Table 4 Intrinsic and extrinsic factors and motivators that influence physicians’ decision-making process on whether to perform a lumbar puncture and relevant quotes

Trusting own judgment

Taking others into account

a. On-call physician

(focus group 1)

b. On-call physician

(focus group 4)

c. On-duty physician

(focus group 6)

d. On-duty physician

(focus group 5)

“A lot is positive with the guideline, but it is not possible to have a guideline which covers all scenarios”

“You get very focused on the guideline instead of trying to get the feeling of the patient, like “How sick is this child?” And I think that is a bit dangerous.”

“I feel safe in my medical judgement. I do not have too much anxiety about this baby because I have built up references. I can see that this, okey, this is a sick baby. Then I pull out the LP-tray.”

“We had few babies which were considered well-appearing and were admitted for observation, and they had meningitis”

g. On-duty physician

(focus group 2)

h. On-duty physician

(focus group 6)

i. On-duty physician

(focus group 3)

“You know, I don’t want to do anything unnecessary to the baby (…) And I do not want to worry parents who do not need to get worried.”

“There are nurses with 25 years of experience, and you arrive as new and you do not have the clinical gaze. Then you may have a dialogue. You know, let’s do this. I always tend to ask ‘Well, what do you think?’”

“And then you present it like it was not a sick baby and then they might say “Well, then you do not need to perform LP.”

Fearing risk or failure

Seeing a need to practice and learn to perform LP

e. On-call physician

(focus group 5)

“I guess, it’s better to perform LP on ten, than to miss one meningitis.”

j. On-call physician

(focus group 5)

“It is better to perform LP, to just do it, and then the physician on duty will also learn and connect the dots: “Okey, this baby looks like this, nothing was growing. Then I had this baby where it still turned into meningitis.” You see, it is their way of building experience.”

Avoiding burdensome work

Balancing guidelines and resources

f. On-call physician

(focus group 5)

“To follow the protocol, creates more resistance if it concerns burdensome things which we physicians must do.”

k. On-duty physician

(focus group 6)

“Even if you yourself don’t have much against doing it, it sort of becomes. It’s a big thing. There is a lot of staff involved, it takes time, it takes space.”