Table 1 Summary table of specific beliefs elicited from semi-structured interviews with Canadian (n = 10) and UK (n = 11) ICU physicians allocated to the 12 theoretical domains

All domains judged as relevant in Canadian and/or UK study

Knowledge*,

I know about the TRICC Trial and other evidence

“Probably the TRICC trial comes up in most frequently” (ICU 5)

“…it did begin addressing which other studies haven’t, is to make us think more rationally about transfusions and their role and their actual benefit.” (ICU 4)

More evidence is required to support restrictive transfusion practice

“There is not a ton of evidence out there.” (ICU 1)

“There is more lack of evidence than evidence period.” (ICU 2)

Social/professional role and Identity*,+

I don’t adhere to any guidelines

“I don’t specifically use those guidelines.” (ICU 8)

I refer to evidence to guide my practice

“…you might as well go right to the source of the studies instead of somebody else’s interpretation of them.” (ICU 10)

“…so you know the major studies that have been out since I trained, you know ten years ago, those would be the main things that I would use.” (ICU 6)

Watching and waiting is part of my professional standard

“…if I was transfusing every patient…my colleague would say what are you doing? So yea, there are standards of care…” (ICU 8)

“…in our group we tend to practice in a similar fashion.” (ICU 6)

I don’t feel constrained by guidelines as long as I have a good reason

“…I think the guidelines are there as a guidelines, but I don’t feel constrained by them…” (ICU 4)

“It’s one of the things where if you go outside the parameters you have to explain yourself as to why you are doing it” (ICU 8)

Guidelines are important for other professionals not me

“The guidelines are excellent for people who do not deal with this clinical question a lot” (ICU 1)

Guidelines do not affect my professional autonomy

Clinical judgment and experience is superior to guidelines and protocols

Beliefs about capabilities*,+

I am confident that the ICU team can manage by watching and waiting

“…if it is a borderline case and nothing significantly changes probably I can trust my team to stick with the plan.” (ICU 3)

“Very confident, they are excellent here.” (ICU 6)

I am confident provided that the patient is stable and in the ICU

“Depending on the situation, if the patient is stable it’s not hard; if they are unstable it is very difficult.” (ICU 2)

“Sometimes the problem is when they are going to another care unit…when they go out of the ICU they get a blood transfusion.” (ICU 7)

I am in complete control

“There are a few ICU physicians, they decide what patients get transfused in the ICU, full stop, nobody else decide.” (ICU 8)

I am confident to watch and wait

“You know I am very comfortable, I don’t have any problems…”(ICU 7)

I am confident most of the time

Beliefs about consequences*,+

Benefits of watching & waiting:

Patients do better in general

“It benefits what I am doing to help patients in general…the greater good of management of patients as a whole.” (ICU 9)

“…there is accumulating data that shows patients do better if you minimize the amount of blood that they get.” (ICU 1)

Reduce infection and harms

“The benefits are you are avoiding the risks of blood transfusion for the patients, so infection all the long list of complications for blood transfusion.” (ICU 3)

It reduces cost and saves resources

“Increased availability of blood for other people that need it.” (ICU 5)

“not to expose the person to the downsides of giving blood and to save money by not giving it.” (ICU 10)

Disadvantages:

Patient’s condition can deteriorate

“…your reserve is significantly less…risks for you are higher if something bad happens to you.” (ICU 2)

“There could be potential organ compromises.” (ICU 6)

It is more work

“It is usually more work. It is a hell of a lot easier to just write the order…” (ICU 1)

Motivation and goals*

It is important to watch and wait

“I think it is important. Very important.” (ICU 5)

“We feel very strongly about it.” (ICU 8)

Not as important as other things

“.so yes important, but it is certainly not as important as a lot of other things we do.” (ICU 1)

It conflicts with other goals

“In the Rivers protocol…they give blood to keep the hematocrit above 30, which is more than the TRICC trial would suggest. So there may be trouble where there is conflicting suggestions of how to manage the person.” (ICU 10)

“If they are going to the OR…I probably would transfuse them before they go.” (ICU 5)

It is generally compatible to the goals

“Most of the time I think it is not incompatible with other strategies.” (ICU 6)

Social influences*,+

Colleagues are uncomfortable to watch and wait

“…members of the healthcare team who don’t really understand what you are trying to do and are feeling a bit more uneasy, or a little more anxious.” (ICU 1)

Other professionals do not influence me

“…I don’t think they [other team members] influence me because I’ve been in that situation before and it hasn’t really affected my decision” (ICU 3)

Other professionals do influence me

“…the cardiologist will in my hospital, (they) would like to have a higher threshold…So they are going to influence me.” (ICU 7)

Team working: there are very little disagreement

“…in our group we tend to practice in a similar fashion…we try to make decisions that are consistent with the general way that we manage things.” (ICU 6)

Patients and family issue influence my practice (Jehovah)

“…the patients, like if they were Jehovah Witness or something like that, that would probably encourage [watching and waiting]” (ICU 5)

Behavioural regulation*,+

Alternatives to transfusion

“Well the alternatives are trying to improve the red cell production, so optimizing nutritional support, vitamin levels and iron and the other way is about EPO…but it doesn’t seem to have any other outcome benefit thus far…there isn’t all of data to support that practice…” (ICU 9)

“I would like to see us take less blood for blood gases and things and prevent iatrogenic anaemia” (ICU 1)

Protocols/Guidelines/Standard of practice

“If [a policy or protocol] was distributed widely and accepted by the group and reviewed” (ICU 6)

Processes to educate health care team

“By emphasizing the issues that are surrounding transfusions and educating residents and house staff they are much more rational in [their] use” (ICU 4)

Increase team communication

“I think for the most part, if communication is at a high level, like team communication is at a high level and we will make plans, then we will likely stick to that plan, until the person in charge of the team agrees to a change.” (ICU 3)

Strong evidence to change practice

“Maybe if there is a big study that is telling me that it is worse to do the kind of practice I am doing, I might wait for another study, but maybe it will influence me to change my practice” (ICU 7)

Audit and feedback

“…we took a look at nursing practices around some things, and when they were given their own data, they definitely changed some of the nursing stuff, but we do not do that as a matter of routine. Maybe we should.” (ICU 1)

Domains judged as not relevant in Canadian and UK study

Skills

Skills needed to watch and wait is not difficult

“It is usually fairly easy I think.” (ICU 6)

“…it is not difficult just to observe and wait.” (ICU 7)

Mainly clinical skills are needed

“I don’t know if there is any specific skill just an awareness of what the possible consequences… I don’t know about the procedural skills, I don’t think there is anything.” (ICU 6)

“Just check the haemoglobin and make sure that they are not bleeding and just watch…Doctor and nursing skills.” (ICU 3)

Memory, attention and decision processes

Patient and clinical factors influence my decision

“I think that first and foremost is their age and their co-morbidities and their functional capacity…” (ICU 4)

Judgment and experience influence my decision

“Your experience, it plays a big role and every patient is different…” (ICU 9)

“…if you have any inkling that things are not going well with your haemoglobin of 75 then you should transfuse.” (ICU 2)

It is an easy decision

“I think it is one of the easier decisions to make actually in the ICU.” (ICU 8)

I usually watch and wait

“That is my default, currently that is the way I practice.” (ICU 4)

Need to pay attention to patient’s changing clinical condition and be able to react quickly

Environmental context and resources

Blood supply and blood quality issues

“Getting the blood from the blood bank can be an issue here.” (ICU 6)

Environmental issues do not influence my practice

“If it’s busy, it doesn’t influence [me].” (ICU 4)

Staffing issues

“Because of the turnover, particularly with house staff, that it often gets forgotten.” (ICU 4)

“The nurses are stretched…the nurses will tell you a million times that they can’t watch Mr. Jones as closely.” (ICU 1)

Changes in patient’s clinical status or haemoglobin trends will influence whether I watch and wait

The patient’s co-morbidities or pre-existing condition will influence whether or not I watch and wait.

Emotion

Emotion is not an issue

“Not really no” (ICU 5)

Watching and waiting is not stressful

“I think on an overall scale it is low stress compared to the other things that we do.” (ICU 9)

I might be concerned in some situations about watching and waiting

Nature of the behaviour

Frequently come across patients with borderline haemoglobin

“It comes up in somebody almost every day.” (ICU 1)

Using less blood and lower haemoglobin triggers

“We don’t transfuse now until a lower trigger, than we used to.” (ICU 10)

Education and learning