Table 2 Major themes and sub-themes with illustrative quotes

Cognitive role of the PPT

[…] and at the moment we try and figure out if they are going to be ok or not from their blunt rib injury, and I think it just draws together a number of factors that we would automatically think of that are really important. […] like how old are they and how frail are they maybe by looking at their lung disease or their age but it also brings into view other factors like anti-coagulation which I would not automatically have thought of. And also it seems to build into it a scoring system of how much weight we should attach to each of those variables that we are maybe juggling in an ethereal way in our head (Clinician4).

Easing cognitive burdens

I do think it reduced my workload because I did not, it sounds awful, but I did not have to think that much about the pre-existing problems with the patient because it was all a tick box for me basically (clinician5).

Patient centred communication

I think patients quite like if you use a scoring system. Because they can understand the risk prediction as well […] I have used it you know not just for this, but for other scoring systems that we use in ED, that as I said to patients “well you know I have put you through our scoring tool and you are high, medium or low risk”. I think patients might ask you about it, what is in it, and it is a good basis for conversation around shared decision making (clinician7)

Reflecting on previous clinical decisions

I think a few of the cases we scored greater than I would’ve expected, but that just sort of made me sort of step back and think perhaps in the past I maybe under treated some of this patient group. So it wasn’t a bad thing, it sort of helped me sort of reflect on my own practice (Clinician8)

I had quite a few comments from the clinical staff being involved and were quite engaged in it, and it’s really been thought provoking for them […] by introducing the intervention they automatically start thinking about their clinical practice and they really sort of, they stand back a bit and go, “Ooh, I hadn’t thought about that.” So it does influence them (FGP1)

Alternative assessments

literally just prompted him to take a step back and actually look at that particular patient in slightly more detail rather than just following a standard clinical process […] and it just added in an extra element that made him go, “Do you know what though, he has got a few risk factors I hadn’t really thought about and maybe I should have a look at him a bit more.” [FGP3]

Smoothing referrals

[…] with this tool you can refer to specialty and it’s something you can hang your hat on, and say, “I’ve done the blunt scoring tool, the score is 25.” And then they can also refer back to that and see, “oh yes, I can see where you’re scoring those points”. And it’s just something--, it just makes referral easier sometimes, asides from the fact that obviously if they come in as a less than ten, that’s considered discharge home. Obviously it says ‘consider’, […] But definitely having the tool, it kind of feels like everybody’s singing off the same hymn sheet (Clinician9)

Actual resource requirements

I think that discussion it created, it actually created more buy-in to the trial because it actually made them stop and think a bit. Because it did create quite a bit of discussion. (FGP1)

Observer status

You throw in some sort of clarity in to how you have come to that decision and then what that means in the terms of percentages and outcomes. It [the STUMBL tool] can really just sharpen everyone’s thinking around it [prognosis] and they do not have to agree with you but at least you have got a basis rather than it just being an idea (Clinician4).

I remember one patient I saw that I probably wouldn’t have considered in ITU but, you know, on their scoring and the injury that they had, I did have that conversation [about whether the patient needed to go to ITU]. So it doesn’t necessarily mean the patient is going to get admitted on to them [ITU], but--, under them [ITU staff], but they sort of open up that clinical discussion to ensure the patient’s got the right pathway and the right care plan (Clinician8)

Validated tool

I know myself and my ENP colleagues have sort of struggled with the fact that there is no sort of validated scoring tool for blunt chest wall trauma. So this was quite sort of an exciting step forward. And I know sort of in my role as teaching--, for teaching ENPs, some of the ENPs do struggle that there is no established tool compared with maybe other injuries (Clinician8).

This is going to make my job easier. And it did because it gave me something that I could base my clinical decisions on (Clinician5).

Questioning validation

people were a bit, jumping the gun a bit, and saying well, like using this score, and saying I don’t know, this shows this, and I don’t know, there isn’t evidence yet (Clinican3).

the real test is whether they actually go and use it properly in practice, for the rest of the patients. Or whether they just ignore it and do their own thing anyway. But with this decision it is actually really interesting that people wanted to follow it. They suggested to me that there was definitely a gap in the evidence people want to have an evidenced base tool to justify what they are doing for these patients and after the trial finished we had a number of people asking where we can get the decision rule from (Clinician2).