Lethal means counseling for suicide prevention: Views of emergency department clinicians

Abstract

Objective:

Lethal means safety – counseling and guidance about reducing access to home firearms and medications – is recommended for emergency department patients at risk of suicide. Decision aids are tools that can facilitate potentially difficult decisions by incorporating personal preferences and values. The present study evaluates clinician perceptions about the implementation and utility of “Lock to Live,” a lethal means safety decision aid.

Method:

One-on-one qualitative interviews were conducted with clinicians (n=15) at three large emergency departments. Interviewees were asked to evaluate the “Lock to Live” decision tool and its potential implementation and utilization in the emergency department. Interviews were recorded and transcribed. Data were coded via thematic analysis; two coders developed a shared codebook iteratively with high interrater reliability.

Results:

Perspectives on the tool fell into three domains: (1) patients (use with patients and families), (2) clinicians, and (3) emergency department system. Interviewees noted that the tool had numerous potential benefits but that its uptake and effectiveness would depend on clinicians’ perceptions on its utility, time constraints, and integration into workflow. Addressable concerns related to relationship to other resources, fit within emergency department workflow, and clarification about which emergency department clinician types should use the tool.

Conclusions:

“Lock to Live” represents a promising new tool for use in suicide prevention as an aid to lethal means counseling. This qualitative study provides insights into the importance of considering the clinical environment when designing and implementing interventions.

INTRODUCTION

A challenging area of emergency department (ED) care is the identification, assessment, and treatment of patients at risk of suicide; current care includes combinations of various clinical techniques, specialty personnel, and screening tools [1–3]. For patients identified at risk of suicide, lethal means counseling (LMC) – counseling about reducing access to home firearms and other potential methods of suicide – is recommended as a way to reduce access to available lethal means for suicide [4]. Despite this, LMC is not uniformly provided in EDs [5].

Patient decision aids are clinical tools that can supplement patient-clinician interactions by educating patients on the risks, benefits, and impacts of decisions and thereby helping them choose the best option for them [6–8]. Decision aids have been studied in varied clinical contexts with preference-sensitive treatment decisions and shown to improve patient outcomes, increase patient-clinician collaboration, and assist in shared decision-making [9,10]. As reported previously, we developed a web-based LMC decision aid tool (“Lock to Live”; http://lock2live.org/; L2L) to support suicidal adults in making informed decisions regarding home safety [11]. L2L was iteratively developed using feedback from over 50 interviews with stakeholders from various backgrounds, and a pilot randomized trial showed high patient acceptability and usability [12].

While these patient-level data suggest promise for L2L, potential implementation into routine ED will also depend on clinician and hospital factors. Here, we sought to solicit the perspectives of ED clinicians at the hospitals from the L2L trial, including physicians, nurses, and behavioral health evaluators. A better understanding of contextual factors that might affect L2L’s implementation and uptake will be critical for effective, efficient use.

METHODS

Study design and setting

Study participants were ED clinicians and associated staff from four EDs where the L2L pilot trial was conducted: an urban safety net hospital, a tertiary care academic center, and a regional medical center with 2 EDs in an area with firearm ownership rates that are higher than state averages. ED attending physicians, ED nurses, behavioral health evaluators (i.e., social workers, psychologists), and ED administrative staff were eligible for inclusion. As part of the L2L trial, clinicians were emailed a brief quantitative survey to assess various measures of tool acceptability, usability, and feedback [13]; the survey offered the option to complete a qualitative interview for an additional incentive of a $15 gift card. Additional interview respondents were recruited via direct email messages from research staff to ED clinicians who did not complete the survey. The survey helped provide a starting point from which to interview clinicians. We learned many ED clinicians, though confident, self-reported that they do not ask suicidal patients about lethal means and many felt additional training and protocols about how to help patients with decisions in this context would be helpful [13]. The qualitative interviews were part of our original mixed-methods design to allow a deeper-dive into provider views, especially concerning how the L2L might be integrated into ED workflow.

After informed consent, interviews with study participants were conducted either in-person or via phone by research staff (BS, EP) with training and experience in qualitative research methods. Interviews were conducted between May and November 2019 and lasted approximately 30 minutes each; they were based on a semi-structured interview guide developed prior to participant recruitment. The interview guide consisted of three distinct sections with open-ended questions. Participants were asked to provide feedback regarding personal decision-making processes in the ED, insights on the tool in general, and how to best implement the tool into clinical practice. The study protocol was approved by the Colorado Multiple Institutional Review Board (COMIRB).

Analysis

Interview data were professionally transcribed using a third-party service. Cleaned transcripts were uploaded into Dedoose (v8.3.17), a secured qualitative analysis platform (SocioCultural Research Consultants, Los Angeles, CA). Data were analyzed following a mixed deductive and inductive approach [14], modelled after that used previously by members of the team.[15] The approach was informed by theory and also allowed for themes to emerge organically from the text. Two members of the research team (BS, EP) reviewed all transcripts and developed a prototype codebook for initial coding. Coders independently coded a sample of transcripts to further refine an initial codebook, using thematic analysis.[16] Coders met with other members of the study team to deliberate, discuss, and refine the codebook, resolving disagreements in code generation, application, or interpretation. These study team meetings allowed for iterative versions of the codebook to be further refined over time as more transcripts were coded. The study team consisted of physicians and social scientists from a variety of backgrounds (anthropology, emergency medicine, decision science, social work, sociology, suicidology), allowing for a breadth of perspectives to assist in interpreting themes, codes, and findings within the data. We followed recommended COREQ guidelines for reporting qualitative research [17]. A final codebook was generated and used for the remaining transcripts, yielding 100% code saturation. Utilizing a theme analysis, codes were grouped into cognitively salient domains based upon thematic similarity and cohesion.

RESULTS

Interviews were completed with 15 participants from three emergency departments: 5 (33%) physicians, 5 (33%) behavioral health evaluators (all social workers), 4 (27%) nurses, and 1 ED administrative staffer (7%); 10 (66%) participants were women. Three (20%) of participants were from an urban safety net county hospital, 8 (53%) were from an urban academic center, and 4 (27%) were from a regional center in a different city. Interviews yielded 155 pages of transcripts for analysis. Qualitative analyses revealed that themes surrounding the implementation of the L2L tool clustered in three domains: (1) patients/families, (2) clinicians, and (3) the ED system (Table 1). Within these themes, participants shared both broad and specific perceived barriers as well as potential solutions (Table 2). We explore further the concerns that need be addressed and how implementation can be successful in the discussion. Consideration of the factors within and across domains is useful in informing use of current and future lethal means counseling tools in ED settings.

Table 1:

Sample Quotes across Three Domains

	Emergent themes	Sample quotes
Patients/Families	• Patient-centered education • Encourages agency • Supports family involvement • Augments (doesn’t replace) existing process • Questions about integration and awareness	“a lot of times family members or a loved one feel extremely helpless when they’re watching somebody who is suicidal or severely depressed and suicidal. They don’t know what to do. By giving them a task such as making sure the home is safe by removing guns or anything that can harm them, medications or sharp objects, that gives them, it makes them feel like their actually helping the person because they don’t know how to help them any other way.”
Clinician	• Questions about when and how to use, whose responsibility • Concerns about time constraints and redundancy • Need for training (tailored to clinician responsibilities)	“I think the only barrier I could see is just making sure that we, especially here in the ED that we train all the multiple disciplines on it. So then that way they understand, so there isn’t this portion of folks who get this and there’s a portion of, ‘I don’t know what you’re talking about. What do you mean a lethal weapon?’ I think that’s the only barrier because at times the ED is a big, obviously, place and you have multiple, multiple teams and multiple people coming in and out. Staff rotating in and out, so I think just making sure that we train everyone on that will be helpful because then it’ll be kind of universal”.
ED system	• Need to integrate into ED workflow • Logistics of computer equipment and internet access • Delineation of clinician roles and recommended • timing for use	“[Issues] like where it’s stocked, how it gets charged, how it gets cleaned, who’s responsible for maintaining it, who’s responsible for troubleshooting it when we can’t get it to work. How to troubleshoot the Wi-Fi issues that invariably come up”.

Table 2:

Identified Barriers and Possible Solutions

Perceived barriers	Representative quotes	Possible solutions
Lack of knowledge / Provider uncertainty around LMC	“ ‘I don’t know what you’re talking about. What do you mean a lethal weapon?’ I think that’s the only barrier because at times the ED is a big, obviously, place and you have multiple, multiple teams and multiple people coming in and out. Staff rotating in and out, so I think just making sure that we train everyone on that will be helpful because then it’ll be kind of universal.” “And it would have to be turned into an actual protocol or pathway that physicians have to be, whether they agree with it or not, this is the best thing for the patient.”	– Training and demonstration on: the benefits of LMC strategies used in the tool – Systems-level policies to clarify which providers are responsible (and when) to provide LMC
Resistance from care providers	“…staff will definitely perceive things as, ‘Oh my gosh here’s one more thing,’ like one more charting thing that we have to do and we already don’t have enough time to like get the bare minimum done.”	– Present the positive outcomes of using the tool – show the data – Provide resources for providers to simplify LMC (e.g., prompts in electronic medical record)
Time / Integrating into busy EDs	“But I think if it were to be nurses helping with this it would be very difficult to actually like go through it with the patient, but maybe if there was a way for that patient to do it while they’re kind of waiting which there’s a lot of that happening then maybe that would be a possibility.” “But if you have patients able to access it asynchronously and can kick that off from somebody earlier in the visit, a physician, an APP, a nurse, and then have someone from behavior health team kind of take it home with talking about it after the patient or family member has had an opportunity to look at it. That in my mind would work well.”	Training and demonstration on: – Efficiency of tool – Giving patient tool to use while alone/ waiting in ED – Immediate use – not discharge paperwork Bridge conversations about suicide risk and home safety – easier to start these challenging necessary topics.
Redundancy / Need to distinguish from other interventions	“we have like all these required screen aids as nurses to ask our patients and I just don’t want this to be like another thing that gets bogged down. It’s like, ‘Okay here’s this other like questionnaire that I got to ask my patient on top of everything else.’ ”	Training and demonstration on: – How the tool is different than existing suicide screening efforts – Novelty of the decision aid

Domain 3: analysis and findings

Patients/Families

In considering L2L as a patient-facing tool, participating clinicians detailed ways it might help patients and others become more engaged in the LMC process. Foremost, interviewees noted that the tool allowed for patients and their families to become better educated on the issue of lethal means safety and access during times of risk, bridging knowledge gaps that might exist. This new educational material might be especially useful given the anecdotal evidence from clinicians expressing how patients in crisis are not typically thinking about home safety risks or may not be considering all potentially lethal means. One clinician stated that, “the friend or family member or accompanying person, or the patient themselves, might actually think about it. Not just firearms, right? But medications or whatever else. I think particularly with firearms, people may be pre-insightful”. Various interviewees noted that patients routinely do not think of this decision as one they have agency over, so introducing L2L could have positive impacts upon discharge. Remarking on this, one clinician shared how a patient, “did not yet realize that he had access to lethal means. But intervening at a point when somebody doesn’t even realize that risk is potentially really beneficial”.

Clinicians also responded positively to the tool based on its ability to include others (namely, family members) in the decision process. Clinicians emphasized that the tool’s use of family members as an additional support system closely mirrored existing practices, further enhancing standard safety planning procedures. One participant stated, “our standard is to try to speak with at least one person that’s in their lives” and that the tool was able to naturally link together this process of leveraging a patient’s social support network to improve home safety. Additional support for suicidal patients could result in someone to talk to during crisis, store potentially lethal means, and assist in other matters (such as routine check-ups and appointments, if necessary). One nurse explained that in the absence of these connections she felt like it was an issue of “do they have the support system to actually do it? Stash these things safely with another person”? Clinicians felt that the tool allows clinical staff to take the next step beyond identifying lethal means, and link resources they could use to safety reduce or remove lethal means access during times of crisis. One clinician expressed how “they call, they find people that are important in the patient’s life, family members, roommates, spouses” and that the tool provides “a perfect opportunity” to discuss additional resources and lethal means safety once the patient is discharged home.

Clinicians

Interviewees noted the tool’s ability to supplement existing ED materials used by clinicians. ED staff were keenly aware of the multitude of resources, pamphlets, and other outreach documents at their disposal. Rather than feel the tool was yet another layer to incorporate (and potentially disregard), clinicians felt that the novelty and utility of the tool justified its use in the ED. Clinicians felt that the current tool was a useful inclusion into clinical care due to its dedicated messaging on firearms access and storage options, and its potential immediate use in patient care (versus resources for after discharge). This was of benefit to the suicidal patients and families, who could have a better idea of what to do with their firearms at home. It was also beneficial to clinicians to feel more empowered when using the tool, providing them more resources to discuss lethal means with patients, as well as knowing that a patient at discharge could be more equipped to safely store or remove a firearm from the home.

At the same time, clinicians noted issues that might impede successful implementation of the tool. These included potential clinician resistance related to time constraints, redundancy, uncertainties about LMC and clinician responsibilities, and need for training.

Some clinicians expressed concern about how the tool would be integrated into high-paced EDs, where clinicians are often short on time. L2L is intended to augment lethal means counseling, which is typically provided by physicians or behavioral health consultants, but some participating nurses expressed concerns that they would be expected to use it. An interviewee expressed how “we have all these required screen aids as nurses to ask our patients and I just don’t want this to be another thing that gets bogged down. It’s like, ‘Okay here’s this other questionnaire that I got to ask my patient on top of everything else’”. Clinician concerns around time constraints highlight the importance of identifying which clinician types are responsible for various tasks, as discussed below, and of integrating tools into ED workflows. Generally, interviewees pointed towards behavioral health evaluators as the ones best positioned to implement the tool with patients. One participant noted that psychiatric nurses alongside behavioral health evaluators could be the best bet for using the tool, saying that “this is their jam”.

Other sources of clinician hesitations in L2L stemmed from beliefs that the tool does not distinguish itself from the suicide prevention interventions already in place. Clinicians noted that in addition to the initial nurse screening, they routinely address issues of suicide risk themselves. One respondent stated that, “Some staff are going to feel like this is somewhat redundant. ‘Aren’t we already covering this? Aren’t resources like this printed out in their discharge summary?’ Like, do we really need to go through this”? This issue of distinguishing the tool as new, novel, or of advantageous benefit would be important to achieve adoption and utilization. Importantly, however, these views varied by clinician type. Discussions with behavioral health evaluators found that the tool could be of great benefit in their workflow, which typically allows for more time with patients than is the case for physicians or nurses. One behavioral health evaluator explained how “I feel like that would be a good thing to work into their [social workers and behavioral health clinicians] workflow when they’re having their sit-down, intimate conversations with these patients”. The tool could complement the work of behavioral health evaluator teams assisting these suicidal patients, being used as a tool to bridge conversations about suicide risk and home safety.

We asked interviewees how they would go about resolving some of these issues and how they would best implement the tool into clinical care. Many found that creating and hosting training sessions would help clarify many of the current ambiguities about the tool, explaining how the tool is different than existing suicide screening efforts, time to use the tool, the benefits of LMC strategies used in the tool, and who/how the tool would be administered. Another suggested solution was a quick demonstration of the tool for clinical team members who wouldn’t be routinely assigned to administering the tool with patient. A brief, concise session like this was described by another interviewee who explained that, “I think the easiest thing for ED staff would be the quick-and-dirty – ‘How do I use this quickly? What are my talking points? What are the key things to say here or get across’?” Another clinician felt that presenting the positive outcomes of using the tool would be advantageous, explaining how, “there’s a lot of value in being able to say ‘We have had feedback that there have been people that have actually used what they went through in planning and it was really worth the while to do it’”. Whether through establishing clear information on how the tool is best used, who is most equipped to do so, or providing succinct timelines for its inclusion into their workflows, increased knowledge and hands-on experiences with ED tools could be beneficial in meeting clinician expectations.

ED System

Many of the systems-level concerns about L2L were practical concerns. Clinicians shared anticipated challenges but thought it was worthwhile if it could be done without bogging down current systems in place or ultimately disrupting workflow. One participant expressed that, “my knee-jerk worry is messing up flow. But as long as we have the time to actually do it and implement it, I think it could be really beneficial”. Others were concerned about the platform of the tool. The L2L tool was designed to be patient-facing and accessible by any internet browser (computer, tablet, mobile phone). While this design generally offers flexibility and accessibility, it becomes more complex in EDs. Clinicians were quick to note that suicidal patients often are not allowed to access their phones, meaning a clinical staff member would have to administer the tool with them. In the psychiatric section of one ED, a clinician noted that, “patients aren’t allowed to have their smartphones or a pen. They have to be stored in a locker…I guess we do have one computer on wheels, but I’m just wondering do we need to have an iPad for the purpose of this? Or do our nurses to get their own smartphones – then what are the logistics of going through it”? This results in a few other practical matters, such as who would pay for the tablets or computers required, and who would keep them updated, charged, functioning, and secure. Additional questions related to connecting to hospital WiFi, either via a secure network or guest access. One participant was concerned about the presence of a digital record, especially given the option to print out the tool’s results, and any resulting conflicts with privacy or compliance.

Interviewees also raised concerns regarding when during the ED care flow it would be best to introduce L2L. Clinicians thought the tool could have maximum efficiency and impact when used after initial intake (following initial suicide screening by a nurse or clinician), during much of the downtime that would exist as patients are under observation or awaiting behavioral health evaluator evaluation. A participant pinpointed how this time period “converts time that feels unproductive to patients into productive time and makes it more likely that they’re going to engage with it”. Conversely, as stated prior, others felt that priming the patient to utilize the tool at discharge – following an introduction and tutorial by a clinical staff member – would be the best allocation of time, making it present on their minds for when they return home.

DISCUSSION

EDs are a key clinical setting for the care of patients with acute suicide risk. Interventions for identification, assessment, and treatment are critical – but they must be both effective and feasible for use. Here, findings from qualitative interviews with a range of ED clinicians highlight opportunities and obstacles to implementing a novel patient-facing tool for lethal means counseling. Considering issues at the level of patients, clinicians, and ED systems can help with efforts for implementation and evaluation of these types of clinical tools. In addition, stepping back to look across levels highlights crucial concerns relevant for ED-.

First, clear guidance and useful resources for clinicians are critical for optimizing care of suicidal patients. This includes delineation of clinician responsibilities is important, including identifying the clinician type who is primarily responsible for providing counseling about reducing access to lethal means. At the same time, basic training about the core concepts of LMC could be important across clinician types, both to ensure that effective counselling is attempted and to maximize the opportunity for patients to have conversations with the specific clinicians with whom they are most comfortable. Findings from these interviews highlight just how important it was for not just patients, but also clinicians, to become more accustomed to the basic tenets of LMC. Beyond clinician training, system-level policies or guidelines are important to support lethal means counseling. A prior 8-state survey found that establishing and communicating policies and guidelines helped clinicians to feel confident in implementing new resources into the workflow [1]. These policies and guidelines will vary across EDs, given the heterogeneity in size, workforce, and availability of mental health specialists. Easily accessible online tools for clinicians may be especially useful for clinicians working in smaller or rural EDs; an example is the new ICAR2E tool, which facilitates overall suicide risk assessment by an ED clinician when a specialist is not available [18]. Tools like L2L might be added to ICAR2E and other guides20 to provide comprehensive resources for clinicians. The COVID-19 pandemic has further increased the urgency of development and implementation of flexible, multi-stakeholder tools available online or via telemedicine. Indeed, increased firearm sales and psychosocial stressors during COVID-19 have raised concern about impending increases in firearm suicide [19].

Second, tools intended for use in EDs need to be designed with the ED in mind [20]. While L2L could also be used at home or in other clinical or community settings, specific features of it were designed to facilitate ED use. L2L can be used by the patient alone, and then followed up with clinician-delivered LMC, so that L2L occupies the patient without an additional time burden for the clinician. Perceptions of clinicians held that adding into their workflow would increase their time commitment in an unsustainable way. With findings on decision aid usage, the time burden is seen to decrease with implementation of shared decision making resources [21]. This study included participants from three urban EDs in one state; even within this generally homogenous sample, there were variances in workflow and clinician interest. Developing clinical tools such as this requires a complete understanding of the context of care – who are the people that are going to be using the tool, who is the target audience, is there something already being utilized, what are some potential ED/hospital systems that might be hard to overcome? Addressing these questions early on (either in design, piloting, or implementation) can prove crucial to improving clinical care.

Taken together, both of these point towards a need to better understand how ED clinicians and clinical staff routinely interact with suicidal patients and how EDs can better optimize strategies to provide efficient, effective, patient-centered care [22]. Interviewees were quick to note the near-universal use of suicide risk screening of patients, in line with Joint Commission recommendations [23]. But our findings confirm prior work showing that LMC could still be further optimized; prior chart reviews show that a minority of suicidal adult patients have documentation of LMC [24]. Questions investigating the prevalence and availability of means can give clinicians more insight into what solutions to recommend [25,26]. Knowing more about the possible social connections a patient has can lead to discussions about moving lethal means out of the house for storage with a trusted individual or at a firearm range or law enforcement agency [27], and provision of locking devices might make clinicians and patients engage in LMC [28]. Many of these strategies can be leveraged with LMC and future efforts to incorporate them into clinical spaces need to be cognizant of the context in which they’re being implemented. Being aware of how LMC is operationalized in ED settings means being conscious of the responsibilities, roles, time commitments, and workflow of these clinical spaces.

Limitations

This study presents data from three local EDs and as such generalizability is limited. These EDs represent a relatively homogenous environment, in that all had 24/7 behavioral health evaluator presence. As such the trends observed – such as thoughts on workflow, LMC, and suicide risk screening – may not be immediately applicable to other settings. We also note that this represents a small sampling of ED clinicians and clinical staff. The heterogeneity of our sample, as related to provider role, makes it difficult to draw broad conclusions about how various providers might differ in their views on L2L. While we reached thematic saturation within this dataset, further insights are needed into clinical considerations when implementing new decision tools. We caution that future research observe emergency departments as their own unique settings, with different clinical workflows and nested within organizations and communities with varying practical pressures and sociocultural expectations, and to review the ways in which future decision aids or clinical tools might best be fit into those locales.

CONCLUSION

The “Lock to Live” tool shows great promise as another tool for use in emergency departments to address suicide prevention. As with any new tool, it becomes imperative to ensure that it reaches suicidal patients and that clinicians have the necessary insights required to administer the tool to the greatest extent. Interviews with a number of emergency department clinicians detailed various aspects of ED care that might influence the implementation of the L2L tool; these findings have implications for future clinical support tools as well. Understanding both the clinical context and audience of a given tool can better improve health outcomes when developing and implementing tools such as this decision aid.

Appendix. Appendix: Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist

Developed from:

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357

No. Item	Guide questions/description	Reported in section or described below
Domain 1: Research team and reflexivity
Personal Characteristics
1. Interviewer/facilitator	Which author/s conducted the interview or focus group?	Methods
2. Credentials	What were the researcher’s credentials? E.g. PhD, MD	Title page, Methods, Acknowledgements
3. Occupation	What was their occupation at the time of the study?	Methods
4. Gender	Was the researcher male or female?	Our team includes all
5. Experience and training	What experience or training did the researcher have?	Methods
Relationship with participants
6. Relationship established	Was a relationship established prior to study commencement?	One study author worked in one of the EDs but was not involved in interviews;
7. Participant knowledge of the interviewer	What did the participants know about the researcher? e.g. personal goals, reasons for doing the research	Participants knew interviewer’s role within the research team
8. Interviewer characteristics	What characteristics were reported about the inter viewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic	Methods
Domain 2: study design
Theoretical framework
9. Methodological orientation and Theory	What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis	Methods
Participant selection
10. Sampling	How were participants selected? e.g. purposive, convenience, consecutive, snowball	Methods
11. Method of approach	How were participants approached? e.g. face-toface, telephone, mail, email	Methods
12. Sample size	How many participants were in the study?	Results
13. Non-participation	How many people refused to participate or dropped out? Reasons?	Participants opted-in following a survey or were reached via snowball sampling, there were no optouts or drop-outs
Setting
14. Setting of data collection	Where was the data collected? e.g. home, clinic, workplace	Methods
15. Presence of non-participants	Was anyone else present besides the participants and researchers?	No one else was present for interviews
16. Description of sample	What are the important characteristics of the sample? e.g. demographic data, date	Results
Data collection
17. Interview guide	Were questions, prompts, guides provided by the authors? Was it pilot tested?	Methods
18. Repeat interviews	Were repeat interviews carried out? If yes, how many?	Repeat interviews were not carried out
19. Audio/visual recording	Did the research use audio or visual recording to collect the data?	Methods
20. Field notes	Were field notes made during and/or after the inter view or focus group?	Methods
21. Duration	What was the duration of the interviews or focus group?	Methods
22. Data saturation	Was data saturation discussed?	Methods, Discussion
23. Transcripts returned	Were transcripts returned to participants for comment and/or correction?	Transcripts were not returned to participants
Domain 3: analysis and findings
Data analysis
24. Number of data coders	How many data coders coded the data?	Methods
25. Description of the coding tree	Did authors provide a description of the coding tree?	A coding tree was not used – a codebook was used
26. Derivation of themes	Were themes identified in advance or derived from the data?	Methods
27. Software	What software, if applicable, was used to manage the data?	Dedoose
28. Participant checking	Did participants provide feedback on the findings?	Not at this time
Reporting
29. Quotations presented	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number	Results
30. Data and findings consistent	Was there consistency between the data presented and the findings?	Methods, Results, Discussion
31. Clarity of major themes	Were major themes clearly presented in the findings?	Results
32. Clarity of minor themes	Is there a description of diverse cases or discussion of minor themes?	Discussion