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Table 3 Clinician perspectives influencing behaviours related to the implementation of a clinical pathway

From: “What is the actual goal of the pathway?”: examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

Domain Theme Sample Quote
1. Knowledge, Skills, and Practice Lack of training on concussion
Ambiguity around concussion and need for evidence-based info
Multiple modalities for knowledge dissemination
Practice variation
“I received no formal training … Nobody’s ever talked to me about pediatric concussion. I have received most of it through advanced certification courses … Most knowledge about pediatric concussions is self-directed.” (04RN)
“The most difficult thing I find with concussion care at the moment is I don’t necessarily know what the right answer is. Like the research is pretty nebulous as to what we should actually be telling people … there’s a lot of unanswered questions.” (24MD)
“Just [use] multiple modalities to reach people. It’s a big team.” (07RN)
“There’s just not a lot of consistency in practice right now, so I think having a little more consistency … to guide their orders or their interventions … is always a benefit.” (22RN)
2. Professional Roles and Identity Respecting clinical autonomy
Distribution and delineation of roles
Managing professional identity and mitigating risks
“Some people might, with pathways, [feel that you are] taking away autonomy from nurses.” (21RN)
“Clinical pathways with defined nursing roles can be very successful.” (19RN)
“If I’m telling a family that I’m sending a referral to X, Y and Z clinic, they will be contacted within 2–3 days for an assessment in 1–2 weeks, that better happen, because [if it doesn’t], then that destroys your credibility.” (11MD)
3. Attitudes, Beliefs, and Motivations Supportive attitudes and motivations
Skepticism, indifference, and potential resistance
Attitudes towards research vs. clinical goals
“I think especially at this site, if you say ‘pediatric’, people will jump because it’s not necessarily everybody’s comfort zone here … so a lot of people really jump at the opportunity to get any more pediatric education just to increase their comforts.” (10RN)
“We have so many other commitments in terms of clinical work and things like that that sometimes it’s a barrier. It’s just one more thing to do in our days … [we wear] many hats as physicians and many of us are involved in teaching and meetings and committee work and all sorts of things.” (29MD)
“I mean it’s still a research project. It’s not mandatory … so that might just be something that takes the back seat when it’s really stressful and busy.” (09RN)
4. Goals and Priorities Enhance patient education and manage expectations
Improve coordination of care
Streamlining processes
“The thing that parents need most when their kids have concussions is reassurance and some guidelines.” (19RN)
“If this pathway tightens up follow-up care after emergency, that would help me immensely. I’ll feel much more confident in making those referrals. So I wish that there was a neater process for that because there’s not many different places I can send them … and the most frustrating is to have a rejection for a referral.” (11MD)
“It has to offer [clinicians] something that they’re not getting right now. Like it’s either easier for them or it’s making the decision pathway clearer, or it’s helping them access resources for people … there has to be some benefit to it, or I think it’s going to be a challenge to sell it.” (24MD)
5. Local Context and Resources Practical considerations
Site-specific considerations
Uniqueness of acute care setting
“From my experience as a manager, you know, the uptake on things isn’t immediate. You have to continue to nurture it and remind and keep going and that’s probably true in most sites if they’re honest about it.” (32RN)
“That’s the nature of emergency medicine. We see episodic care. We never find out follow-up … All emergency departments all do the same thing, they only see people once, and they’re more interested in the diagnosis than the follow-up per se.” (15MD)
6. Engagement and Collaboration Stakeholder engagement
Other collaborations
“[It is important to] make sure that it’s not being dictated down from the Children’s Hospital, that this is our protocol. Really kind of incorporating and bringing it to the department, rather than just being implemented or forced.” (04RN)
“I feel like the most successful pathway is asthma and that’s definitely multi-disciplinary … the strength of the asthma pathway was it not only empowered nursing, but RTs [as well]. So [there were] two groups for keeping this pathway alive and well … [and] multiple champions in different disciplines that provided for its successful outcome, rather than having one or two.” (07RN)
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