Análisis Interno

A professional transcriber transcribed the interviews verbatim. Once the first batch of transcriptions was complete, I was able to conduct an initial read-

through of a printed copy of the interviews. This familiarisation process enabled me to get to know the data and the narratives that were beginning to emerge across the data. I read the transcripts in the order that they were received. This approach allowed for progressive focusing, where interviews in the later stages of the data collection process were able to focus down on particular issues of interest (Parlett and Hamilton, 1976; Stake, 1995).

All data was uploaded and stored in NVivo 11 (QSR, 2015), in order to help code, sort and analyse the data. Documents collected as part of the document analysis process were also uploaded into the database, according to site reference. Observation field notes were hand-written in field journals and hence were not uploaded into the database as text files. These notes were used to support my analysis and framing of the situations I observed. Examples I used were taken directly from my observation log and were selected and transcribed personally. I selected one interview from each group (n=3) as available and coded each one line-by-line using the highlight and nodes features of NVivo 11. These codes represented varying levels of abstraction in the data. As an example, codes such as ‘implant selection’ reflected high-level coding whereas ‘changing innovators’ used the exact words that were present in the transcript. An initial coding framework was developed throughout the coding process. This acted as a

thought aid to help structure the new and developing codes as they emerged during the data collection.

Once all transcripts had been coded, 404 individual codes had been generated. I assessed the similarities and differences between codes and expanded or

collapsed them into groups where appropriate. These codes were presented to the supervisory team for discussion. After this process, 328 codes remained. The fully-developed coding framework was used to help organise the 328 codes into larger categories. This next stage of consideration resulted in 29 categories, which enabled me to collapse codes and reduce the overall number. A category summary description was produced to enable me to explain the meaning of the category and the codes it represented. This helped me to remain consistent throughout the process of data collection and analysis, which occurred

simultaneously at each site and sequentially across the three sites. Presenting the codes and category summary ensures transparency in the data analysis and helps to establishing the robustness of the research process. Table 9 presents the final categories and corresponding codes of the data. Throughout this coding and categorisation process, I noted points of interest and queried parts of text; I referred to these notes as reflexive coding summaries. I was able to refer back to particular sections of key documents and the field journals that reported my thoughts after the interviews had been conducted. These helped me to further interpret my reflective account of what was said and how it linked to my developing ideas.

Table 9. Final categories and codes in thematic analysis

Category summary Codes included

Group decisions: decisions made by more than one person Stakeholder meetings, Group decision, Multidisciplinary decision making, Stakeholder complexity

Different views, Conflict, Collective decision-making, Collaboration under competition, Multidisciplinary engagement

Exceptions: instances and examples of when normal practice did not occur Clinician not response, Variation for a special case, Clinician error, Confidence in ability (to make an exception), Deviant behaviour, Deviate from guidelines, Make exceptions, Special care surgeon, Just in case decisions, knee jerk decisions, Confidence to disobey guidelines

Cost: any reference to cost or finance that included a decision Cost rationalisation, Service improvement driven by cost, Loan kit cost, Surgeon knowledge of cost, Cost based decisions, Cost as a driver to change, Cost and efficiency, Volume and cost decisions, Cost versus quality, Value for money

Learning on the job / mentor: examples of learning or knowledge acquisition from a respected other

Role model, Apprenticeship, Mentors, What I was trained in, What my consultant taught me, Knowledge acquisition, Learned in practice, Learned from Seniors, Learn on the job, Sharing information

Personal experience: examples of a person’s prior experience that influenced their decision making

Its established practice, Typical patients do not need evidence, The way we do it, It becomes normal, Personal experience, What I’ve always done, Surgeon philosophy, It worked before, Light bulb experience, Experience over implant, Practice based evidence, Works in my hands, My decision to operate

External influence / political: reference to factors outside of the organisation that could impact on practice

External influence, Changing patient demographics, Policy, External environment, Quality Care Commission, Political influence, Best Practice Tariff, Policy for cost reduction, Indemnity of implants, National priorities

ODEP, Political strategy, Political conflict, Clinical Commissioning Groups

Off table on table decisions: examples of decisions that do not follow the norm or that can change based on contextual contingencies

What takes clinical priority, Outcomes are variable, Off table decisions, Depends on the situation, Individual versus public decisions, Inside outside influence, Layered decisions, Balancing acts, Need to balance new and old, Internal verses external problems, Just do what you like

Intangible / legacy: knowledge and evidence that cannot be identified in the physical form

Intangible decision, Value of legacy knowledge, Insider knowledge, Historic events, Narrative decisions, Intangible knowledge, Beliefs in treatment

Compliance: reference to areas where compliance and rule following is expected

Governance reporting to Trust, Monitoring, Influence of commissioners, Internal audit, Assumed compliance, Mandates from NICE, Scrutiny of outcomes, Rule following, Monitoring and reporting

Leading lights: instance of people who take the role of influence and whose opinions can be a source of evidence

Expert opinion, Surgeon at the policy level, Kudos, Reputation, Credibility, The face of research, National influence, Interface role, Leading light, Opinion leader, Influential people

Professional networks: examples of other orthopaedic surgeons acting as a source of influence over decisions

Learning from colleague, Conversations with colleagues, Only trust in surgeons, The norms of surgery Surgical

community, Personal relationships, Relationship management, The ‘team’, Talk the same language, Peer pressure, Group think, Everyone does it, Socialised knowledge, Common knowledge, Group behaviour, Conform to colleagues

Professional hierarchy: reference to the impact of the hierarchy that exists within the hospital organisation

Allied Health Professionals, Management versus clinicians, Clinical lead for NICE, Differences between professional groups, Dependence on one person, Understanding professional groups, Hierarchy of staff, Professional fit, What my consultant taught me, Position in theatre, Who dictates decisions, Professional politics, Experience equals respect, Differences between groups, Role conflict

Beliefs about orthopaedic surgery: individuals beliefs about surgeons as a type of person and orthopaedics as a clinical specialty

Beliefs about orthopaedic surgery, Surgeons only do surgery, Challenges to orthopaedic surgery, Orthopaedics is different, Evidence based orthopaedic surgery, Clinical engagement control, Job description, Change surgeons’ behavior, Job role, Play to egos, Surgeon individual differences, Surgeon autonomy, Surgeon personality, Surgeon’s learning curve, Variation by specialty, Surgeon’s power, Variation by area and surgeon, Surgeons are competitive, Surgeons do not understand the bigger picture

Patient factors: features that influence decisions that are directly related to patients being treated

Decision for patient surgery, Patient demographics, Patient factors, Patient experience, What is best for the patient, Patient evidence, What the patient wants, Patient expectations, Public expectations

Training and development: reference to the surgeons training and how that influences decisions that they make

Training, Develop staff to problem solve, Education, Influence of trainer, Staff development, Fellowship training, Academic credibility, Academic training, Level of training

NICE-specific beliefs: all references about NICE and their relevance to clinical practice and clinical decision making

Beliefs about NICE, Challenge NICE, Is NICE applicable to the Trust, Use NICE for own benefit, NICE is a carrot or a stick, Make guidance fit for purpose, Guidelines are too general, We do NICE already, Too much guidance, Open to

interpretation, NICE dissemination and access, Guideline resistance, Implementation problems, Whose responsibility

Implant discussion: examples of evidence that influence how implants are selected for patients

Car analogies, Buying and contracting, Implant selection same for everyone, Product availability, Implant selection using hard data, Passion for a joint, Implant selection, What’s in vogue, Implant selection justify to Trust, Price variation, Implant selection conflict and uncertainty, Implants made available by Trust, Shiny new kit

Process internal: all reference to the internal process of the hospital and how it is run as an organisation

Coding process, Feedback, Communication, Process variation, Internal protocols, Process transparency Local polices, Process black holes, NICE internal processes, System wide thinking, Lack knowledge of the process, Ownership, Traditional services, Standardisation, Pragmatic choices, Medicine is repetitive, Efficiency savings

Innate drivers: evidence that stems from intangible assets of the decision makers

Craft versus science, Skill versus science, Innate passion, Confidence, Fear, Refuse to change, Enthusiasm, Personal reflection, Mind-set, Perception of outcomes, Blame, Responsibility for surgery, Ownership of the process and surgery

Management: all reference to managers working within hospitals Management versus surgery, Non-clinical managers, Joint roles, Top-down support, Management decisions, Leaders and business style, Management influence, Management support, Management power, Board level decision-making, Management control or lack of control

Organisational issues/operational: all reference to the organisation and its mechanisms

Organisational benchmarking, Staffing issues, Organisational business and structure, Theatre availability, Organisational culture, Proactive versus reactive decisions, Organisational restraints, Organisational mentality, Price benchmarking, Priorities of the organization, Procurement procedure of implants, Organisational flexibility, Time constraints

Evidence-based medicine (EBM): all examples of evidence linked to the traditional definition of EBM

Beliefs about EBM, Learning EBM, Time to do EBM, Levels of evidence in practice, Academic influence practice, Changing practice towards EBM, Codified evidence base, Develop services based on EBM, Multiple sources of guidance or evidence, Journal articles, National drivers for EBM, Inappropriate evidence, Access to evidence, EBM limited use in practice, Attitudes towards EBM

Gaming and incentivisation: examples of issues that go against what would be expected within the organisation

Incentives, Hidden agendas, Tariffs, Performance not influence your pay, Playing the clinical card, Game playing, Targets, Plant the seed and let it grow, Who shouts the loudest, Tick box compliance, Incentive decision making

Innovation versus routine practice: reference to new technology and treatment when compared to established technology and treatment

Bad innovation, Stifle innovation, Early adoption, Tinkering around the edges, Established implant technology, Barriers to innovation, Experimental procedures, Production line services, Innovation within an RCT, Commodity services (hips), Personalisation agenda

Professional societies: examples of the wider community of orthopaedic surgeons acting as a source of influence over decisions

Conferences, Comparison outside, Professional societies, Benchmarking to societies, Trust in own society, Professional guidelines

NHS versus private practice: all reference to non-NHS work and how it influences decision-making

Influence of private practice, Private practice is different, Public versus private decisions

Data / big data: the importance of data as a source of evidence at all levels of practice

Internal data at Trust, Poor data quality, Trusting data, Need to access data yourself, Influence of National data, Feedback and monitoring, Data monitoring decisions, Personal data is our responsibility, Try to understand data, Baselining, Control over data, Information is power, Data interpretation

Ethics: all reference to ethical issues and decision making Ethical considerations, Faith to do the right thing, Not clinically safe (to change), Ethical decision making, Ethical targets

Big Pharma. / manufactures: the influence of external organisations who develop and sell orthopaedic implants on decisions that are made

Influence of manufacturing companies, Training provision, Pharmaceutical representatives, Relationships with reps, Commercial decisions, Rep access, Control over reps, Incentives from manufactures, Provision of research and evidence, Marketing influence, Loyalty to company