Table 2

Summary of belief statements and illustrative quotes by domain of the TDF

DomainBarrier/
facilitator
Belief statementQuoteExample quoteNo. of transcriptsRichness of description
Beliefs about capabilitiesBarriersI/my colleagues do not have the confidence to administer TXA to a trauma patientQ13 There’s a couple of patients that I thought about it but I wasn't 100% sure so I kind of left it to somebody else to make the decision I suppose (P018)7Medium
Paramedics get insufficient feedback on whether or not TXA was appropriately given, which hinders our confidence in administering itQ14 We rarely get a chance to follow up on our patients, we never know whether what we've done is right or wrong so we don't know if a particular patient we went to did get TXA in hospital and did benefit from it. (P008)4
FacilitatorsI feel comfortable administering TXA to a trauma patientQ12 I haven't known of any adverse reactions or hypertension or anything from giving the drug. So, I think they're sort of, they're not scared of using it. (P014)9Medium
I observe HEMS administer TXA frequently, which has given me more confidence to administer itQ15 I've also had quite a lot of experience using it on … on HEMS, without any adverse effects that I've ever been aware of, and I've also seen it given fairly liberally in A&E. (P005)4
Beliefs about consequencesBarrierIf I administer TXA, it means that they are a major trauma patient (and so they need to go to a trauma centre)Q18 I think people get a bit nervous of it because it kind of signifies actually we have got quite a significant injury here and I think sometimes people are a bit scared of making that call. (P009)5Medium
BothI am aware/not aware of the safety of TXAQ16 I suppose I don't fully understand what the drug can do. You know - is it going to be a dangerous drug that if I give it and they are not bleeding, is it going to harm them? (P018)8Medium
FacilitatorThe benefits of administering TXA outweigh the risksQ17 The risks of not giving it outweigh the risks of giving it, if you know what I mean. (P009)14High
EmotionBarrierThe stress of a trauma job means that TXA is sometimes forgotten/not prioritisedQ34 There’s so much going on, we want to get lines in, we want to get fluids, we want to sort airways out. Sometimes it does slip your mind because you're just trying to think about so many things and you know TXA sometimes is a bit of an afterthought. (P017)3Low
Environmental context and resourcesBarrierI/we do not have sufficient resources (staff; time) to administer TXAQ27
Q28
I think one of the biggest barriers I see of TXA…is the time it takes to draw up because it’s quite labour intensive (P001).
And I think also the need to give it over 10 minutes is probably the biggest barrier. Because if you do sort of comply with the guideline and give it over 10 minutes its - one it’s very difficult to do and - secondly it ties you up for 10 minutes trying to administer that through an IV. And generally, in those sorts of situations, there’s other things that you'd like to be doing really. (P005)
13High
FacilitatorsTXA might be administered more often if it could be given in a different wayQ29 The more simple the medicine administration the more likely it’s going to get thought of and done…if we were allowed to add it into the fluid bag as part of an infusion, I don't know if that would work any better (P007).5Medium
TXA might be administered more often if paramedics had specialised equipment to help them identify bleedingQ30 If there was another diagnostics tool like ultrasound just to see if physically you can see the bleed, rather than going on the observations - I think that would just be a big positive and that would like, give people even more confidence to give it in those certain situations. (P004)6
GoalsBarrierAdministration of TXA is not seen as a priority for trauma jobsQ21 And I think some people in situations where you've got somebody that’s that injured it is ‘right let’s get going, let’s get out, let’s get in the ambulance, and let’s get to hospital’. I think some people are worried about wasting too much time doing interventions when that sort of thing you can do it on the way. (P009)8Medium
Knowledge and skillsBarriersParamedics do not understand how TXA worksQ1
Q2
Essentially it was due to a lack of knowledge around how the drug works and what the drug is actually indicated for… I think the level of understanding of what the drug actually does is quite low within the paramedics, you know. Just from who I've spoken to and the conversations I've had. (P001)
Maybe a few people are unsure of the doses. I know…that a lot of people assume that its one ampule is the dose. I mean its … its not, its actually two ampules. Uh, so I come across, not so much now, but I come across people giving just one ampule or 500 mg and they think that that’s the dose. (P005)
11High
I have not had enough training on when to administer TXAQ5I think maybe perhaps it hasn't been emphasised enough during training. (P014)16
BothI do/do not have much experience using TXAQ6 I can probably count on one hand the amount of times I've given it in the past three and a half years just purely because we don't see that much trauma. (P017)13High
FacilitatorI/we know the evidence base behind administering TXAQ3
Q4
I've done a bit of reading up on TXA, I've listened to some podcasts and things on it and I think I've got a good idea of what the current thinking is on it. (P005)
We’re mindful the quicker we give TXA the greater benefit. (P007)
13High
Memory, attention and decision processesBarrierIt can be difficult to identify whether or not trauma patients are at risk of bleedingQ24
Q25
I think in theory it’s easy because I can run off a list of things that we should be looking for but I think in practice it’s not that easy. (P017)
I think if they are really unwell it’s really obvious, it’s the ones that the sort of moderate ones that can be really difficult. (P008)
15High
BothWhen the patients’ bleeding risk is unclear (ie, no obvious external/internal bleeding) I use one/a number of the following factors to make my decision on whether or not to administer TXA:
  • Clinical observations (CO)

  • Mechanism of injury (MOI)

  • Patient presentation (PP)

  • Type of injury (TOI)

  • Patient history (PH)

  • Clinical judgement (CJ)

Q22
Q23
So characteristics, I'd be looking for systemic changes such as tachycardia, and hypotension. (P017)
I think actually to be honest, I've gone by mechanism a lot of the time, and if the mechanism is suggestive of an internal bleed then I've used that clue to guide things really. (P005)
CO: 18
MOI: 18
PP: 15
TOI: 11
PH: 4
CJ: 4
High
FacilitatorIt would be helpful to have a triage tool/flow chart like the major trauma tool to help me decide when to administer TXAQ26 Maybe kind of like a flow chart type thing, like we have with the major trauma tool. A flow chart to maybe encourage patients with more moderate bleeding to be given it - could help. (P008)9Medium
ReinforcementBarriersThe lack of immediate visible effect of TXA on patients inhibits its use by paramedics.Q20 I do remember that whenever I, as a student even seeing TXA being used, I was kind of, it was a bit of an anti-climax because I was kind of like what’s going to happen now. I was like ah okay (nothing). And it was, you kind of, you look at these things and you are expecting to see something great and fantastic happening but it doesn’t. (P003)2Low
I/my colleagues have a fear of repercussion of administering TXA to patients who do not need itQ19 The fear of repercussion can obviously impact people’s clinical decisions, and that can either be the repercussion from the patient or the repercussions from management. (P003)5
Social influencesBarrierTrust culture hinders administration of TXA (TXA is only given for major trauma)Q31 It probably is almost like a cultural thing that TXA is a kind of a major trauma thing, rather than a routine for use drug. (P002)4Low
BothMy colleagues’ opinions affect my administration of TXAQ32 I discussed it with another paramedic who was on with me at the time, so we had this discussion as to whether to administer or not and that’s how we came to the decision. (P017)6Medium
FacilitatorI usually check with a senior colleague/doctor before administering TXAQ33 I'd probably call up (the hospital) and say ‘this is what I'm bringing you, I'm going to be an hour, do you want me to start TXA?’ (P007)7Medium
Social/ professional role and identityBarriersThe restrictions of working to a PGD hinder the administration of TXA to patients who would benefit from itQ7 I don't know whether it needs to be a change in the wording of the guidance to encourage (TXA administration). I am just actually having a look at the guidance now, even the fact that itself that it is a PGD. I just don't really get why it should be a PGD. (P003)18High
I/my colleagues are unsure as to which conditions/injuries we are able to administer TXA forQ8
Q9
I also think that gynaecological and GI bleeds or trauma also need to be clarified in the guidance. I'd like to see that given a mention because people are never sure whether to give that or not. (P005)
It’s like any of our guidelines in the JRCALC, they can be a little bit vague, and that’s what they are they are guidelines but they can be a little bit too open to interpretation in my mind. (P009)
6
BothThere are differences in TXA administration guidelines between paramedics and HEMS/doctorsQ11 I think, obviously the critical care and HEMS and things probably get on board a little bit quicker. So then obviously when sometimes when they turn up they'll start doing things or administering things slightly differently because their guidelines are slightly different, and obviously, a doctor can do things slightly differently to a paramedic. (P007)4Low
FacilitatorParamedics should be able to administer TXA for more conditions/injuriesQ10 I think for a drug that we do use, maybe there’s scope to expand or extend our protocols for use in patients that have other symptoms, maybe not just a very specific set of vital signs. (P007)12High
  • HEMS, helicopter emergency medical services; JRCALC, Joint Royal Colleges Ambulance Liaison Committee; PGD, patient group direction; TDF, theoretical domains framework; TXA, tranexamic acid.