Table 2 Examples of belief statements and sample quotes from anesthesiologists (A), internists (I), surgeons (S), and nurse participants (N) assigned to the theoretical domains identified as relevant

Knowledge

Guidelines are helpful

“I think that they should definitely exist. They are really important to reduce unnecessary testing, and to standardize patient care pre-operatively. I think that there should be a solid guideline for all the pre-op testing that we do.” (A2)

10

There is evidence to support the guidelines

“From what I’ve seen for the most part, yes. They seem to be…” (A7)

8

I do not know all of the evidence in guidelines

“[…] I’m not aware of who developed the guidelines or what the evidence behind them is…” (S1)

5

The quality of the evidence is not good

“…So far, most guidelines are based on a few small studies. My interpretation of—is that we would—it—we need stronger evidence.” (A1)

3

Quality of evidence behind guidelines varies

“[…] The evidence is actually very contradictory, because there’s different—it really depends on the data set that you use. There’s many guidelines that are based on local situations that just don’t exist in Calgary.” (I1)

2

Social/professional role and identity

I (internist/anesthesiologist/surgeon) should be responsible for ordering ECGs/CXRs

Realistically, it better be the surgeons [responsible for ordering ECGs/CXRs], because a low-risk patient shouldn’t have to go through a pre-admission clinic.” (S1)

9

“Either anesthesiologists or internal medicine. […] I’d say mostly anesthesiologists, because they understand better what type of procedure and what anesthetic is involved.” (A2)

The roles and responsibilities of the different specialties for pre-op assessment are not clearly defined

“…I think it’s more the system. I think we have a system in place where a patient is first seen by a surgeon, and then maybe by a nurse in the pre-admission clinic who has a clinical practice and a jurisdiction that allows them to order certain investigations, or maybe by an anesthetist in the pre-admission clinic, or any caregiver along the way.” (I2)

5

“Sometimes the surgeon will order tests because, just because without any reason for ordering, and sometimes internal medicine will order.” (A2)

I sometimes do not play a role in the ordering of tests—other HCPs do

“In our clinical environment, it’s the surgeons that order the chest x-rays. We [internal medicine] don’t, and anaesthesia doesn’t.” (I1)

5

“but it also depends, because sometimes internal medicine sees the patient, and then there is—individual physicians will order tests following their own criteria.” (A2)

I order tests to justify the consultation

“ECGs, I must admit I typically order them, usually because I’m wondering why I’m even seeing the patient. I’m going, “There must be something going on here that I am missing. “Right?” (I1)

2

Beliefs about capabilities

It is easy for me to not order/cancel tests

“If there’s—for example, if we’re using a sunrise clinical manager, and there’s an order set and I see that something’s been ordered that doesn’t need to be, then I’m happy to cancel that.” (A3)

13

“If I don’t need to order anything, I don’t need to order anything, so it’s easy.” (S2)

I am confident that I can perform a pre-op evaluation without testing

“Yes… [I am confident to perform a pre-op evaluation for a low-risk surgery without pre-op tests].” (I2)

12

It is too easy to order tests

“I guess the problem is that it’s so easy for me to do an ECG that I have to have a really good reason not to order one.” (I1)

10

I am comfortable proceeding without testing

“Yes, for most surgeries [I am comfortable proceeding without testing]. Again, it depends on if it’s low risk with a low-risk patient, yes.” (S1)

9

It is difficult for me to cancel tests ordered by another physician

“I don’t routinely in my low-risk surgeries order the tests, but if—let’s say the surgeon orders it, I can’t cancel the surgeons order.” (A6)

6

“Even if I were to contact a referring physician and to say there’s no need to do a chest x-ray in this particular case, that wouldn’t necessarily prevent a chest x-ray from being done.” (I2)

Beliefs about consequences

ECGs/CXRs are unnecessary for patients undergoing low-risk procedures

“Tests are unnecessary and are not going to identify [conditions] that would either be treatable or exist or influence treatments like surgery." (S1)

10

“…those tests are of no value in the patients where they’re not indicated.” (A4)

Reducing unnecessary tests would save time, money, and resources

“…We need to be judicious in ordering our investigations, because we need to be responsible to the limited resources that we work within." (I2)

10

Tests are ordered to prevent surgery cancellation or post op complications

“My main purpose in that setting is to prevent a cancellation of the surgery. So, if I anticipate that… there is a reason that the anesthesiologist of the day will cancel their surgery based on the absence of some sort of information, then I will order the tests so they have that available.” (I3)

7

Tests are ordered to prevent problems in the OR

“I order them for myself, so I don’t have any problems in the operating room.” (S2)

4

“We’ll just go ahead and get an ECG, because it’s, I think, still—it’s safer to have one onboard that everybody can look at, then to ignore it, and then something does happen.” (N1)

Ordering routine tests may catch something that’s asymptomatic

“…The negative could be if I don’t order a chest x-ray and the patient comes in in six months’ time with lung cancer, which could have been detected, or a heart attack on the ECG which could have been detected if I had done the EKG, so that is a negative.” (I4)

3

Motivation and goals

Ordering pre-op tests is sometimes important to me

"It’s important if it’s clinically necessary, and if it’s not clinically necessary, it’s not important at all.” (A5)

9

Ordering pre-op tests isn’t important to me

“To do it, I don’t think it’s necessary to do as part of the pre-operative workup. I don’t think it’s an incomplete pre-op workup if you don’t do it.” (S1)

7

Environmental context and resources

My environment (access to ECGs/CXRs) makes it easy to order tests

“I see these patients in an environment where I can order the tests and get them pretty much immediately. There’s no environmental restriction…” (I1)

10

“Because we have nurses that will put in all of our orders for us, and all the requisition sheets are available as well as our computers and the centre’s clinical managers. Whenever I’m logged into a patient, it’s fairly easy to order anything I might need for that patient.” (A3)

Hospital/departmental guidelines/policy dictates whether tests are ordered/not ordered

“Because we have a policy within the department. So most people just follow the department policy.” (A1)

7

Due to clinic setup for efficiency, tests are ordered before I see the patient

“It’s easier if everybody has an ECG because if you have to wait until you could see the patient… it disrupts the flow of the patients in a busy clinic because the high pre-op clinics are high volume, so if the ECG is automatically done in rotation on everyone’s chart, then that makes the flow of the clinic faster.” (I3)

4

Social influences

My colleagues and I generally have similar opinions about test ordering

"Yeah [colleagues generally agree on pre-op testing practices], because we have discussion every couple of years. We discuss as a group considering our own culture, our own surgical culture, our own patient populations. Our experience with certain surgeons, so yeah, we as a group. Generally, I mean, there’s always going to be outliers but, for the most part, we reflect together every few years." (A1)

15

"I would like to say yes, because, again, we do meet on a regular basis, and we discuss these things.” (I1)

The views/opinions of others don’t/rarely influence my decision to order/not order tests

“Other’s opinions may not matter if I have done my job properly because that’s why I’m here for my patients. If I’m practicing evidence-based medicine, then I should not be influenced by the opinions of others.” (I4)

8

“I wouldn’t expect a surgeon to make decisions that would change my management. I would not expect. Yeah. For example, I wouldn’t expect a surgeon to say, "Oh, this patient needs a chest x-ray because they might have a general anesthetic." I wouldn’t expect them to know what would change my practice and what wouldn’t.” (A3)

I would only order pre-op tests if a physician requests them

“So, if I anticipate that if there—based on the history and physical—that there is a reason that the anesthesiologist of the day will cancel their surgery based on the absence of some sort of information, then I will order the tests so they have that available.” (I3)

4

Other HCPs (nurses, surgeons) are ordering tests and they shouldn’t

“…as a result, some patient’s getting lab tests or that, you know, if a physician had seen them first, they wouldn’t be ordered because it’s being based on a nursing history not a physician assessment.” (A1)

3

“Yes, I would [prefer surgeons to order pre-op tests] if they could do it appropriately, I think that would be nice, but because they can’t, the grid is fantastic for that.” (N1)

The views/opinions of others might influence my decision to order pre-op tests if not ordering could lead to negative outcomes (surgery cancelation, negative patient outcomes)

“Sure, it would be done [view or opinions of others affect my test ordering], it’s if they weren’t involved in the procedure, I wouldn’t care, because I think that my practice is within guidelines, but if they were going to delay or cancel the procedure and become a barrier to us, then it would substantially influence me.” (S1)

2

“This is a difficult part, because another physician has indicated that they should get it [the test] done. If I disagree and go on without the test, and then there’s a bad outcome—which is again, still unlikely, then it opens yourself up to legal ramifications.” (A6)