Table 7.

Identified domains and quotes from included studies

Factor	Illustrative quotes
System
Environmental context	Workload: “The difficulty is not actually doing the observation, it’s …having the time to go and write it down, and then talk to somebody about it” (Ward co-ordinator) [27] Availability: “It’s not always easy depending on the staffing levels on the ward. Obviously, if you’ve got a lot off sick or on annual leave or whatever, the numbers are short, it’s not always possible….”(Ward co-ordinator) [27] Burden falls on small number of staff: “I tried to leave [POS] questionnaires for people in the diary and it just didn’t work. I actually came in [on days off] to do it, because I rang up to see if anyone had bothered and they hadn’t” [31] Need for institution level support: “There needs to be explicit support from the institution that spending time on these issues is time well spent. That it’s valued and supported, … and that it is a priority (Psychiatrist)” [6] Physical space: “There are too many people for too little space, especially for people who are only going to watch.” [41] Workflow systems: “[We] need to address the hospital management so that they can revise the system of allocating…who is the responsible team even on the weekend. (Physician)” [5] IT: “(we need the)…ability to track referrals and see whether the patient actually saw the psycho-oncologist because it doesn’t always happen…and to have that in some sort of standardized, accessible way, ideally as part of the medical record.” (Medical oncologist) [6] System level: “support should be at the system level in terms of how it’s integrated, in routine documentation, in IT systems and in quality review.” (Nurse clinician-researcher) [6]
Culture	Attitude toward change: “Sometimes it seems a very big mountain’; it’s going to take a while to change”(Focus Group) [37] System level commitment: “My coworkers are flexible and even double their workload so you can talk with the parents in peace, it’s considered such an important thing” [40] Role flexibility: “Doctors have their title and so they think that no one else knows anything. . . . They are going to be hostile [towards us]” [41] Staff role: “I don’t mind [having the role of ward coordinator]. I’m the infection control link nurse, so I see it as part of that role really, hand hygiene…” (Ward coordinator) [27] Champions: “I did find sometimes [as a consequence of delivering the intervention], people in groups was like against me [.. .] they try to find another problem of me and go talk to the manager regarding that... because I pick them up on their problem they’re going to talk to the manager” (Ward coordinator) [27]
Communication processes	Lack of interdepartmental communication: “Developing this program requires so much collaboration between so many different departments–I don’t know if it happens all the time or all that easily.… it’s tough to have a communication system between departments and across systems–e-mail and access to patient information is not always smooth” [67] Culture of open communication: “We have a new administration that promotes a very openness in communication, and is very quick to recognize systems problems and not people problems, so to speak” [44]
External requirements	“If you have no accreditation then you don’t get reimbursed and you don’t stay open.” [44] “So we wrote the policy to be a mandatory directive so that those people at the ground level had the topdown support. To be able to say we have been told we have to do this, so you (hospital management) need to support us” (Focus group) [37] “And if… you’ve got senior buy-in to say ‘this is an expectation of our cancer services… if you provide the support underneath that and the resourcing of the implementation to a certain degree, you’re kind of covering both ends” (Nurse) [6]
Staff
Staff commitment and attitudes	Attitude toward the intervention: “the cardiologists say they don’t need it, they know what to do with these patients” [45] Beliefs regarding need for intervention: “if we’re able to communicate the difference that this has the potential to make to women in their care, they’re far more likely to champion it…” [28] Motivation: “They may feel that they’re losing control or that they’re being forced to do something” [45] “I’m really very passionate about this [the intervention] that we’re doing, so I’m really striving to do it” (Ward coordinator) [27] Ownership:“…getting engagement with psychosocial services and the nursing staff… is really important because the bottom line is that at the end of the day they’re going to implement it” (Nurse) [6]
Understanding/awareness	“I still feel that there’s a view out there that it’s…a fanatical way of operating” (Focus Group) [37]
Role identity	“(there is) …a lack of clarity about who’s role it is, who the decision maker is… It’s not that uncommon that someone says ‘well that’s my role’ and everyone in the rest of the team goes ‘is it?’” (Nurse) [6] “I think it’s everybody’s responsibility you know. . .Just getting everybody involved rather than a few motivated members of the team who are interested in it” (Nurse) [47]
Skills, ability, confidence	Confidence: “I do not have the confidence to work with a doctor.” (Traditional Midwife) [41] Skill: “I felt that if I disturbed something while I was talking to them, I don’t have the psychological back up for them” [31]. Patient-related barriers: “some of the patients are so very rude. Angry and rude. You won’t even be able to approach the to ask them questions” [35] Time management: “I’ve felt stressed in terms of, I’ve got to get it done and, you know, the clock’s ticking and I’ve got other things to do” (Ward coordinator) [27] Competing demands: “Social workers have too many clients to add positive prevention to their caseloads. The workload was unmanageable” [32]
Intervention
Ease of integration	Multiple stages of intervention: “me in the unit telling them “there’s a counselor that you have to come and see tomorrow”, there’s no way he’s coming back” [35] Simplicity: “Just looking at the ten steps... it is achievable” [37] Resources and workload: “We were getting a large number of phone calls…and it was easier, frankly, to do what we’ve been doing …and not have to put up with numerous calls” [45] “It became time consuming, with the end result being the same” [45] Suitability and fit“. . . it’s a part of your routine already so I don’t find it difficult, it’s just finding ways of how to do it, I mean it’s not too difficult” [49] Acceptability to staff: “Clinical pathways are used in lots of different areas and the ease at which it is to implement these things is a challenge and… (there is a) degree of fatigue around different things that get implemented… particularly once you get down to department level” (Nurse) [6] Fit for patient populations: “we focus a great deal on changing clinicians’ expectations and skills, but I don’t think we’ve even tackled too closely an understanding of what’s needed in order to make services more acceptable to patients.” (Psychiatrist) [6]
Face validity/evidence base	Evidence: “I feel there has to be overwhelming evidence of the benefits in using it and also some kind of reassurance in the evidence that using the i.v. component wasn’t going to have a negative impact in terms of development of resistance” [49] Awareness: “I think there is certainly plenty of evidence there that some of us should be looking at and I think the big problem is . .not everybody has fully appraised the papers” [49]
Safety/legal/ethical concerns	Safety: “Sometimes I feel a little bit worried that, have I given them the right advice. . . the right advice I should be giving them” (Allied Health professional) [47] Responsibility: “I would not have so much responsibility. Any complications would be the responsibility of the doctor”(Traditional midwife) [41] Ethics: “I don’t like having my name attached to it in some way by endorsing it. By giving it to the patient I’m endorsing its content …. That makes me feel uncomfortable” [53] Liability: “I think that is a part of our culture, when people feel very protective and somewhat defensive because they are concerned about sitting on a witness stand, or being sued, or having some risk” [44]
Supportive components	Training: “We are getting new doctors especially interns every time. Updating when new information arises or when changing protocols happens is very important for proper care of patients. (Nurse)” [5] Repetition: “It’s not just the education getting them past the bad habits, you have to keep going back and back and repeating and then they get into a rhythm . . . they need constant reinforcement” [44] Professional support: “We don’t receive clinical supervision at all and when you call them after months and try to recollect the child’s death… it would give me strength to provide more phone calls and to invest in this program” [40] Audit and feedback: “Anytime you’re monitoring something, compliance is better . . . everyone is willing to change…it’s just a habit and habits are hard to break” [44] Evidence of outcomes: “Someone needs to show that this will actually lead to not necessarily a substantial increase in referrals to the high end of the services, but actually a better utilization of those resources.” (Nurse) [6] End user involvement:“…people need to feel that this is an important priority, that they’re involved in shaping it, localizing it, customizing it, that it reflects what they can do and achieve, that they’re supported in it”(Psychiatrist) [6]