Perceptual Reasons for Resistance to Change in the Emergency Department Use of Holding Chambers for Children With Asthma
Study objective
We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of β-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change.
Methods
This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes.
Results
At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED.
Conclusion
Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.
To access this article, please choose from the options below
Supervising editor: Kathy N. Shaw, MD, MSCE
Author contributions: KH and DS conceived the study. KH, JS, and J Duffy designed the trial. IS and DS obtained research funding. KH recruited participants, carried out the interviews and focus groups, and primarily undertook data analysis. KH, JS, J Duffy, and DS discussed the coding categories and their relationships and reviewed participant quotes. KH managed the data, including quality control. JS and J Duffy provided advice on qualitative data analysis. KH drafted the article, and all authors contributed substantially to its revision. KH takes responsibility for the paper as a whole.
Disclaimer: The observations and opinions in this article are those of the investigators and do not represent the opinions of the Nova Scotia Department of Health, Canadian Institute of Health Research/Canadian Health Services Research Foundation; or Nova Scotia Health Research Foundation.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that may create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statment. Dr. Sketris holds a chair in drug use management and policy funded by the Canadian Institute of Health Research/Canadian Health Services Research Foundation, cosponsored by the Nova Scotia Health Research Foundation. Dr. Hurley received salary support under this chair as part of the Drug Use Management and Policy Residency. Other project funding was provided by the emergency departments of the 2 hospitals that participated in this study.
Publication dates: Available online June 7, 2007.
Reprints not available from the authors.
PII: S0196-0644(07)00485-4
doi:10.1016/j.annemergmed.2007.04.008
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.