Table 3 Sub-themes identified in all 14 domains of Theoretical Domains Framework

1. Knowledge

(An awareness of the existence of something)

Limited awareness

“No, never heard of it.” (P03, Certified Respiratory Educator)

“I've attended a few presentations that [PI] made and you've made that you’ve come and presented in our Education Day.” (P01, Administrator)

2. Skills

(An ability or proficiency acquired through practice)

Communication skills

I feel like all health care providers have general communication skills that would allow them to ask these questions.” (P15, Allied health professional)

“I think that there should be a skill, in terms of teaching the families how to fill this out.……. just a basic training in terms of how to present it to the families, how to frame it.” (P09, Pediatrician)

Data interpretation skills

“in terms of the data interpretation, or how you use that in your clinical practice.” (P09, Pediatrician)

“I think that level of understanding of “what are the questions?” “what are the variability between different participants answers?” and therefore “what would que you to potentially pursue a particular area?” I think would be helpful.” (P04, Pediatrician)

Other skills

“I would need like, technology skills to be able to view the results in an efficient manner prior to the clinic so nothing more clinically but to be understanding on how to incorporate into practice and probably some technical skills.” (P11, Pediatric Respirologist)

“I think they have to be able to incorporate this piece of information into their scheduling for the clinic.” (P01, Administrator)

3. Social/professional role and identity

(A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting)

Providing patient and family-centered care

“it (PROMs) would give a good understanding of how kids are feeling, and coping, how they're doing in all aspects of their lives and their parents perceptions of how they're doing as well. And that can better help the team understand different challenges that might come up with their medical management.” (P01, Administrator)

“So, this is where PROMs are important in that you have to align your goals with theirs (patients).” (P13, Pediatric Respirologist)

Lack of guidelines from professional organizations

“I would say I don’t- I am not aware of anything formal that is out there.” (P04, Pediatrician)

4. Beliefs about capabilities

(Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use)

Resistance to change culture

“I think the devil is always in the details and requires culture change, you know, changing processes and then sustaining that process overtime until it becomes part of what we do all the time.” (P04, Pediatrician)

“Some are going to embrace it; some are going to see the value and others are gonna “there's nothing wrong with the way I'm doing it.” (P02, Pediatric Respirologist)

PROMs as standardization tools

“in asthma you know everybody likes to do things their own way. Really hard with something that is actually helping people standardize what they're doing.” (P07, Administrator)

“Just because every time a patient comes to the clinic, they may be seeing different physician, so standardized approach is difficult to do for anything that we add in our clinics.” (P11, Pediatric Respirologist)

Confidence in self-ability

“I think it would be it would be easy if the information is provided beforehand or at the time of the arrive at the clinical appointment. In an easy way for the healthcare provider to view the result.” (P10, Allied health professional)

“I think, pretty confident. Yeah, I think we do it all the time in an informal way, but I think it's actually, it's probably going to be a nice add on to our history taking anyway, because we probably should be.” (P09, Pediatrician)

5. Optimism

(The confidence that things will happen for the best or that desired goals will be attained)

Optimism about positive impact of PROMs

“in general, I would feel confident that it could improve quality of life for families.” (P16, Allied health professional)

“they (patients and families) think that its an ongoing care even if they are at home, they can answer the questionnaire and really think about it, come to the clinic with, with all the information that we need. So, in that way improve patient care.” (P11, Pediatric Respirologist)

6. Beliefs about consequences

(Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation)

PROMs for comprehensive health

“I think the biggest benefit is improving the comprehensive health of the patient. Moving beyond just dealing with the chief complaint.” (P07, Administrator)

“those psychosocial things that we don't normally investigate but are very important things that may have links with other places…… I mean I think big picture using a tool like that (PROM) really does add to the Comprehensive Assessment of a patient.” (P04, Pediatrician)

Optimizing healthcare delivery

“I think it really helps people think about their symptoms and their expectations prior to when they come for appointment.” (P03, Certified Respiratory Educator)

“Results are given prior to seeing the patient, and they give you an idea of what things around and they have kind of didn't we, we are you going to address things.” (P12, Pediatrician)

Benefits of using PROMs outweighs harms

“I think that as long as the “how” is done well, then the benefits should definitely well outweigh the harms.” (P17, Allied health professional)

“I think the benefits definitely outweigh the risks for our patients, knowing a bit more about them ahead of time I think is a huge benefit.” (P08, Certified Respiratory Educator)

Lack of clear processes and strategies

“because when someone flags, you know, their top three concerns, I think it would be- it's not professional for us not to deal with them. And so, we better have some strategies or some plans in place for what do we do when families say this?” (P02, Pediatric Respirologist)

Potential negative consequences

“we obviously we don’t want to overburden families, especially those with a child with chronic illness.” (P16, Allied health professional)

“you have a scoring system like this, sometimes you don't want to fail so people will give you the answer that you- that they think you want, and it may not be the truthful answer.” (P03, Certified Respiratory Educator)

“I think that we might end up identifying things that are less directly associated with that, with their medical condition potentially. And while that might be a very good thing, because it might influence their care in that area, (but) it could also divert time and energy into somethings that maybe aren’t directly as related, let’s say in this case to their asthma.” (P04, Pediatrician)

7. Reinforcement

(Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus)

Incentives

“I think it might make our job a wee bit easier.” (P05, Certified Respiratory Educator)

“our main incentive is to always try to better understand how we can meet a family’s needs while trying to improve their child’s trajectory of their chronic illness, asthma in this case.” (P06, Administrator)

Mixed perceptions with time

“barrier. I think that's the biggest thing is, how much extra time would it take for you to go through it. Before the clinic or during the clinic.” (P11, Pediatric Respirologist)

“I know people always say “oh, it's a barrier of time,” well really, it's no barrier of time at all, you're doing the work anyway. In fact, this may actually improve your time because some- some of these- this is all answered for you, so it would- it will be really interesting.” (P03, Certified Respiratory Educator)

“It (PROMs) may keep it (time) neutral; it may raise some areas that take more time to address it. But I think they do more comprehensive job on providing care so maybe depends on how you look at it.” (P12, Pediatrician)

Motivation for clinicians

“(it depends on) how easy you're going to make it for my team members when they come into a patient appointment to be able to see those results so that they can frame their conversation.” (P02, Pediatric Respirologist)

“I think it'd be pretty easy to use. I think uptake would be dependent on how much the patients buy into it.” (P14, Pediatrician)

Motivation for patients and families

“what the parents and families and kids feel they're going to get out of it is also another concern, because if they don't feel it's relevant or important, then they're not going to do it.” (P01, Administrator)

8. Intentions

(A conscious decision to perform a behaviour or a resolve to act in a certain way)

High importance

“I think we should give it a 10 (out of 10).” (P03, Certified Respiratory Educator)

“I would say the PROMs are at the 8 to 10 scale.” (P01, Administrator)

9. Goals

(Mental representations of outcomes or end states that an individual wants to achieve)

Compatibility

“I think I would still continue doing what I was doing, but I think it would help to inform maybe where to focus on.” (P15, Allied health professional)

“It's definitely compatible our current practice because we're very electronic based on the fact thar we have a new electronic system that's gonna be implemented in the next year.” (P01, Administrator)

10. Memory, attention and decision processes

(The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives)

Language barriers

“Probably just the language barriers. You know we create so many of our documents so many of our questionnaires are for the English-speaking people at a certain grade level. But not everybody is English speaking or at that grade level.” (P14, Pediatrician)

“And things like language barrier and things like that we have some strategies for using interpreters and that kind of thing, which mitigate things to some degree.” (P10, Allied health professional)

Technological barriers

“I think it may be difficult if the patient doesn't have electronic access or doesn't have a cell phone or an iPad or we don't have iPads available, that's going to be another impediment.” (P01, Administrator)

“I think having access to maybe the technology. You know, if they go online and their computer is not up to date, you can’t open it, you can't get the password, like I'm not going to spend five minutes trying to do that as a patient.” (P13, Pediatric Respirologist)

Complex family background

‘We have lots of kids that live in multiple households -mom, dad, grandparent, aunt- just like [name] was saying, so it gets complicated. Where- who's giving you the insight, right?” (P03, Certified Respiratory Educator)

“I think kind of high conflict family, where there's parental conflict, or challenges between parents, I think certainly families that are maybe, generally, quote unquote non compliant with medical care.” (P15, Allied health professional)

11. Environmental context and resources

(Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour)

Challenges of working within larger system

“Challenge is more working…. working within the system, like AHS (Alberta Health System) that can make it more challenging for you with an existing system.” (P12, Pediatrician)

“I think, it would be pretty easy if we had the frontline nurse get them set up with that, ahead of time, even have iPads (at the clinics) and results could just be automatically uploaded to EMR. I think that would be pretty slick.” (P09, Pediatrician)

Acuity of the patient

“Obviously, if a child is acutely unwell at the time, which does sometimes happen, it might be inappropriate potentially to veer away from trying to acutely address the problem at hand, where the child might have a deteriorating condition or might need to have acute management and really that has to be the focus of the time that we spend that time on, so I could see that playing a role. That would probably be the main situation where it would be not possible to kinda go there (PROMs).” (P04, Pediatrician)

“acuity, acute status of patients would be one of the clinical factors associated with clinical environment (impacting use of PROMs).” (P13, Pediatric Respirologist)

Disruption to clinical workflow

“if we were already running way behind and had particular time constraints for patients in clinic it might be a choice that we have to decide what we’re going to address that day.” (P07, Administrator)

“I'm doing now is using our pulmonary function testing results and discussion to family and physical examination I think that's our core and key aspect and if it's starting to, you know, interfere with that piece I may not use it on a regular basis.” (P13, Pediatric Respirologist)

12. Social influences

(Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours)

Influence of leaders and team members

“It kind be of very high level; I think behind being positive idea. "yes this makes sense" there's been a very high level.” (P12, Pediatrician)

“Multiple people, like clinic lead, Alberta Health Services supporting it, buy-in from all the support staff. Nursing—that’s a big one.” (P09, Pediatrician)

Patients’ and families’ emotions

“Because parents, that’s who influenced us, that’s how we got where we were, our parents influenced us, parents influence children.” (P03, Certified Respiratory Educator)

“If the patient and family are not routinely doing them, then it’s less likely that we’ll be successful in integrating them because it will be more kind of one-off instead of the usual, so that’s really important.” (P04, Pediatrician)

13. Emotion

(A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event)

Excitement

“I think it’s always kind of exciting to see us move into a more patient and family focused direction.” (P14, Pediatrician)

“excited sounds kind of, like, sort of sounds like a personal thing rather than a professional thing but I think our group is excited about doing new things that are proven to be better and challenging our skills.” (P05, Certified Respiratory Educator)

14. Behavioural regulation

(Anything aimed at managing or changing objectively observed or measured actions)

Electronic PROMs

“And I think our population and our parents are keen to use electronic measures as opposed to paper questionnaires.” (P06, Administrator)

“think having it online is helpful, especially for teens, they’re more likely to do things online, so then they don't have to worry about bringing the paper with them, so you have tried to take away that barrier.” (P10, Allied health professional)

Engagement with stakeholders at the asthma clinic

“So having communication with all the stakeholders from administration to pediatric division, to respiratory division, to allied health division, to the family division, to patient division, we have to make sure we have all the right players involved in decision making all the way along that we communicate effectively.” (P01, Administrator)

“I think if you can bring them a compelling story that resonates to them about how this can make a difference, if they can see it in action and if they can hear some feedback from a family that says this made all the difference in the world.” (P02, Pediatric Respirologist)