Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Implementation Science
Published in: Implementation Science 1/2012

Open Access 01-12-2012 | Research

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework

Authors: André E Bussières, Andrea M Patey, Jill J Francis, Anne E Sales, Jeremy M Grimshaw, the Canada PRIme Plus Team

Published in: Implementation Science | Issue 1/2012

Login to get access

Abstract

Background

The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays.

Methods

Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF.

Results

Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge).

Conclusions

Chiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.
Appendix
Available only for authorised users
Literature
1.
Isaacs DM, Marinac J, Sun C: Radiograph use in low back pain: a United States Emergency Department database analysis. Emergency med. 2004, 26: 37-45. 10.1016/j.jemermed.2003.06.002.CrossRef
2.
Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, Fahridin S, Harrison C, Latimer J: Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010, 170: 271-277. 10.1001/archinternmed.2009.507.CrossRefPubMed
3.
Ferriman A: UK rate of x ray examination less than half the US rate. BMJ. 2001, 322: 384d-10.1136/bmj.322.7283.384.CrossRef
4.
Chou R, Fu R, Carrino JA, Deyo RA: Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009, 373: 463-472. 10.1016/S0140-6736(09)60172-0.CrossRefPubMed
5.
Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R: Views on radiography use for patients with acute low back pain among chiropractors in an Ontario community. J Manipulative Physiol Ther. 2002, 25: 511-520. 10.1067/mmt.2002.127075.CrossRefPubMed
6.
Ammendolia C, Hogg-Johnson S, Pennick V, Glazier R, Bombardier C: Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community. J J Manipulative Physiol Ther. 2004, 27: 170-179. 10.1016/j.jmpt.2003.12.021.CrossRefPubMed
7.
Assendelft W, Pfeifle C, Bouter L: Chiropractic in The Netherlands: a survey of Dutch chiropractors. J Manipulative Physiol Ther. 1995, 18: 129-134.PubMed
8.
Carey TS, Garrett J: North Carolina back pain project. Patterns of ordering diagnostic tests for patients with acute low back pain. Ann Intern Med. 1996, 125: 807-813.CrossRefPubMed
9.
10.
Scheurmier N, Breen AC: A pilot study of the purchase of manipulation services for acute low back pain in the United Kingdom. J Manipulative Physiol Ther. 1998, 21: 14-18.PubMed
11.
de González Berrington A, Darby S: Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet. 2004, 363: 345-351. 10.1016/S0140-6736(04)15433-0.CrossRef
12.
Chou R, Qaseem A, Owens DK, Shekelle P: Physicians ftCGCotACo: Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Internal Med. 2011, 154: 181-189.CrossRef
13.
14.
Chou R, Qaseem A, Snow V, Casey D, Cross J, Shekelle P, Owens D: Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Managment of Acute Musculoskeletal Pain Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Internal Med. 2003, 147: 478-491.CrossRef
15.
Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK, Clinical Efficacy Assessment Subcommittee of the American College of P American College of P American Pain Society Low Back Pain Guidelines P, Clinical Efficacy Assessment Subcommittee of the American College of P American College of P American Pain Society Low Back Pain Guidelines P: Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Internal Med. 2007, 147: 478-491.CrossRef
16.
Sevigny P, Kunteze S, Watson P, Underwood M, Ritchie G, Cotterell : Low back pain early management of persistent non-specific low back pain. 2009, National Collaborating Centre for Primary Care and Royal College of General Practitioners, London
17.
Ammendolia C: Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. J Manipulative Physiol Ther. 2005, 28: 375-CrossRefPubMed
18.
Ammendolia C, Cote P, Hogg-Johnson S, Bombardier C: Do chiropractors adhere to guidelines for back radiographs? A study of chiropractic teaching clinics in Canada. Spine. 2007, 32: 2509-2514. 10.1097/BRS.0b013e3181578dee.CrossRefPubMed
19.
Ammendolia C, Taylor JAM, Pennick V, Cote P, Hogg-Johnson S, Bombardier C: Adherence to radiography guidelines for low back pain: a survey of chiropractic schools worldwide. J Manipulative Physiol Ther. 2008, 31: 412-418. 10.1016/j.jmpt.2008.06.010.CrossRefPubMed
20.
Bussières AE, Peterson C, Taylor JAM: Diagnostic imaging practice guidelines for musculoskeletal complaints in adults–an evidence-based approach: introduction. J Manipulative Physiol Ther. 2007, 30: 617-683. 10.1016/j.jmpt.2007.10.003.CrossRefPubMed
21.
Nyiendo J, Haas M, Goldberg B, Sexton G: Patient characteristics and physicians' practice activities for patients with chronic low back pain: A practice-based study of primary care and chiropractic physicians. J Manipulative Physiol Ther. 2001, 24: 92-100. 10.1067/mmt.2001.112565.CrossRefPubMed
22.
Nyiendo J, Haas M, Goodwin P: Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: A practice-based feasibility study. J Manipulative Physiol Ther. 2000, 23: 239-245.CrossRefPubMed
23.
24.
Hurwitz EL, Coulter ID, Adams AH: Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health. 1998, 88: 771-776. 10.2105/AJPH.88.5.771.CrossRefPubMedPubMedCentral
25.
Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR: The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons. New Engl J Med. 1995, 333: 913-917. 10.1056/NEJM199510053331406.CrossRefPubMed
26.
Cherkin C, MacCornack F, Berg A: Managing low back pain. A comparison of the beliefs and behaviours of family physicians and chiropractors. West J Med. 1988, 149: 475-480.PubMedPubMedCentral
27.
Aker P, Bombardier C, Jansz G, Bressler H: Chiropractic management of low back pain: a survey of Ontario chiropractors. Second International Forum for Primary Care Research on Low Back Pain; May 30–31; 1997. 1998, The Hague, The Netherlands
28.
Bussières AE, Taylor JAM, Peterson C: Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther. 2008, 31: 33-88. 10.1016/j.jmpt.2007.11.003.CrossRefPubMed
29.
Grimshaw JM, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, Vale L: Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med. 2006, 21 (Suppl 2): S14-S20.PubMedPubMedCentral
30.
Solomon DH, Hashimoto H, Daltroy L, Liang MH: Techniques to improve physicians' use of diagnostic tests: a new conceptual framework. JAMA. 1998, 280: 2020-2027. 10.1001/jama.280.23.2020.CrossRefPubMed
31.
Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan J, Wolf Fredric J: Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2008, 3: CD004398-PubMed
32.
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L, Shirran L: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess (Winchester, England). 2004, 8: iii-iiv. 1–72
33.
Cabana M, Rand C, Powe N, Wu A, Wilson M, Abboud P, Rubin H: Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999, 282: 1458-1465. 10.1001/jama.282.15.1458.CrossRefPubMed
34.
Shaw B, Cheater F, Baker R, Gillies C, Hearnshaw H, Flottorp S, Robertson N: Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2005, 3: CD005470-PubMed
35.
Wensing M, Grol RM: Determinants of effective change. Improving patient care. Edited by: Grol R. 2005, The implementation of change in clinical practice Edinburgh Elsevier, Butterworth, Heinemann, 94-108.
36.
Légaré F: Assessing barriers and facilitators to knowledge use. Knowledge translation in health care Moving from evidence to practice. Edited by: Straus S, Tetroe J, Graham ID. 2009, Wiley-Blackwell, BMJI Books, , 83-93.
37.
Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N: Lost in knowledge translation: Time for a map?. J Contin Edu Health Prof. 2006, 26: 13-24. 10.1002/chp.47.CrossRef
38.
Baker R, Lecouturier J, Bond S: Explaining variation in GP referral rates for x-rays for back pain. Implementation Sci. 2006, 1: 15-10.1186/1748-5908-1-15.CrossRef
39.
Carey TS, Garrett J: Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project. Ann Internal Med. 1996, 125: 807-814.CrossRef
40.
Little P, Cantrell T, Roberts L, Chapman J, Langridge J, Pickering R: Why do GPs perform investigations?: the medical and social agendas in arranging back X-rays. Fam Pract. 1998, 15: 264-265. 10.1093/fampra/15.3.264.CrossRefPubMed
41.
Shye D, Freeborn DK, Romeo J, Eraker S: Understanding physicians' imaging test use in low back pain care: the role of focus groups. Qual Health Care. 1998, 10: 83-91. 10.1093/intqhc/10.2.83.CrossRef
42.
Ryynanen OP, Lehtovirta J, Soimakallio S, Takala J: General practitioners' willingness to request plain lumbar spine radiographic examinations. Eur J Radiol. 2001, 37: 47-53. 10.1016/S0720-048X(00)00234-5.CrossRefPubMed
43.
Espeland A, Baerheim A: Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers - a qualitative study. BMC Health Serv Res. 2003, 3: 8-10.1186/1472-6963-3-8.CrossRefPubMedPubMedCentral
44.
McKenzie J, French S, O'Connor D, Grimshaw J, Mortimer D, Michie S, Francis J, Spike N, Schattner P, Kent P: IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol. Implementation Sci. 2008, 3: 11-10.1186/1748-5908-3-11.CrossRef
45.
Di Iorio D, Henley E, Doughty A: A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med. 2000, 9: 1015-1021. 10.1001/archfami.9.10.1015.CrossRefPubMed
46.
Chenot J, Scherer M, Becker A, Donner-Banzhoff N, Baum E, Leonhardt C, Keller S, Pfingsten M, Hildebrandt J, Basler H, Kochen M: Acceptance and perceived barriers of implementing a guideline for managing low back in general practice. Implementation Sci. 2008, 3: 7-10.1186/1748-5908-3-7.CrossRef
47.
Phillips R: Plain film radiology in chiropractic. J Manipulative Physiol Ther. 1992, 15: 47-50.PubMed
48.
McKenzie J, O'Connor D, Page M, Mortimer D, French S, Walker B, Keating J, Grimshaw J, Michie S, Francis J, Green S: Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol. Implementation Sci. 2010, 5: 86-10.1186/1748-5908-5-86.CrossRef
49.
Kok G, Schaalma H, Ruiter RAC, van Empelen P, Brug J: Intervention mapping: protocol for applying health psychology theory to prevention programmes. Health Psychol. 2004, 9: 85-98. 10.1177/1359105304038379.CrossRef
50.
Bartholomew LK, Parcel GS, Kok G: Intervention mapping: a process for developing theory- and evidence-based health education programs. Health Educ Behav. 1998, 25: 545-563. 10.1177/109019819802500502.CrossRefPubMed
51.
Foy R, Francis J, Johnston M, Eccles M, Lecouturier J, Bamford C, Grimshaw J: The development of a theory-based intervention to promote appropriate disclosure of a diagnosis of dementia. BMC Health Serv Res. 2007, 7: 207-10.1186/1472-6963-7-207.CrossRefPubMedPubMedCentral
52.
Etches V, Frank J, Di Ruggeiro E, Manuel D: Measuring population health: a review of indicators. Annu Rev Public Health. 2006, 27: 29-55. 10.1146/annurev.publhealth.27.021405.102141.CrossRefPubMed
53.
Graham ID, Tetroe J: KT TRG: Some theoretical underpinnings of knowledge translation. Acad Emerg Med. 2007, 14: 936-941.CrossRefPubMed
54.
Grol R, Wensing M, Eccles M: Improving patient care. The implementation of change in clinical practice. 2005, Edinburgh Elsevier, Butterworth, Heinemann, 290-
55.
Grol R: Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2003, 39: 46-54.
56.
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M: Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008, 337: a1655-10.1136/bmj.a1655.CrossRefPubMedPubMedCentral
57.
58.
Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A: Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality & Safety In Health Care. 2005, 14: 26-33. 10.1136/qshc.2004.011155.CrossRef
59.
Francis J, O'Connor D, Curran J: Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implementation Sci. 2012, 7: 35-10.1186/1748-5908-7-35.CrossRef
60.
Kamberelis G, Dimitraidis G: Focus groups: Strategic articulations of pedagogy, politics, and inquiry. Handbook of qualitative research 3rd ed Thousand Oakes. Edited by: Denzin NK, Lincoln YS. 2005, Sage, CA, 887-907.
61.
Morgan D, Kreuger R: When to use focus groups and why’. Successful Focus Groups. Edited by: Morgan DL. 1993, Sage, LondonCrossRef
62.
63.
Bishop A, Thomas E, Foster NE: Health care practitioners' attitudes and beliefs about low back pain: A systematic search and critical review of available measurement tools. Pain. 2007, 132: 91-101. 10.1016/j.pain.2007.01.028.CrossRefPubMed
64.
Pincus T, Foster NE, Vogel S, Santos R, Breen A, Underwood M: Attitudes to back pain amongst musculoskeletal practitioners: A comparison of professional groups and practice settings using the ABS-mp. Manual Ther. 2007, 12: 167-175. 10.1016/j.math.2006.06.005.CrossRef
65.
Biggs L, Mierau D, Hay D: Measuring philosophy: a philosophy index. J Can Chiropr Assoc. 2002, 46: 173-184.PubMedCentral
66.
Francis J, Stockton C, Eccles M, Johnston M, Cuthbertson B, Grimshaw J, Hyde C, Tinmouth A, Stanworth S: Evidence-based selection of theories for designing behaviour change interventions: using methods based on theoretical construct domains to understand clinicians' blood transfusion behaviour. Br J Health Psychol. 2009, 14: 625-10.1348/135910708X397025.CrossRefPubMed
67.
Francis J, Tinmouth A, Stanworth S, Grimshaw J, Johnston M, Hyde C, Stockton C, Brehaut J, Fergusson D, Eccles M: Using theories of behaviour to understand transfusion prescribing in three clinical contexts in two countries: Development work for an implementation trial. Implementation Sci. 2009, 4: 70-10.1186/1748-5908-4-70.CrossRef
68.
Bogdan R, Biklen SK: Fieldwork. Qualitative Research for Education: An Introduction to Theories and Methods: International Edition, 5th ed. 2007, Pearson Higher Education, Boston, 320-
69.
Hsieh H, Shannon S: Three approaches to qualitative content analysis. Qual Health Res. 2005, 15: 1277-1288. 10.1177/1049732305276687.CrossRefPubMed
70.
Francis J, Johnston M, Robertson C, Glidewella L, Entwistle V, Eccles M, Grimshawe J: What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010, 25: 1229-1245. 10.1080/08870440903194015.CrossRefPubMed
71.
72.
Intellipulse Pamr: Canadian Chiropractic Resources Databank 2007 – National Report. 2007, 98-
73.
Francke A, Smit M, de Veer A, Mistiaen P: Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak. 2008, 8: 11-10.1186/1472-6947-8-11.CrossRef
74.
Fullen BM, Baxter GD, O'Donovan BGG, Doody C, Daly LE, Hurley DA: Factors impacting on doctors' management of acute low back pain: A systematic review. Euro Journal Pain. 2009, 13: 908-914. 10.1016/j.ejpain.2008.11.013.CrossRef
75.
Saillour-Glenisson F, Michel P: Individual and collective facilitators of and barriers to the use of clinical practice guidelines by physicians: a literature review. Revue Épidémiol Santé Publique. 2003, 51: 65-80.
76.
Fullen BM, Baxter GD, O'Donovan BGG, Doody C, Daly L, Hurley DA: Doctors' attitudes and beliefs regarding acute low back pain management: A systematic review. Pain. 2008, 136: 388-396. 10.1016/j.pain.2008.01.003.CrossRefPubMed
77.
Corbett M, Foster N, Ong BN: GP attitudes and self-reported behaviour in primary care consultations for low back pain. Family Pract. 2009, 26: 359-364. 10.1093/fampra/cmp042.CrossRef
78.
Cochrane L, Olson C, Murray S, Dupuis M, Tooman T, Hayes S: Gaps between knowing and doing: understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof. 2007, 27: 94-102. 10.1002/chp.106.CrossRefPubMed
79.
Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R: Implementation barriers for general practice guidelines on low back pain. A qualitative study. Spine. 2001, 26: E348-E353. 10.1097/00007632-200108010-00013.CrossRefPubMed
80.
Kaptchuk TJ, Eisenberg DM: Chiropractic: Origins, Controversies, and Contributions. Arch Intern Med. 1998, 158: 2215-2224. 10.1001/archinte.158.20.2215.CrossRefPubMed
81.
Yvonne V-R: Caught in the crosshairs: Identity and cultural authority within chiropractic. Social Science & Med. 2011, 72: 1826-1837. 10.1016/j.socscimed.2011.03.038.CrossRef
82.
Godin G, Belanger-Gravel A, Eccles M, Grimshaw J: Healthcare professionals' intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Sci. 2008, 3: 36-10.1186/1748-5908-3-36.CrossRef
83.
84.
Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA, Maynard CD, Thrall JH, Wallner PE: Addressing overutilization in medical imaging. Radiology. 2010, 257: 240-245. 10.1148/radiol.10100063.CrossRefPubMed
85.
Carlsen B, Glenton C: What about N? A methodological study of sample-size reporting in focus group studies. BMC Med Res Methodol. 2011, 11: 26-10.1186/1471-2288-11-26.CrossRefPubMedPubMedCentral
86.
87.
Espeland A, Baerheim A, Albrektsen G, Korsbrekke K, Larsen JL: Patients' views on importance and usefulness of plain radiography for low back pain. Spine. 2001, 26: 1356-1363. 10.1097/00007632-200106150-00020.CrossRefPubMed
88.
Légaré F, Ratté S, Stacey D, Kryworuchko J, Gravel K, Graham I, Turcotte S: Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2010, 5: CD006732-PubMed
89.
Cane J, O'Connor D, Michie S: Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Sci. 2012, 7: 37-10.1186/1748-5908-7-37.CrossRef
Metadata
Title
Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework
Authors
André E Bussières
Andrea M Patey
Jill J Francis
Anne E Sales
Jeremy M Grimshaw
the Canada PRIme Plus Team
Publication date
01-12-2012
Publisher
BioMed Central
Published in
Implementation Science / Issue 1/2012
Electronic ISSN: 1748-5908
DOI
https://doi.org/10.1186/1748-5908-7-82

Other articles of this Issue 1/2012

Implementation Science 1/2012 Go to the issue

Research

Chief nursing officers’ perspectives on Medicare’s hospital-acquired conditions non-payment policy: implications for policy design and implementation

Research

Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care

Research

Implementing community-based provider participation in research: an empirical study

Research

Integrating guideline development and implementation: analysis of guideline development manual instructions for generating implementation advice

Research

A modest start, but a steady rise in research use: a longitudinal study of nurses during the first five years in professional life

Study protocol

Data for improvement and clinical excellence: protocol for an audit with feedback intervention in home care and supportive living