Table 1 Example of the analytic process of qualitative content analysis within theme 2 “The encounter”

“Following the present guidelines, we ask about smoking and alcohol, but you don’t do anything about it

No action is taken on the information provided” (Doctor, field notes, day 28)

The doctors ask about alcohol and smoking habits but do not act on the info

Health policy requires lifestyle issues to be addressed, practice follows requirements without further action

Professional differences

The encounter

”It’s also a matter of subjective assessment (…) I’m a little suspicious and think… I look at their clothes and they are maybe a little untidy and I wonder if their home situation is OK”

(Interview 7)

Patients appearing unkempt with an unclear home situation may give rise to suspicion of an unhealthy alcohol use

Clinical assessment of an unhealthy alcohol use is (among other things) based on both visual appearances and patients’ capabilities

Gut-feeling vs. clinical parameters

The encounter

"If they initiated a dialogue, they should also finish it, which they did not feel they had time for

It would be unethical to start something they could not finish” (field notes, day 7)

It is unethical to start a talk you cannot finish

Time is a barrier for asking about alcohol and is used as an ethical argument, that governs the patient encounter

Ethical reasoning

The encounter

"An alarm sounds […] Secretary said that a ‘drunk’ man had punched a female patient in the face

So, they had ‘kicked’ him out” (field notes, day 27)

The alarm went off. An intoxicated man hit a fellow patient and has been thrown out of the hospital

A safe hospital stay is a top priority. Patients who cross the line of accepted behavior must leave

From compliance to zero tolerance

The encounter