Using theoretical frameworks of behaviour to understand and improve health care delivery

Abstract

The development of new knowledge about patient care continues to progress at an ever-increasing rate but its transfer into clinical practice can be slow and unpredictable. This doctoral statement provides a critical overview of a substantial programme of work that has explored the utility of theoretical models of behaviour for promoting the uptake of research findings into routine care. Guided by the MRC Framework for the design and evaluation of complex interventions, the supporting publications describe the development and testing of an innovative and systematic approach to intervention design. As well as providing methods for identifying and applying behavioural theory, this work has also set standards for transparency in the intervention development processes. The work demonstrates that psychological theories of behaviour do have an important function for improving healthcare delivery by supporting clinical behaviour change, but important limitations remain. In my critical reflection of this body of work I discuss these challenges, considering in particular the omission of the patient perspective and the dynamic influence of the patient-professional interaction during the clinical encounter. I go on to propose an extended dual-perspective model supported by theory and evidence from other improvement literatures, epistemologies and disciplinary perspectives. The dual perspective model functions at the very core of healthcare delivery and illustrates the interdependency of professional and patient behaviour in determining healthcare decision making and patient outcomes. By formally including the patient perspective the revised model encompasses all three dimensions of the EBM paradigm. I argue for a focus on better understanding of the interactional and relational processes that are generated during the clinical encounter as an essential step forward for implementation and improvement science. The paradigm of patient-centred care is then revisited through the lens of capabilities thinking and is proposed as a vital mechanism for supporting the uptake of appropriate, evidence-based healthcare.