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Table 2 TDF domains and barriers/facilitators identified, with example quotes

From: Barriers to and facilitators of the development and utilization of context appropriate evidence based clinical algorithms to optimize clinical care and patient outcomes in the Tikur Anbessa emergency department: a multi-component qualitative study

Relevant TDF Domain

Barrier/Facilitator

Example Quote

Knowledge

Lack of awareness of/experience using EBCAs

“I have heard of (EBCAs) but i do not have a deep understanding off it”

Skills

Skill development essential to adoption of EBCAs

(in deciding whether or not to use an EBCA) “I decide whether I am comfortable with the procedure or not”

Social/professional roles and identity

Importance of leadership stressed

“If its accepted by the MOH and hospital we will use”

Beliefs about capabilities

Confidence in ability of TASH-ED to employ EBCAs given tailored to context

‘“everyone can use them”

“every discipline should be involved”

Optimism

Continued investment by the Ministry of health will improve resources

“the concern (interest/investment) of the government is now good”

“they are building a new ED”

Beliefs about consequences

Use of EBCA will improve efficiency and may improve allocation of resources to ED

Expectation of benefits for patient and/or provider important facilitator

“keeping the algorithm in mind makes me efficient”

“they (hospital and ministry of health) will want to follow the guideline... They will avail the materials and human power”

“It may help us from providing unnecessary medication. And even may help us to save the patient’s life”

“It make life easy”,

“if I read from the EBCA, I feel confident”

Reinforcement

Belief that making use of the EBCA a requirement and use of sanctions may be needed for staff reluctant to adopt EBCA

“we may not easily take the protocol. To take time, (we) have to be enforced to use”

“we make sure the nurses are using the algorithm by making them sign it... monitor and follow-up”

Memory, attention, decision processes

EBCA will act as a memory aid/reminder

EBCA should be easy to memorize

“(EBCA helps) something will not be forgotten”

“clear and easy to memorize”

Environmental context and resources

Many EBCAs poor fit to TASH-ED resource context

Computer/information technology access limited

Lack of human resources and high turnover of resources important barriers

“there are medications we don’t have, we don’t have the resources”

“we have to base it on what we have here.”

“hard to access them. Internet down”

“processes/ways of working, and lack of nursing staff (are barriers)”

“I think a barrier would come from trainees from other departments... Won’t want to use unless comes from their department”

Social Influences

Group norms and modelling by senior clinicians important to EBCA uptake/use

“whether my peers are using it.. it is accepted by the speciality in general, and other specialities”

“I want to see the seniors are doing it, accepting it”

Behavioural regulation

Hard to break habits, new discipline fewer habits to break

“There are some human factors. It is difficult to change what they are used to doing”

“it is a new specialty, there is a lot of enthusiasm to develop new ideas, they are very creative”