Table 2 Barriers and enablers identified for bronchiolitis target behaviours by Theoretical Domains Framework

Beliefs about consequences

Clinician concern that missing an alternative diagnosis e.g., pneumonia, particularly when infant has significant increased work of breathing (CXR, salbutamol, antibiotics).

Undertaking investigation will confirm the diagnosis (CXR).

Some clinicians believing there is benefit from a trial of the therapy to prevent admission, with others disagreeing (Salbutamol).

Conflicting beliefs of little or no harm, or benefit from therapy (CXR, salbutamol, antibiotics, glucocorticoids).

Belief that the new bronchiolitis guideline would benefit evidence-based bronchiolitis management; some senior doctors stating the guideline would not change their practice (CXR, salbutamol, glucocorticoids, antibiotics, adrenaline).

Infants from deprived populations may benefit from therapy (Antibiotics).

Confidence in de-prescribing/ceasing therapy already commenced (Salbutamol, antibiotics, glucocorticoids).

Knowledge

Lack of experience in caring for infants with bronchiolitis (CXR, salbutamol, antibiotics, glucocorticoids).

Lack of knowledge of current bronchiolitis evidence (CXR, salbutamol, antibiotics, glucocorticoids, adrenaline).

Social professional role and identity

Nurses supporting junior doctors in caring for infants with bronchiolitis (CXR, salbutamol, glucocorticoids).

Nurses being disregarded when questioning treatments (CXR, salbutamol, antibiotics).

Junior doctors lacking confidence in contacting seniors for advice (CXR, salbutamol).

Importance of medical and nursing teamwork when managing infants with bronchiolitis (CXR, salbutamol, antibiotics, glucocorticoids).

Environmental context and resources

Reduced senior medical support after hours; time pressures in ED leading to undertaking investigation (CXR).

Regional hospitals having significant distance to tertiary care and less paediatric trained/experienced staff with more overseas trained doctors who may practice differently leading to investigations and therapies (CXR, salbutamol, antibiotics, glucocorticoids).

Challenges with staff turnover and maintain regular bronchiolitis education (CXR, salbutamol, antibiotics, glucocorticoids).

Importance of positive relationships between ED and inpatient paediatric units (CXR, salbutamol, antibiotics, glucocorticoids).

Skills

Lack of confidence in diagnosing and managing bronchiolitis (CXR, salbutamol, antibiotics, glucocorticoids).

Importance of nursing involvement in bronchiolitis management (CXR, salbutamol, antibiotics, glucocorticoids).

Lack of confidence in discussing supportive bronchiolitis management with families/caregivers (CXR, salbutamol, antibiotics, glucocorticoids).

Social influences

Pressure from parent/caregiver and other clinicians to investigate or prescribe therapy (CXR, salbutamol, antibiotics, glucocorticoids).

Beliefs about capabilities

Importance for families/caregivers to maintain positive relationships with primary care providers when ceasing treatments (Salbutamol, glucocorticoids, antibiotics)

Wanting to “do something” or prevent deterioration (CXR, salbutamol, antibiotics, glucocorticoids).