Table 2

Barriers and enablers to OR Black Box implementation identified using the theoretical domains framework (TDF)

Relevant TDF domain	Key themes*	Patients	Clinicians	Senior leadership
Knowledge	Familiarity with concept of black box (aviation)
Knowledge	Technical and logistical questions/details unclear
Beliefs about consequences	Will improve future care/make surgery safer
	Potential negative impact on clinical performance (eg, nervousness, change dynamic, distraction, pressure)
	Can be used to learn from and improve practice
	Potential negative reactions of staff if used punitively
Memory, attention and decision processes	Participation would be an easy decision to make
Memory, attention and decision processes	Decision would take time/cost-benefit analysis needed
Social Influences	Trust in principal investigator
Social Influences	Support of colleagues
Environmental context and resources	Hospital reputation/trustworthiness
	Hospital is a learning environment
	Time pressure in OR
Emotions	Comfortable/excited
Emotions	Worried/scared/threatened
Behavioural regulation	Adequate information is required to participate (eg, research goals, privacy/security)
Behavioural regulation	Negative impacts on clinical practice would prevent participation
Social/professional role and identity	Part of being a patient/playing a role in own care
Reinforcement	Improving care for others is incentive enough
Optimism	Will create positive change/gain momentum
Optimism	Doubtful that significant change will occur
Intentions	Motivated to participate
Intentions	Not motivated to participate