In this preliminary study, we identified a range of perceived facilitators and barriers to CPW uptake and utilization by FPs. The Family Physicians alluded to various TDF domains throughout the FG discussions. Key TDF domains were centered on knowledge (including communication); belief about consequences; goals; environmental context and resources; and reinforcement.
System level barriers – TDF Domain of: Knowledge
Focus group discussions identified knowledge, which also encompasses communication in the TDF domain, as one of the recurring barriers to CPW uptake.
Knowledge
Knowledge includes general awareness/existence, and detailed knowledge of each CPW. FG participants revealed lack of systematic CPW promotion as the main barrier to uptake. Physicians stated they had only received targeted promotions regarding Spine, Pelvic Floor and Prostate Assessment Pathway. Perhaps the reason most FPs stated they were more aware of Hip & Knee and Spine is because they are the oldest pathways in Saskatchewan, originating in 2009 and 2010 respectively (9). FPs recognized a lack of pathway related education and training for themselves and related allied health professionals. It was discussed that even if CPWs are promoted and educational materials/workshops are available; Physicians found barriers in accessing that information. There were noticeable inconsistencies depending on the location of FPs practice (i.e. urban vs rural). FPs also observed when CPWs information sessions occurred locally, CPWs were utilized more often. This highlighted discrepancies in the way the CPW was promoted among the different regions of Saskatchewan.
Communication
The TDF domain of knowledge also includes communication between organization to practitioner, organization to organization, and practitioner to practitioner.
Organization to practitioner communication includes engagement of FPs prior to the inception of pathways. It begins with “needs assessment”, followed by awareness and promotion, and finally ongoing education and evaluation of CPWs. Family Physicians as the primary care providers are usually the first point of contact in CPWs for patients entering the healthcare system. Results from the FG discussions implied inadequate engagement of FPs as key personnel in the identification, creation and development of CPW which may have precluded utilization(12). Findings from the KI interview indicated that MoH formed an advisory group responsible for the development and implementation of CPWs, however findings from the KI did not clarify the protocols for FP participation and engagement in the advisory groups. For instance, as indicted in TABLE 1 only three of the seven currently operational CPWs included Family physician engagement (9). The engagement of the FPs in quality of care initiatives is fundamental to increase success of health interventions and quality improvement (12), (27).
Organization to organization communication barriers were also noted in the focus groups. Many participants observed an absence of readily available data indicating improved patient outcomes with CPW implementation. Adequate evaluation of CPWs is associated with improved uptake (28). CPW monitoring and evaluation reports could be used to provide feedback to decision makers (i.e. MoH and Saskatchewan Health Authority (SHA)) and also help make adjustments to increase CPW efficiency. Hence, a collaborative approach with FPs is recommended to encourage uptake and utilization.
Lastly and importantly, ineffective communication between practitioners to practitioners has emerged as a barrier in all FG sessions. Participants identified disruptions in the continuity of care once their patient entered the pathway. Most FPs attributed this to gaps in communications with both allied health professionals and specialists (e.g. not receiving a report from specialist regarding the patient current status on the CPW) (29).
Although FPs sought to improve inter-professional collaboration, the lack of communication among practitioners deterred the anticipated result. Effective communication is necessary to achieve CPW goals as it allows for appropriate follows up and optimizes patient care (8). Other publications also support the role of effective communication as a core competency for collaborative practice (29). Our findings suggest facilitating CPW into clinical practice is possible if knowledge and communication barriers are addressed (14). This could be through promotional efforts and increasing Physicians CPW familiarity (12), (14), (30), (31).
Objective clarification – TDF Domains of: Belief about consequences & Goals
Our preliminary findings showed a difference concerning CPW goals, and objectives between the FPs and policy makers (e.g. MoH). TDF domains relating to goals and belief about consequences, illustrate differences in the interpretation of CPW utilization.
The goals as defined by the MoH are centered on developing, implementing and evaluating provincial CPWs to ensure best practices are standardized, so patients receive appropriate and timely care. Furthermore, MoH aims to create effective communication (via educational and operational) tools, by working collaboratively to improve access to health services, and improve the overall patient experience and outcome (9).
Aside from optimizing patient care, reducing specialist referrals (i.e. ultimately reducing patient wait times) and unnecessary surgeries; FP’s ultimate goal for CPWs, is a tool delivering high quality care with FPs acting as the point of care. However, the current perception based on FG interviews indicates Family Physicians feel they are left out in the process. This disengages FPs interest in using CPWs in their practice. Thus, streamlining and clarifying goals between FPs and MoH can increase CPW adherence and outcome expectations (32).
Technical and resource related – TDF Domain of: Environmental Context and Resources & Reinforcement
Perceived barriers identified by Family Physicians suggest that FPs already felt burdened by the volume of paperwork they completed in their daily practice and therefore deterred by the complexity of CPW forms. The findings inferred that shortening the pathway intake forms from several pages to a single page as well as providing financial compensation incentivize CPW uptake.
Other factors noted as impeding CPWs usage included difficulties in accessing referral forms and patient education documents. The findings indicated incorporation of all the materials in one place like Electronic Medical Records (EMR) may be a facilitator toward CPWs utilization.
The results showed that the accessibility to the components of the CPW and geographic location may impede CPW uptake in some areas. Access to local specialists, especially in rural areas affected whether FPs would use the pathways. For instance, FPs in the rural communities could contact specialists directly and promptly, without needing to send a referral through the pathway.
Research limitation
Despite effort of the research team, we were unable to recruit all of anticipated key informants in different CPWs. It may have limited the research team from understanding the full scope of the clinical pathway development from the KI perspective for all the seven pathways (16). However, since this was a component of the exploratory method, it did not affect the outcome of this research (16).
Another notable limitation goes back to the focus group limitations as the selected method. Compared with one on one interviews, FGs discussions sometimes may suffer from losing the direction of the objectives or receive less participation from some participants (16). By having researchers use a carefully prepared interview guide and using their discretion to redirect the conversation when needed, and providing opportunity for everyone to contribute we were able to mitigate these limitations.
Finally, the research team was aware of the limitation of the study related to the recruitment of rural Family Physicians in the focus group due to location and financial constraint. Thus, the research group addressed this barrier by purposefully selecting the rural areas at this stage of the study recognizing the subsequent survey will be implemented province wide.