Table 10.

Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for Domains 9,10, 11,12,13 (Beliefs About Consequences, Reinforcement, Optimism, Intention, Social Influences)

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Implementation Strategies from Participants
Domain.9 (Belief about consequences) Adverse health outcomes due to COPD guidelines adherence in ED	2	P7. Pharmacist: -“We get referrals where we can’t necessarily see everyone, so we’ve got to decide who the highest risk is and who we’re going to see. You can’t take up an Emergency bed to wait for a Pharmacist to arrive” P1. Physio.1:- “I would suspect if they will follow up with their GP within 24 to 48 hours to make sure that they are not deteriorating and I suspect that they are routinely followed up within the Respiratory team as well in the Outpatients Clinic in	Motivation Reflective	Education Environmental restructuring	Refer or arrange community pharmacist review (P7) Direct referrals to respiratory outpatient clinic for interdisciplinary input (smoking cessation, pulmonary rehabilitation, inhaler technique education) (P1, P7)
Domain.10 (Reinforcement) Reinforcing Clinician and interdisciplinary staff knowledge utilization and resource provision will improve guideline adherence	3	P1. Physio.1: -“COPD primary core practice nurse coming in and doing In-services and education training, easily accessible information, tool kits that are available on the Intranet”. P2. Physio.2:-“Providing information on who to refer to, how to refer to them, having someone based in the Department would be awesome, because that would break down the barrier of not being able to find them or they work ‘these’ hours and you don’t know where they are” P3. Nurse.1: - “Inhaler technique, we don’t give education to carers and family members who might be helping them at home, using their inhalers so that’s a huge barrier” P1. Physio.1- “consultants within ED or staff who are here more on the longer term could be involved in projects about COPD so that they are championing the cause”	Motivation Automatic	Education coercion	Education/in-service by ED and Thoracic respiratory department to increase utilisation (P1) Automatic referrals and documentation of the same during clinical care (P2) Pharmacy department to initiate inhaler technique educational sessions for staff (P3, P7) Automatic referrals to community for allied health input (P1, P7,P8)
Domain.11 (Optimism) Clinician and interdisciplinary staff attitude about COPD guideline adherence	3	P1. Physio.1: -“It might be possible with education awareness and perhaps – I know that there is a respiratory resource nurse or, someone like that who can be aware of the COPD patients coming to the hospital, coming through the ED and sort of making sure that these patients are getting those guidelines met” P4. Nurse.2: - -“There is a potential if patient getting discharged from ED to continue that multi-disciplinary care, exploring with the current network or service model. We’ve got an inpatient medical team with the multi-disciplinary support and how can that be expanded into the ED or community like hospital to home programme” P2. Physio.2:-“Community health staff provide antibiotics, nursing care and physiotherapy inputted into their care. So that will probably be the sort of expansion of the service that I can foresee happening. Would this also reduce inpatient admissions which would be more beneficial”	Motivation Reflective	Education Persuasion Enablement	Provide resources/guideline easily accessible for reference (P1) Improvise present systems and process based on staff opinion and less time consumption to complete (P4) Utilise Community health providers for referrals (P2)
Domain. 12 (Intention) Motivation and initiative to change and better care	2	P8. Doctor.2: - “As part of their discharge letter, there is an opportunity provide guidance to the Primary Care Physician about what should be done next” P6. Doctor.1: - “Communicating with the ward and saying “look we’re admitting this person or they need admission, but during this admission perhaps, we could focus on why they keep coming back frequently or what we can do that’s extra to what we’re doing?”	Motivation Reflective	Environmental restructuring Education	COPD discharge templates (P8) Direct referrals to ward or outpatient allied health for pulmonary rehabilitation (P1)
Domain. 13 (Social influences) Communication and suggestion of care might help	2	P3. Nurse.1:”Respiratory CNC won’t always come through Emergency and if it’s someone who’s going home, they’re probably seen as not that critical and I’m not sure how often they would be able to come or be willing to come down to Emergency” P6. Doctor.1:-“On our system we can flag frequent presenters so if it was used to streamline or communicate to the Respiratory Team then perhaps that could bring in some kind of intervention” P8. Doctor.2:- “Almost invariably, the last sentence to the GP is “can you please re-refer this patient to the Respiratory Outpatients for follow up”. This may or may not be done for the patient as it is not often followed up (p8)	Opportunity Social	Restriction Environmental restructuring Persuasion	Improve interdisciplinary communication using digital technology (P6) Reassuring staff with less time consuming referrals may lead to improve adherence (P7, P3, P8)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel; GP, general practitioner; CNC, clinical nurse consultant.