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Table 3 Domains describing barriers and facilitators to accurate application of decision aid

From: Barriers and facilitators affecting implementation of the Canadian clinical practice guidelines for the diagnosis of acute aortic syndrome

TDF domain Specific belief Barrier or facilitator Representative quotes (interview ID) N
Skills Physician vary in their ability to obtain the required physical exam findings required B “What I don't have is this clinical skill, and I don't think probably anybody in our department has the ability (or it would be very rare) to be able to measure aortic regurgitation or insufficiency.” (1) 4
Memory, attention and decision processes The clinical decision aid is too long to memorize and requires an app B “It has to be published and … on MD calc. That would be useful. I don't think this is a tool you can memorize.” (4) 3
  The decision aid is difficult to use B “I get a little lost at first because the way you score each one is different” (1, 3)
“When you pick up any kind of clinical decision rule we want to know if the patient’s meeting the inclusion criteria to begin with. CT head rule is a great example of that right? … it's a little misleading because it actually doesn't tell you who to apply the rule to. So not getting it confused with the components of the rule versus who to even apply the rule to.” (2)
4
  The decision aid is easy to use F “It's relatively easy to use, I mean the exclusions are very straightforward, that’s not hard to manage.” (9) 2
Environmental context and resources Results of a D-dimer are fast and may accelerate care F “That's one of the advantages we have in our rural hospital, is that we have point of care testing, because we don't have lab 24/7.” (9) 2
  Waiting for a D-dimer may delay care B “One of the barriers, perhaps you could say, is the delay between investigating and getting a result.” (3) 2
  Required information may be unavailable B “A lot of this information we either don’t have, or we just have to assume.” (9) 2
Reinforcement I will not order a D-dimer in patients for whom I suspect D-dimer will be positive for other reasons B “the patients I think are going to have a positive d-dimer for ten other reasons: I’m just going to go ahead and CT them… usually I just pull the trigger and make my day easier and order the scan upfront.” (1) 4
Beliefs about capabilities Additional training/clarification is needed to correctly apply the clinical decision aid B “And I would hope that people are not saying, Oh, this person's blood pressure is 180 and they have some abdominal pain, therefore they go to CT. And I don't think that's the rule’s intent.” (3) 2
Beliefs about consequences Subjectivity may lead to over-testing. B “is there potential that we will start over-investigating? Because a lot of patients will, for example, describe that their pain is severe, and so that automatically gives them, you know, one point…I think that severe pain requires a sort of a clinical judgment call.” (5)
“One of my colleagues… CT scans a lot of people who I don’t necessarily think need it. So [they are] always going to say ‘aortic dissection is the most likely diagnosis’ whereas my cognitive bias is going to say ‘well, I think it's probably not’ … We're coming to a different conclusion from the same tool.” (1)
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