about this and we don’t want to use blood products inappropriately. We don’t want to treat with a therapy that just isn't needed, not necessary. So that's our brick wall, that's our problem here, we can’t get around that” (A)
“Private pathology is not supporting that sort of stuff, because there is no reason really for them to do it” (A)
Participants overwhelming recognised that effective teamwork, collaboration, and communication between disciplines was critical for successful implementation and management of bleeding.
“I think the things most contingent on managing bleeding, are the roles and relationships between the clinicians” (P)
“… because if you’ve got a bleeding patient and we’re at the operating table, I’m trying to deal with my bits, trying to fix the bleeding the ways I can, and so I rely on my anaesthetist to look at the ROTEM, interpret the ROTEM, and start to communicate what he thinks is the best way forward. It’s absolutely collaborative. It can’t be done any other way” (S)
“it’s a multi-disciplinary program. To me, that is absolutely fundamental for the program having success, that everyone believes that they are part of the program they have developed, and they have ownership” (A)
“Listening to the conversations between the surgeons and anaesthetists…. for me, was the point in time when I thought this has a chance of working, of being sustainable” (P)
“We have discussions about what best based on evidence or not best guess. That’s the advantage we have now, we can talk about the deficits are, how we are going to correct that, so we are empowered to discuss more about the best fit for the patient” (A)
“it’s not the machines or the tests that make them (projects or programs) successful and make them right. It’s the human interactions and the protocols and the building of teams that leads to success. I think the way to overcome the barriers is to build strong teams” (A)
Motivation
Reflective Motivation, Automatic Motivation
‘Motivation’ (COM-B) refers to all the cerebral processes that direct behaviour, for example identifying with a professional role and evaluating potential consequences and benefits. Six barriers and five facilitators were categorised as influencing participants’ motivation to manage bleeding or implement change to improve practice. These included three each related to “Belief about capabilities”, and “Belief about consequences”, and two each related to “Social professional roles and identity” and “Emotion”.
Belief about Capabilities (reflective motivation)
Participants perceived a lack of confidence or familiarity with change or project management limited their ability to implement improvements.
“The project management skills that you need to set up a program are quite significant, and I think many of us, not only don’t have the time to do it, but don’t have the skills unless you have them in change management is a huge big deal. It’s not just evidence, you know, it’s leadership, it’s bringing people on board, it’s building a team behind you and getting that first four and the second four and moving forward. I think there is a lack of skill in change management. Intrinsically they’re not there” (A)
“You virtually need a champion really; I don’t know whether there would be resources within ######## to support this. But it’s a lot of work and it’s a lot of effort and you’ve got to drive it and you’ve got to be persistent and dogged, and those are personality traits that don’t universally exist” (A)
“…in other words, if you feel as though the action you are going to take is not really going to change practice or you don’t feel like know how, or if you’re not empowered to make change then you’re less likely to even attempt to do so” (P)
Nevertheless, participants were confident that patients received the best care they could provide considering varied contexts, settings, as well as the resources they had available.
“So, between my anaesthetist and my perfusionist and myself, whether it’s here or ####, you sort of cover most of your bases with the resources you have. Most of the people that I’m involved with either here, or next door are pretty knowledgeable about blood and roughly where the boundaries are for treatment, no treatment, so I think most of the bases are covered” (S)
“It’s not a matter of going off and having a coffee and talking about it. It’s finding the best solution in the immediate term and clearly sometimes that is a compromise” (A)
“We’re not able to control or measure, we don’t have a TEG or ROTEM, which means intellectually we’ve got an understanding of what the problem might be, but we have to make a decision based on the clinical environment in those situations. There isn’t enough factual evidence to support every decision that you make” (A)
However, there was consensus by anaesthetists of a balance required to keep the surgeons “happy” and supported during difficult situations when patients were bleeding and potentially unstable. It was also considered that, as surgeons were responsible for overall patient outcomes, they were accountable in a final decision-making role. Consequently, anaesthetists felt less empowered to deliver interventions.
“At the end of the day, the surgeon’s name is on the head of the bed and an ongoing problem that we have, is when I haven’t done a ROTEM yet post-bypass that the surgeon just says, this patient is going to need platelets because they are on antiplatelets” (A)
“There have been times that I have just stopped transfusing. “Stop telling me it’s a coagulopathy”. It becomes a difficult position. You have got a bleeding patient and now you have got conflict and sometimes it’s about for the safety of the patient, you just have to try and move past that conflict” (A)
“here it’s definitely a team approach. I feel part of that team and I feel that I can use my knowledge to help come to a team decision but ultimately if a surgeon feels that there is a specific intervention that he or she would like me to do, then they are ultimately the ones managing the bleeding” (A)
“…. there’s an inherent need for the anaesthetist doing the list to keep the surgeon happy. The surgeon doesn’t like the concept of blood conservation, then the anaesthetist would find it a struggle to put those things in place” (A)
“I try and monitor it all and bring it all together. At the end of the day, the surgeon’s name is on the head of the bed” (A)
“I’m not going to say to a surgeon, don’t use that product on a particular patient because they are at the point of treatment and I’m not” (A)
“there are some anaesthetists that work with some surgeons, mostly they follow their pattern of practice. So, it can be difficult sometimes applying all the guidelines” (A)
Social professional roles and identity (reflective motivation)
Several conflicting constructs around “social professional roles and identity” were evident. These centred around drivers for change, implementation of practice improvement, and the influence of the public or private setting. Anaesthesia were primarily perceived as the drivers to change practice however, there was consensus that success was dependent on surgeon ‘buy-in’.
“The anaesthetists are really the ones who are the overarching drivers of blood management, the surgeons seemed to have embraced that as well… well they have to, or it won’t work” (P)
“At an institution level, program level, I think anaesthesia probably have more involvement than surgery does” (S)
“It's more than just managing the bleeding, you have to manage the surgeon, perfusion, the situation, the environment as well as everything else going on with the patient. You learn this with time, some never learn” (A)
“If you’ve got the surgeon on board, everybody is on board in the whole process” (A)
“Well, intraoperatively it’s the anaesthetic team that has a primary role because we’re at the point of care. The surgeon is busy doing their highly skilled job and they are trying to stop as much bleeding as possible and minimise the amount but we’re the ones who have got the full picture at that stage. We’ve got the clinical picture. We know what lab results are. We know what the status is of blood bank. We know the status is of cell saver and perfusion” (A)
“I think it’s a collaborative approach, but I think it’s mainly between surgeons and anaesthetics is the two biggest ones, however, I do think anaesthetics is the one who needs to take the role. In these situations, especially stressful situations with large amounts of bleeding, the surgeon is busy. They are operating. It’s good to have their input but I think at that moment in time the anaesthetist is best suited to lead that charge” (A)
“I think surgeons……… it’s hard for them because they are distracted by managing the bleeding surgically, they can’t necessarily take an overall view at the time but in terms of strategies and hospital wide policies, there is no reason why a surgeon couldn’t, here it’s just been anaesthesia, we’ve done it”(A)
“I do actually because I think…. there are several reasons. One is that, it’s perioperative blood management. Anaesthetists are peri-op physicians, very well placed to do that. We often have a window to see our patients pre-operatively and it’s a task that we can take, that honestly the surgeons would rather we did I think, because they have got plenty of other things to do” (A)
Participants provided insights into the social/professional differences and behaviours displayed by individuals operating in, or across the public and private sectors.
“Where this falls down (especially in the private sector) is the working relationship that the anaesthetist has to have with a surgeon, your private work is contingent on that” (A)
“It’s different, in the private sector, I work with the same team all the time so it’s a bit easier because my anaesthetist has a similar approach. In the public, it’s not so easy from a staffing point of view because you’re working with different people but in public, we have a better structure for what should happen to patients” (S)
“In the private sector, the surgeon definitely takes the lead because there is less of a system around you to manage blood and it’s less easy, for instance, simple things like getting blood. You can wait hours for blood or platelets at some hospitals” (S)
“I work in a small institution that is private practice and I am responsible for my patients, so I have to take all the decisions” (S)
Belief about Consequences (reflective motivation)
Many participants reported differences in applying bleeding management strategies relating to private/public context with potential important consequences. Specifically, in the private sector, organisational culture meant that delaying surgery due to known bleeding risk (i.e. platelet dysfunction) was not desirable owing to financial implications, or the patient’s desire not to delay surgery.
“There’s a lot more pressure in the private sector, even though there is documented evidence of platelet disfunction, they’ll still push for the patient to have surgery because there is a patient desire to get the surgery done, so they bleed, and they just give platelets” (A)
“So, the private centres are all competing with each other in order to get the surgery and the money, so they don’t want to be the one that seemed to be delaying patients” (A)
“Their bottom line just comes down to dollars more than anything else. It has to be seen to be costing less money, or saving money in some aspect for it to be valid” (P)
Participants were not confident that implementing improvements bleeding management could be achieved with variable funding incentives such as the acquisition of blood products. The differences varied across states, and public and private hospitals.
“I believe that the expense that we can take in order to prevent bleeding would be more than mitigated by the outcomes of reduced bleeding, reduced transfusions, improved patients’ haemoglobin post-operatively, the improved outcomes they would get, speedier recovery, 100%” (A)
“It has a cost-benefit. It’s harder to prove a cost-benefit to the hospital because we don’t pay for blood. Blood is free. Everything else costs, blood management costs, cell salvage costs money. Trying to get cell salvage in and they just said, what’s the cost benefit, how much will it cost? You try like a business case, but you can’t use blood cost as a cost. You have to find other cost savings” (A)
“I would hate to be at the point which will happen soon, where we’ve made most of our cost savings from changing a transfusion practice and be wanting to implement other things that we know improve clinical care but come at a cost, it’s going to be an uphill battle to try and argue for the cost, even though it’s for better patient management” (A)
“Bleeding has to be managed well otherwise the consequences will be poorer outcomes. That is well established” (A)
Participants consistently reported the belief that managing bleeding with evidence-based strategies provided benefits to the patient and the organisation.
“The other thing that is really fascinating about this, is that it’s not just we’re doing it here, its reproducible between institutions, because having fostered the same change in ##### Hospital we actually have the equivalent outcome. So, this is a reproducible process” (S)
“There should be an expectation now that when you walk in for an elective operation that you walk out without having to be transfused. That will be the norm and it would be unusual to be transfused if you’re doing everything in the bundle of care” (A)
“Because all of these blood related issues with regard to mortality and some morbidities are in the low percentages and can a long time to actually see a difference, a change or a positive benefit for patients and its only when they see it, that they can go “there is merit to this, it’s not just anti transfusion, there is patient benefit, there is hospital benefit, there is financial benefit” (P)
“I knew that we could do better and if we did better, then we wouldn’t have to take our patients back as much. So, that was actually what drove me to try and get a better understanding of what was going on” (A)
“The consequences of poor bleeding management are that we’re most likely going to have more bleeding, poorer patient outcomes, and higher costs associated with it” (A)
Emotion (automatic motivation)
Participants unanimously reported that they were generally not troubled by emotion related to managing actual clinical bleeding.
“You know, a difficult case, there can be certain emotions around but that’s generally, not usually a problem” (A)
“Not really, not more than any other aspect of clinical care” (A)
“No, emotions aren't helpful in difficult clinical situations” (A)
“Not really. I mean, it’s part of our game” (A)
Participants did however, report frustration that evidence-based bleeding management strategies existed, and clinicians were not able to implement these strategies to improve patient care.
“If you can’t get buy-in from any of the other teams, from management, it’s just you, the lonely voice, it’s hard” (A)
“Administrative bureaucracy that prevents improvements from happening. That’s one thing you have to overcome. I think that’s definitely a big barrier, it’s frustrating” (A)