TABLE 3.

Illustrative Quotations of Barriers and Facilitators in Deimplementation

Domain/Theme	Quote
Barriers
Outer setting: Perception of parental preference	Nurse: “I think that, if it was a parent that has already had numerous of their children in the hospital, like within one family for similar things and they’re used to that level of care, then they might be a little bit apprehensive and questioning as to why you weren’t providing the same level of monitoring.” Site PI: “Sometimes it’s challenging to get parents to let go of the pulse ox. Especially if that child is housed in a unit where other patients are getting continuous pulse ox.”
Inner setting: Pathways to discontinuation	Physician: “I think once it’s started, like you said, we need a weaning protocol. There isn’t always a clear protocol. Yes, we know when to stop the oxygen, but we don’t necessarily think to stop the pulse ox.” Physician: “If the order set is continuous pulse oximetry and in parentheses it says while on oxygen. That may be interpreted as, the order never gets discontinued because it technically has, like, an ‘If this happens, then you do this.’”
Inner setting: Educating staff	Nurse: “It got really good for a while, but we get new residents every year, and so I don’t feel like it gets pushed again. It got good, and then every month they change over as well.” Site PI: “The nurses are crucial to the success of this, and so there’s so many nurses and so many shifts that I think it’s really hard to educate nurses at all levels at all times.”
Inner setting: Culture of monitoring	Administrator: “So a nurse can be a part of a four- or sometimes five-patient assignment, two of which are getting chemotherapy, and so they want all of the safeguards they can have, which they interpret that as sometimes having continuous pulse ox.” Site PI: “We’re doing our job if we have a fancy monitor hooked up and we’re recording all this stuff. That, again, is a cultural thing that I think is going to have to be removed or taken away.”
Characteristics of individuals: Clinician discomfort	Nurse: “Sometimes it benefits you to have the baby on pulse ox. You can keep a good eye on them, and then you can judge when they need to be suctioned.” Respiratory therapist: “I would expect to see people resistant to change, to start. Nobody likes change to start off with, and the continuous pulse ox is viewed as a safety net. And so, taking away that safety net will be a challenge.”
Facilitators
Outer setting	Administrator: “So I think that’s going to be information that is driven by data and nursing tend to like the specifics and data and numbers like that. I think that they would also buy in from the American Academy of Pediatrics… Obviously that’s a very reputable organization that they will trust, and so it would help with their buy-in. But if we tell the staff there’s evidence to suggest that this new way is better for patients, they want to do what’s best for their patients, so they’re going to understand, and that will help tremendously.” Administrator: “I mean we do have this, we have guidelines, but if there was a huge intervention that was kind of national, yeah, I think that adds a lot of credibility.”
Inner setting: Leadership	Physician: “Yeah, I really think that our, you know, our—the nurse educator and the nurse manager would be great facilitators for change to happen.” Site PI: “At the same time, you do have to have, I think, physician champions or nurse champions, particularly people that are seasoned and more well respected, so getting some of those folks.”
Inner setting: EHR	Administrator: “Changing the order set so that there isn’t even a box that can be checked for it.” Site PI: “Now, the order 2 years ago used to say to ‘monitor pulse oximetry continuously,’ and period, that was the end of the order. Couple of years ago, we change that order to say, ‘Monitor while they’re on oxygen,’ and then once they’re off of oxygen, or move to O2 sat monitoring.”
Intervention characteristics/inner setting: Guidelines	Nurse: “They haven’t really made any policies or procedures quite yet on exactly what kids need to be monitored and what kids don’t, but more of just an FYI, newsletter, flier thing. ‘Hey, rethink this.’ ‘Think about this.’” Site PI: “I think creating an evidence-based policy. Making sure that the entire staff has higher education on that policy.”

Abbreviations: EHR, electronic health record; PI, principal investigator; pulse ox, pulse oximetry; sat, saturation.