Table 6 Factors influencing clinical behaviors related to tobacco counseling among PED/UC professionals overall and by professional group: intentions; memory, attention, and decision processes; social influences; behavioral regulation; and reinforcement TDF domains
TDF domain | Sub-theme | Professional group | Sample responses | ||
|---|---|---|---|---|---|
Nurse | Physician | Administrator | |||
Intentions | Intentions to Ask and Advise are higher when patients have TSE-related symptoms and illnesses | ✓ | ✓ | ✓ | “I generally focus on patients who come in for respiratory diseases such as asthma, but it’s not a routine question that I ask.” — Administrator |
Intentions to Ask and Advise are higher when patients’ clothing or room smell like smoke | ✓ | ✓ | ✓ | “I usually tend to talk about it more if they actually go out for smoke break or if they smell like smoke in the ED.” — Physician | |
Intentions to provide counseling are lower when there are competing time demands of stabilizing acute care with fast patient turnover time | ✓ | ✓ | ✓ | “The biggest thing is time. It’s not like it’s inpatient where it’s like, oh I can’t do it now… they’re going to be here all night [so] I’ll do it after rounds this evening. We don’t have that luxury [and] sometimes we really need the patient to be discharged so we can have the room.” — Nurse | |
Memory, attention, and decision processes | Topic is not thought of unless patient has TSE-related complaint or illness | ✓ | ✓ | ✓ | “It is more forefront in my mind when the disease process that I am seeing the child for is related to smoke. Not because I don’t want to do it the rest of time, but because it doesn’t occur to me to do it the rest of the time as clearly.” — Physician |
Topic is not thought of unless room smells like smoke | ✓ | ✓ | - | “I don’t necessarily screen everybody. I would say it would be more if you smell smoke in the room... Something like that usually triggers me to ask more about social history versus somebody there for an injury.” — Nurse | |
Not reminded to screen for and counsel parental smokers | ✓ | ✓ | - | “I think the more we talk about things, the more they come to mind in a clinic visit. Sort of having something that reminds me to talk about it in clinic or talk about it in the UC. Also, I think [electronic medical record program] reminders.” — Physician | |
Social influences | Parents do not want tobacco counseling | ✓ | ✓ | ✓ | “People get very defensive about it. They lie straight to your face… [I’ve] had babies in distress and I can smell the cigarette smoke on the caregiver that brings them in and [say], you really can’t smoke in the car with them in the car, and they’ll say they didn’t.” — Nurse |
Do not know what motivates parents’ smoking behavior | ✓ | ✓ | ✓ | “I think you have to be delicate about it because it’s a lot of people’s vice. It’s very hard to give up, and so I think you have to kind of be mindful of that. You’re asking a lot for someone to give up smoking when most of the time people are doing it because that’s what relieves them.” — Nurse | |
Difficult to build rapport with families in the acute care setting | ✓ | ✓ | ✓ | “I have to be willing to sit down and talk to them. I can’t stand and lecture with my hands on my hips at the door. I have all the things that I think are more about rapport development and about them seeing you as a person and not as a preacher telling them to do something. I think that’s important. I think from an ED [perspective], it’s important how stressed they are by this specific encounter, [and] what they’re worried about that day. So that is going to often either increase the distance for them or maybe help depending on how open they are to things.” — Administrator | |
Behavioral regulation | Require screening for parental tobacco use | ✓ | ✓ | ✓ | “I think things that would encourage people would be a standardized approach or some sort of checklist that you went through with your discharge instructions [with] a little box or something that would pop up and remind you in [the electronic medical record program] that it’s been noted that the patient is exposed to secondhand smoke to encourage counseling.” — Physician |
Receive training with discussion aids | ✓ | ✓ | ✓ | “I think definitely providing a concise resource for the providers to go to [for] handouts, phone numbers for resources, and website links [available in the electronic medical record program]. Maybe even an online course or a 30-minute or 1-hour course about how we can be effective… even ways to maybe bring up the topic… like one liners that you could open up with to get the conversation going with parents.” — Nurse | |
Having electronic information available to provide to parents | ✓ | ✓ | ✓ | “Nowadays, people don’t want anything on paper and we should decrease paper waste… through some online resources, things like that. I think having tons of handouts is probably not ideal because I think I see more people throw them away… a video to watch would probably be a good thing. Something short and sweet that talks about the harmfulness of it.” — Nurse | |
Reinforcement | Implementing screening questions into the routine clinical flow | ✓ | ✓ | ✓ | “I think if that was built into the triage or screening questions, or if there was a practice alert that popped up when you opened the chart of a patient whose parent identified as a smoker who is interested in getting information, I think that would help.” — Physician |
Receiving feedback on the clinical benefit of tobacco counseling | ✓ | ✓ | ✓ | “We know the benefits of not smoking and not being around secondhand smoke… I think if we had something that we could present to them, a tool to help them get passed that, that would be more than enough of an incentive because we know that we’re making an impact on that child’s health.” — Nurse | |