Table 6 Themes, subthemes, and quotations for adoption and maintenance dimensions

Ultrasound use:

Participants expressed they were using ultrasound at least at some level in all targeted specialties (OB-GYN, pediatrician, and radiologist), independently or with support from the radiology department

Process/events:

General practice of ultrasound and occasions of use in the participant’s institution

“...In our institution, routine ultrasound is performed by the radiologist. However, for screening purposes such as emergency ultrasound, it has been performed by other healthcare workers in other departments including emergency department and obstetrics and gynecology department” – Pediatrician

“To determine early pregnancy, the general condition of the fetus during late pregnancy, the appropriate location of the placenta, the alignment of the uterus, ultrasound in gynecology is required. Moreover, to confirm the presence of tumors and fibrocystic lesions or latencies, performing ultrasound is an essential part of our practice.” – OB-GYN

“Cranial ultrasound, regular echocardiography, and abdominal ultrasound including renal scan are performed regularly to screen and to diagnose more complicated cases and to immediately respond to emergency department and intensive care unit care” – Pediatrician

Frequency:

Number of cases participants directly perform ultrasound

“….Hence possibly in a day we examine approximately 55 patients; among them, I examine possibly 10 patients daily…” – OB-GYN

“I perform ultrasound in nearly 50% of admitted cases and 10 to 20% of outpatient department cases” –Pediatrician

“In the past, ultrasonography and sonography were considered as the standard modalities, but they were mostly unavailable. However, today, these modalities are regularly performed in clinical practice in wards, outpatient departments, and even in the emergency department. It has been well accepted by the patients as well.” – OB-GYN

Perspective toward educational program:

Respondents expressed their views and observations regarding the educational program and changes attributed to the program

Use of ultrasound in regular practice:

Use of ultrasound in regular practice attributed to the program

“...nowadays, everyone is competent to perform ultrasound regularly. Moreover, healthcare workers already decide on the dose of inotropes based on echo results.” – Pediatrician

“...the training has addressed the topics we dealt in daily practice, improving confidence in establishing clinical decisions…” – OB-GYN

Correction in practice:

Previously used techniques were corrected or improved based on the program

“The ultrasound was already used during the past years, but specific guidelines in performing ultrasound to assess congenital anomalies were not yet established... after attending the course, we already properly performed ultrasonography. The knowledge obtained was shared with the resident students as well, and they significantly improved.” – OB-GYN

Negative perspectives:

The negative views toward the program and its potential negative outcomes

“...This type of program has several controversies, specifically in Nepal...there is no system of accreditation. It encourages the use of ultrasound without any proper certification. There is potential misuse of ultrasound. There is no proper follow-up.” – Radiologist

Challenges in the use of ultrasound: The participants expressed reasons for not using ultrasound when they first start or for the optimal use

Lack of ultrasound machine: Participants mentioned that there are no ultrasound machines or fewer ultrasound machines

“The gynecologists are not performing ultrasonography in their clinics because of the unavailability of any ultrasound machine, including my clinic. In private hospital or clinic setup, it is expensive to keep an ultrasound machine.” – OB-GYN

“Initially, lack of ultrasound equipment was one of the challenges; however, currently, it is now gradually addressed; for instance, the Seoul National University donated a decent echo machine, and we are significantly grateful for that. We are using this machine for pediatric echocardiography and transcranial scans. Gradually, our department is also equipped with few other machines.” –Pediatrician

“Every single day, one doctor has to perform 10 to 15 congenital anomaly scans; hence, it is a difficult job. If the cases were significantly few, that is, 4 to 5 per day, it would have been covered by the current infrastructure.” –Radiologist

Lower competency:

Participants expressed low competency and nonconfidence in performing ultrasound on their own

“During emergency conditions in high-risk pregnancy, OB-GYNshould be able to perform ultrasonography, but considering the insufficient training programs for OB-GYN, performing ultrasonography is the major cause of OB-GYN’s lower competencies.” – OB-GYN

Perspective on ultrasound use: How individual observed the use of ultrasound in the current context

Overuse of ultrasound:

Use of ultrasound where it was not absolutely required. High dependency on the ultrasound giving lower importance to other aspects

“We over diagnosed several diseases because of ultrasound. However, sometimes, we try to overlook our clinical practice and our clinical skills similar to what we do when using the stethoscope and when performing palpitations, and our clinical practice is sometimes insufficient, and we depend on the ultrasound machines. Hence, I think that sometimes we have to assess the risks and benefits. It has changed our decision-making skills.” – Pediatrician

Misuse of ultrasound:

Use of ultrasound guided other intentions

“The use of ultrasound for inappropriate cases and for commercial purposes. It is easy to obtain 1000 rupee if you use ultrasound. People undergo 15 days of training and can subsequently open their ultrasound service center. This is considered a significant unethical issue.” - Radiologist

Important diagnostic tools:

Participants express ultrasound as the important tool for diagnosis and investigation

“Ultrasound is one of the most important diagnostic or investigative tools.”

Improved quality of patient management:

Participants associate ultrasound use with improved patient management

“When performing clinical practice and when using the ultrasound machines to confirm our clinical diagnosis, disease diagnosis and management is significantly easier and accurate. Hence, I think ultrasound machine has changed our decision-making skills and improve our patient care.” - Pediatrician

Infrastructure maintenance:

The participants expressed recent developments or improvements in instruments, spaces, and human resource empowerment

Availability of ultrasound machines: Participants mentioned about the upgrade or addition of ultrasound machines

“In Nepal, we have a relatively good number of ultrasound machines that are available not only in hospital but also in outreach centers such as in remote areas. For the past 2 years, I think we added 20 ultrasound machines.” –Radiologist

“Our hospital has provided ultrasound machines in our wards, labor rooms, emergency rooms, and in all areas where we might need an ultrasound machine.” – OB-GYN

Competency of human resources: Participants mentioned the availability of trained human resources or doctors who can perform ultrasound and opportunity for getting human resources trained

“….the consultants and junior doctors in my department are competent in performing basic ultrasonography by themselves.” – OB-GYN

“Sometimes, when we encountered difficult cases, we used to discuss with healthcare professors who were able to undergo trainings from Korea via emails and discuss the ultrasound images.” – Pediatrician

Policy:

The participants expressed national or institutional policy including formal written policy or informal practice-related policy

Institutional policy to encourage practice:

Participants mentioned about written policy or unwritten but understandable policy that encourages the use of ultrasound

“There is no written protocol regarding the use of ultrasound, but limitations regarding its use are not yet established. When we train the resident doctors, they perform the ultrasound scan for inpatient children during the evening whenever they are free.” – Pediatrician

“There is no written guideline stating that ultrasonography should be performed by a gynecologist, but in the department, the use of ultrasound is encouraged. During the department meeting, we encourage colleagues to perform ultrasonography to establish the diagnosis of a disease.” – OB-GYN

“When I joined the residence here, a consultant doctor (teacher) said that I will be doing transvaginal sonography gradually and will be diagnosing the intrauterine pregnancy.” – OB-GYN

Restriction in practice by policy: Participants mentioned about restriction in use of ultrasound in practice or incorporation in formal guidelines by policy

“We do not have any written (formal) document indicating ultrasound scans need to be performed by obstetricians, but as part of our examinations, we perform it.” – OB-GYN

“The eligibility of a healthcare worker to perform ultrasound and the guidelines used to certify a healthcare worker regarding the use of ultrasound are not yet established in Nepal. Currently, any healthcare worker (including staff nurse, health assistant, and even Ayurvedic doctor) with an ultrasound machine can perform ultrasonography. There is no proper system of accreditation.” – Radiologist

“My findings will not be as strong as it is when evaluated by a radiologist for documentation, even if we can identify the problem, we need to refer our findings to a radiologist.” – OB-GYN

Local initiatives:

The participants expressed about how they are taking forward the ultrasound knowledge dissemination and promotion

“An ultrasound training center had been established in Dhulikhel Hospital with good infrastructures. Separate department had been established to handle this. The institution has started the ultrasound training on their own and also has expanded their collaborations. The curriculums and modules for various levels of ultrasound education had been developed, and education is being provided continuously.” – Radiologist