Table 3 Summary of relevant TDF domains, belief statements and representative quotes about diagnosing and treating OSA in tetraplegia

Skills

I don't have the necessary skills to interpret diagnostic tests and prescribe treatments for OSA.

“I don’t order oximetry or spirometry or something myself because I’m not sure how to interpret it.”

11

“Lack of confidence and lack of training. Especially about the machines and about what pressures, and so on, to start with. I know that we would titrate it depending on the oximetry or the sleep study, but I would not know exactly how to start.”

Social/Professional Role and Identity

The diagnosis and treatment of OSA is outside my scope of practice. It should be managed by a sleep/respiratory specialist.

“If I was looking up the literature that wouldn’t be something I’d look up because it would never be appropriate for me to be the one prescribing the treatment for sleep-disordered breathing.”

6

“I don’t have the appropriate speciality qualification to interpret the results and prescribe the treatment. So, it would be sort of a, I’m trying to think of the word, it would be breaching my scope of practice. It would be implying to the patient that I know what I’m talking about when I don’t.”

“The way our system works is once I get pulmonologists involved it’s sort of like their thing.”

“I don’t consider myself a sleep specialist so if they’ve got symptoms that are consistent with that and there’s concerns on the oxygen saturation, that’s when I take them to the respirologist to see.”

Beliefs about Capabilities

I am not confident to diagnose and treat OSA without sleep/respiratory specialist involvement.

“But I think I like having the respirologist there to discuss sort of a game plan of what pressures to start them at, even though it’s auto CPAP or, you know.”

12

[Regarding diagnosing OSA] “I’ve not been trained in it. You know, I can read a graph but just because I can read labels I am not confidently able to say, “Yes, you have sleep apnoea.””

“Personally, I don’t feel confident in prescribing.”

Beliefs about Consequences

CPAP is beneficial to my patients with tetraplegia and OSA.

“So once patients are diagnosed and treated successfully, the change in terms of cognitive improvement, we have patients who would sleep through their therapy sessions, their family meetings, because they were so tired. We have patients who are on numerous sleep inducers just to get them to sleep. So once we see that patients can come off of these medications, they’re fully participating and learning about their spinal cord injury, that’s huge, right, because that will decrease the length of stay in rehab, and all of the other complications associated with them.”

9

“And then I’d say the more impressive thing that has happened, not uncommonly in patients who use it on our unit, is all of a sudden they do way better in tolerating therapies the next day, even day-to-day, like, “We’re going to try this tonight,” and the next day the therapists are like, “What did you do differently with Mr Smith? He’s like a different guy today.” It’s like, “Well, I think he has sleep apnoea and used CPAP last night. I guess his sleep apnoea was really affecting him.” And we have lots of the patients like that, I would say.”

Adherence to CPAP is poor/good in our unit.

“Of the patients who can’t take the mask off themselves, I'd say 80% of them don’t tolerate it. It’s bad but what are you going to do. I totally understand.”

7

“I think the biggest challenge for us right now is to get people to adhere to the CPAP machine.”

“But patients just find it [CPAP] really difficult to tolerate, so most patients go untreated.”

4

“No I would say normally we have a high compliance in tetraplegics… I would say 80% is compliant. We have of course some person who are not compliant and we check their compliance with the usual things.”

Environmental Context and Resources

We have poor/good access to overnight sleep studies and sleep specialists.

“It’s hard to get an in-patient sleep study now…But, yeah, that’s been a bit of an inhibitory factor, you know, to ask about patients early on and then say, “Well, you can have a sleep study in 14 months when you’re out of hospital.””

6

“It’s a logistical problem if they need a lot of care or ceiling lifts or anything like that, or an attendant. Because you know what sleep labs look like. They’re not designed for people in wheelchairs.”

“Having a sleep study is very difficult, for our inpatients, because [nearby acute hospital] has a sleep service but that is not manned, there is no nursing support.”

4

“In a few weeks patients can go there and get the measurements, yep. And when we do it in our ward then it’s also very quickly, so the waiting list is no problem, no.”

I can’t diagnose OSA and/or prescribe treatment because the patient’s CPAP machine won’t be funded.

“But most commercial payers in [XX country] require that a polysomnography is done, documented before they’ll pay for it. So we’re kind of hamstrung a little bit in that way.”

7

“I prescribe it, they won’t get funded. So there is a minority who can get funding or self-fund, but you still need to involve a respiratory professional in the set-up and reading and the compliance.

Our spinal unit has trained nurses and allied health to help manage OSA / We would need trained nurses and allied health to help manage OSA.

“Yeah we’ve got nurses involved in this part of our clinic. The nurses would go to the patients with our CPAPs and then advise them around the mask they would use and instruct them and all that.”

9

“So, we use a couple of our physios that kind of are the respiratory leads but, actually, any of our physios have the competence to set up BiPAP, CPAP, etcetera.”

“We also need the nurses of course, they have to be knowledgeable about this, we have to train the team, the doctors, everybody else, so maybe in the future we will, yes.”

4

“I need to have other special respiratory nurse who needs to train and they need to educate.”

I practice in the same way as my colleagues from the same spinal unit.

“We do the same thing. Whoever it is, they’ll be doing the same thing in our unit.”

16

“I think we have a clear policy of all the screening and referring and intervention for sleep apnoea is probably standard practice.”

Social influences

Our OSA management program is the result of a “clinical champion”

“It started with my colleague…maybe even 10 years ago or a bit longer he saw [another hospital’s] sleep laboratory and you know the screening on sleep apnoea they do in their spinal cord centre … my colleague got inspired and started to set up a similar department here which existed of nurses and himself and later I would take part in that as well and over the years kind of grew in our expertise I guess.”

6

Participant: “You sort of need a champion.” Interviewer: “Right, so you’ve basically, you’re the one who set up this program for your unit?” Participant: “Yep, pretty much, yeah, yeah.”

“My colleague and I started 20 years ago and realised that our tetraplegic patients were falling asleep during therapies... And then, and then we started assessing our patients, realised this is a problem. And then since this experience done 20 years ago now and then it became the standard. It was just translation from research to daily routine and now it’s well implemented.”