Table 4 Overview of CFIR constructs linked to common themes across groups

 Relative advantage: perception of the advantage of implementing the intervention versus an alternative solution.

Empowering tool

“I feel like there was a really good balance between all the scientific information, but it is user-friendly... it’s not dumbed down too much either” (Clinical nutritionist/research associate, HNIS)

“I think it’s a great tool to get patients to understand more about their disease and help making the decision along with the clinician by having them understand and all the details and side effects of medications and choices that are available. So, all of that is helpful for the patients to understand and if you see it on a formal slide or information sheet, they will believe in it more and make it easier for us to move forward.” (Physician, MNIS)

“…it is very useful for a person who may need more help in talking with their doctor about their care. It breaks down their risk in a way that might help them understand what they really need to know about that specific treatment.” (Clinical research coordinator, LNIS)

 Design Quality and Packaging: perceived excellence in how the intervention is bundled and presented.

Time and duration as a barrier

“I’m a little bit worried about its length and then the attention span for people for doing this within the clinic. It seems like the length may be more appropriate for review at home, kind of an on-demand type of thing.” (Physician, HNIS)

“They [patients] disregard the late policy…may arrive 1.5–2 hours late to their appointment and still be seen here. Now you are taking an extra 20 minutes as well [to view the DA]. I don’t know whether our providers are going to be on….” (Registered nurse, MNIS)

“So, I only have about 20 minutes per patient for a follow-up, and some of that time is often spent checking patients in, and I’m booked every 20 minutes. If the decision aid takes 20 minutes for the patient to read, then the only way I could see it working is to send the patient home with that information and then do a follow-up. Or alternatively, have them come back in. The problem is a lot of our patients come from a significant distance, so getting them to come back in within a short turnaround time, both for their logistics and our schedule, is often not convenient.” (Physician, LNIS)

 Complexity: perceived difficulty of implementation

The added workload of technology

“The study is not a problem because I’ll be able to coordinate how many patients are coming in a day. So, if we have five iPads, we won’t schedule more than five appointments within the same hour or two. But, if it’s going to be implemented as a regular thing in the clinic, our supply would be an issue and another for front desk staff to worry about distributing, collecting. Because it’s going to have to be charged, and if someone drops it or it breaks, we must send it out for repairs, things like that.” (Study coordinator, HNIS)

“…we must find a place to lock them [iPad] up when we leave and there should be a station to charge them. So, those kinds of things we have to look into.” (Dynamic scheduler service rep, MNIS)

“There would be a need a specific person who is in charge of making sure they [tablets] were returned. I don’t know if it would be the front desk or the nurses, but someone would need to be in charge of making sure it doesn’t get lost or something.” (Research coordinator, LNIS)

 Patient Needs and Resources: extent to which patient needs are accurately known and prioritized by the organization

Implementation challenges of a diverse patient mix

“The person, whoever is implementing the study, should have specific training about how to introduce this in a way that a patient is more likely to say yes than no. Our patient population is fairly educated, highly educated and professional, and in many cases they’re not here for half a day. They’re here in and out. So that is going to be the challenge in our clinic.” (Physician, HNIS)

“I think it would be accepted well, depending on patient though. We have a pretty research active lupus population. We have a registry study that is involved with the patient, so I just feel like the association of research is familiar with a lot of patients that come to our clinic, so they would be more accepting of looking at the decision aid” (Study coordinator, MNIS)

“We see a lot of indigent patients, and those with lower socioeconomic backgrounds. I feel like this is going to be hard for not all of them, but some of them [to] really understand. I think it’s a little overwhelming. We have some really sick patients and to have this on top of them not feeling good, or they have their kids with them and can’t concentrate, just stuff like that I could see interfering with it.” (Research nurse, LNIS)

 Structural characteristics: age, maturity, or size of the organization

Compatibility: integration into existing work processes

Fitting in a workflow

“We are going to have to figure out how to integrate in our already complicated workflow…and ultimately, I think that is going to be the biggest barrier. How do we implement this without disruption to their primary tasks?” (Physician, HNIS)

“I think one problem is going to be its effect on the workflow, because we’re an extremely busy clinic, and if the patient shows up late which they often do, how is it going to impact our office flow? (Physician, MNIS)

“…the concerns I have are just workflow and diagnosis…if the doctors get bought in and they want their patients to have it, they’re going to have to find a way to pre-identify patients because we wouldn’t have the bandwidth to go snooping through patients’ charts. It would have to be something that was ideally in place before the patient got here and all we would have to do is give it to them and maybe explain what it is.” (Administrative supervisor, LNIS)

 Culture: norms, values, and basic assumptions of a given organization

Openness to change, conditional upon conducive structure and culture

“I think people [clinic members] would be pretty open to it. People would not be afraid to try something new. Some of the older staff who have been there longer may be a little bit more ingrained, but I would say it is mostly younger staff that is here. They would be open to changes.” (Physician, MNIS)

“The clinic is very open to trying new things. For instance, one of our studies that we’re working on is the influence of incorporating virtual reality to reduce stress in patients with autoimmune disease. That is just an example of us using a novel technology as an experimental intervention to see if it can help our patients. So, we’re very open to it.” (Clinical research coordinator, HNIS)

“We are open to change. We’ve been changing rules. I’ve been here six years, during that period they changed computer systems and we adapted to it. I don’t think it’s the employees against the change. I mean, providers might not be against it, but I don’t have that type of conversation with them. But that’s where I feel like we’ll have an issue. (Certified clinical medical assistant, LNIS)

 Knowledge and Beliefs about Intervention: individual staff knowledge and attitude towards the intervention

Positive attitude

“It’s definitely a novel approach. It could be very helpful. There could be a few barriers to it. It’ll take a little bit of doing and trying, but it’s definitely something that could be implemented.” (Physician assistant, HNIS)

“I think that once the tool is introduced and is set up, I don’t anticipate at this point that they need to do any changes in the clinic.” (Triage RN, MNIS)

“Well, the opportunities lie in the enthusiasm we all have in making the care of lupus patients more streamlined, efficient and of quality…. So, I think that it’s fine. I don’t see any issues.” (Director of the clinic/physician, LNIS)

 Self-efficacy: an individual’s belief in his/her capabilities to execute the implementation

Clinical personnel experience with research and improvement

“I think we are in a unique situation; we are pretty flexible in our clinic where we can start to implement these things relatively straightforward. It is not getting without growing pains, but nonetheless, I don’t see a huge hurdle in terms of implementing that once we are all familiar with the factual assessment and everything.” (Physician assistant, HNIS)

“For quality improvement, one initiative that we have implemented is we have what we call a friends and family forum. That was very well received, and I initiated that because we’re in triage and when we’re on the phone and call people, we have to have that form in place so we can give information that’s appropriate. When there is a need, or we see an initiative or a project that can be started, it is very well received by our staff. Ideas bounce off each other. That is a positive for our clinic.” (Triage registered nurse, MNIS)

“I think we have been reasonably successful before. We do sort of have patient clinic questionnaires that we have been implementing for a while and we had to change our infrastructure around that as well….so, that will sort of help us if we have more challenges, but we have been reasonably successful in incorporating changes.” (Physician, LNIS)

 Engaging: engaging individuals in implementation process

Need for buy-in from physicians

“We have a lot of different goals in mind at this clinic. It be confusing with what study you want to take priority. So, usually we will focus most of our resources on getting what he [physician] wants to get done first, and then after we finish that, we will be able to handle the auxiliary studies. So, if he sets a priority, we definitely would put most of our time and effort into it to make sure it is done well.” (Clinical research coordinator, HNIS)

“It’d be better if everyone is on board. Obviously, getting the physicians on board is critical, but I think it’s the nurses, PAs or whoever is framing the patients, and even for that matter, the secretaries at the front. I think they would be the ones first mentioning the decision aid to the patient. So, getting them involved, as well, like the secretaries and the nurses would be pretty important, too, since they’re the people who have the first interactions with the patient when they arrive to the clinic.” (Physician, MNIS)

“…we really need strong physician engagement. Leadership can only do so much, in my opinion. We really need the physicians and have them lead the implementation. And I think with [physician], he’s been very engaged and he’s very involved in all his patient care. So, we really need someone like [physician] be the spearhead of programs like this. In the past we haven’t done it because of physician engagement, but I think now they’re very engaged and they really want their patients to be more educated for their condition. (Clinic administrator, LNIS)