Themes	Frequency (n HCPs)	Example quotations
Awareness of risk / safety
Risks mitigated by safe transfusion practices	12	‘…it's all quite safe, erm, in terms of, em, getting the right blood product for the patient, cause it's different steps in safeguarding steps to do that’ (HCP 10, Senior House Office, Site 2)
Risks and benefits established with patients	9	‘so you just try to reassure it's a rarity, for you to obviously get anything from transfusion, and erm, reactions is the one that commonly comes up as well, they worry about reacting to, cause, ‘does it have any side effects?’ is the common question I get asked’ (HCP 8, Nurse, Site 2)
Iron overload considered a key risk	7	‘the downside is if they continue to have lots and lots and lots of blood transfusions they will become / have high iron levels … so then you have the problem of the liver being affected because high ferritin, so that's the downside of it’ (HCP 2, Nurse, Site 1)
Infections, antibodies and reactions risks	7	‘um, long‐term wise I think it is probably not good for them because the more you get transfusion, the more becomes/ they develop the risk of having antibodies, er, and that can be very bad for them in the long run because you are/ every time we cross‐match their blood products, it becomes rarer and rarer’ (HCP 9, Senior Charge Nurse, Site 2)
Short and long term medical and psychological impact	6	‘they're also concerned about getting addicted to blood transfusions’ (HCP 12, Clinical Psychologist, Site 2)
Risk of not providing a transfusion	5	‘they've got Leukaemia or MDS (Myelodysplasia Syndromes) and they just, and they know that this is all you can do, they just need to have their transfusion every how ever many weeks, and if you're not providing a chair for them, then they could end up on our medical assessment unit’ (HCP 2, Nurse, Site 1)
Health benefits
Symptom improvement, making patients feel better	11	‘Yeah, so largely it erm, taking away the tiredness and lethargy, which is, er, a symptom of patients that are anaemic, er, and for some of them improving their symptoms of shortness of breath on exertion’ (HCP 7, Specialist Registrar, Site 1)
Supportive care to carry on with normal daily living	10	‘it's about trying to give them a quality of life, so trying to work out what's the best, you know, what's the best, amount of blood to give them if you like’ (HCP 2, Nurse, Site 1)
Benefits last a limited time only	8	‘… it's really tricky to say to that person, or to their relatives ‘right, we don't think you're benefitting from blood anymore’ because they know if they don't have the blood they will die’ (HCP 3, Specialty doctor (Haematology), Site 1)
Shared HCP agreement of transfusion benefits	5	‘yeah I think generally we all share the same view that actually it's benefiting the patient’ (HCP 9, Senior Charge Nurse, Site 2)
Patient questioned on benefits to provide / continue transfusions	5	‘…when we see them in clinic or when we see them in the day unit, um, and if we find they're having symptomatic benefit from it, you know then we carry on with it’ (HCP 3, Specialty doctor, Site 1)
Some risk‐benefit for patients questionable	3	‘I think quite, some of my patients who've maybe only got a slight anaemia, sort of eight to nine, haven't felt any better on transfusions, I think they'd rather have the slightly low count, so I think it really depends how low their haemoglobin goes’ (HCP 13, Consultant Haematologist, Site 2)
Necessity
Transfusions support chemotherapy or used to treat anaemia	12	‘as I've said, it's the only way, with a lot of these people, it's the only thing that's keeping them alive, or it's the thing that's allowing them to have treatment, that's hopefully going to keep them alive’ (HCP 8, Nurse, Site 2)
Transfusions are vital, aiding survival	10	‘it is palliative technically, it is because we are keeping them alive cause if we didn't transfuse them, they will die’ (HCP 5, Consultant Haematologist, Site 1)
Transfusions given to protect health	8	‘if somebody has got a really low haemoglobin, they need the blood, cause obviously they're struggling, sometimes they're breathless, it puts a strain on the heart’ (HCP 4, Transfusion Practitioner, Site 1)
Necessity established using clinical and patient factors	8	‘it (frequency of the transfusions) depends on their haemoglobin, the clinical symptoms, and the data, I mean, the blood results’ (HCP 11, Haematology Specialist Nurse, Site 2)
Patients rely on and express need for transfusion	5	‘but other patients are so fixated by it, and it is keeping them going, that I think sometime it's, I think, they really rely on it’ (HCP 1, Haematology Specialist Nurse, Site 1)
Negative emotions
Patients’ unexpressed potential negative emotions	12	‘Erm, I'm not quite sure though, how they exactly feel about their specific transfusion going in at the time, whether they're anxious, or? whether they feel happy, or? I dunno’ (HCP 10, Senior House Office, Site 2)
Patient anxiety and upset with receiving regular transfusions	10	‘they do get really worried if they come in and their haemoglobin's low, they immediately start thinking something bad's happening or worrying that they're going to have to start coming in every week’ (HCP 8, Nurse, Site 2)
Concern about downsides of transfusions for patients	10	‘it is worrying, I mean people, if they've got cardiac problems, they can get chest pain, just really really unwell’ (HCP 2, Nurse, Site 1)
Practice concerns and frustrations	9	‘I do worry here that we don't have enough capacity to get patients who are becoming acutely unwell and there isn't a space for them, and that really frightens me’ (HCP 4, Transfusion Practitioner, Site 1)
HCPs’ strategies to reduce patient anxiety	6	‘[transfusion] is not treating the underlying cause and therefore their transfusion requirement will go up and at some point, we will stop. Because we warn them early that that's gonna happen; when that does happen they're less shocked’ (HCP 7, Specialist Registrar, Site 1)
Patients perceiving transfusion positively, as a lifeline	5	‘I think people tend to be positive about it cause I think they get the fact that, you know, this is, this is all we've got for you, but actually it does work, you know’ (HCP 3, Specialty doctor, Site 1)
Upset in witnessing patients’ worsening health or death	3	‘yeah, it's quite distressing, it's quite distressing, especially when you've known somebody for a number of years and then it gets to that point, you do sort of kind of think ‘oh why are they coming in’’ (HCP 5, Consultant Haematologist, Site 1)
Alternatives
Alternatives considered or already in use	10	‘most of these patients that are on such regular transfusion programmes are on EPO (erythropoietin) are on iron, are on all the other kind of alternatives to blood that they can be on and despite that are still requiring a blood transfusion’ (HCP 10, Senior House Office, Site 2)
No alternatives, transfusion only option	7	‘I think as clinicians, people always weight that up and I think it's very difficult because I think there genuinely isn't an alternative … I just think there really isn't an alternative unfortunately’ (HCP 4, Transfusion Practitioner, Site 1)
Support for greater consideration and use of alternatives	6	‘in terms of the patients who require regular top up transfusions, it doesn't seem like there's much research done into alternative therapies and things and so we just readily assume ‘oh we'll do bloods’ as that's all we know, that's all we're readily exposed to’ (HCP 9, Senior Charge Nurse, Site 2)
Committed to giving regular transfusions once started	3	‘So once you get someone in to having transfusion, you can't, if you could/ you switch the on switch, but you can't flick it off again and it usually ends up with that person being admitted to the main hospital with some infection…’ (HCP 2, Nurse, Site 1)
Involvement in decision making
HCPs advocate and involve patients in decisions	13	‘… other patients want to take control of it and not be told what to do, so you have to be, erm, I think you have to be flexible about that’ (HCP 7, Specialist Registrar, Site 1)
Team decision on transfusion prescription	13	‘the nursing staff had reviewed the bloods and felt that they needed a blood transfusion, but then also/ ultimately the decision is with, um, with the doctor’ (HCP 1, Haematology Specialist Nurse, Site 1)
Patient autonomy in their own transfusion decisions	11	‘I think he/she pushes it quite far, so he/she might avoid coming out for a transfusion to see if his/her haemoglobin gets better’ (HCP 3, Specialty doctor, Site 1)
Individual transfusion regime for each patient	11	‘we try and individualise transfusion practice per patient, so if you have a patient whose haemoglobin drops down to below, I don't know, 70, on every two weeks, that's how often you give them their blood, so it is individualised’ (HCP 5, Consultant Haematologist, Site 1)
Transfusions prescribed appropriately using guidelines	12	‘to actually have something like that to say ‘well I am following NICE guidance, therefore, I've got this huge! weight of evidence behind me, so I feel confident to make that decision'‘ (HCP 4, Transfusion Practitioner, Site 1)
Deferral of decision making to HCPs	6	‘I think a lot of patients rightly so place their trust in the medical team, the nurses and the doctors, so if somebody said they need a transfusion, I think it's very few and far between patients that say no’ (HCP 14, Specialist Registrar, Site 2)
Barriers to discussing transfusion or obtaining consent	5	‘it is not always possible (obtaining and documenting verbal consent), especially in patients who are either unable to give consent or, you know, patients who are not in a state, because of the physical condition to give consent’ (HCP 3, Specialty doctor, Site 1)
Tendency towards providing transfusion	4	‘if they're very symptomatic with it, and even if the level is slightly off the baseline but they're very symptomatic then we like to give it’ (HCP 10, Senior House Office, Site 2)
Burden
Anticipated attendance burden for patients	11	‘if they're really regular I suppose it's the fact they're having blood test and they're here, and they're seeing the doctors, and you do, it must be quite hard, patients must feel they're like here all the time almost’ (HCP 1, Haematology Specialist Nurse, Site 1)
Transfusion's become a part of patient's routine life	7	‘I think for some, it's just like a way of life for them, em, it's just something that they do and they know other patients who are on a similar sort of path and then they're quite pally with them…’ (HCP 9, Senior Charge Nurse, Site 2)
Organisational factors
Solutions needed to improve processes and ease capacity strain	7	‘… we're trying to organise transfusions, at short notice, for our patients at short notice on the day unit and ˆ they've got no capacity to deliver the transfusion’ (HCP 6, Consultant Haematologist, Site 1)
Constraints to greater discussion of patients’ views	6	‘there's only one of you, and seven patients, it's not always easy to sit with the patient, discuss any concerns or issues or just have a general conversation’ (HCP 8, Nurse, Site 2)
Solutions needed to enhance communication	6	‘I think there's the other side about educating staff as well about blood transfusion, you know, and how to define risks and you know, encouraging them to discuss with the patients’ (HCP 2, Nurse, Site 1)
High and costly blood use for hospital	6	‘I mean blood transfusion can work, but, um, it is quite a bit more costly both for the hospital and for the patient's time’ (HCP 12, Clinical Psychologist, Site 2)
Complicated management of transfusion slots	5	‘so they send me a letter or an e‐mail or something saying ‘this person is going to need blood product support and then we're like ‘well, where are we gonna put them in then?’ (HCP 3, Specialty Doctor, Site 1)
Stability and variability of transfusion perceptions
Views consistent and similar to colleagues	7	‘I think there's a general agreement about the use of transfusions for this patient group… yeah, I'd say we pretty much all have the same view’ (HCP 10, Senior House Office, Site 2)
Views broadened through haematology exposure	7	‘before blood transfusions were a one‐off sort of thing … since being here, it's actual haematology conditions that require regular blood transfusions, so I see a different side now, and I see, erm how reliant people are on them’ (HCP 5, Consultant Haematologist, Site 1)
Patients’ transfusion perceptions variable	2	‘I think it's very variable, I don't think there's like one general consensus across the patients definitely’ (HCP 14, Specialist Registrar, Site 2)
Supportive relationships
HCPs approachable and bond with patients	5	‘… one of our regulars died in, in the week on the ward, and it's upsetting because you know, we get to know them so well and all about them, they talk to you a lot and erm, and it gets quite personal’ (HCP 3, Specialty Doctor, Site 1)
Efforts to increase patient comfort in unit	4	‘they are often coming in with someone, erm, that you know, they bring someone with them … just to ensure that they've got relatives, or they've got people involved’ (HCP 8, Nurse, Site 2)