The ethnographic study was designed to generate understanding about influences on admission and discharge decisions, primarily through fully participant observation and semistructured interviews with patients and practitioners. During an initial period of orientation, researchers focused on understanding the ED’s geography, teams, systems and patient pathways; this included some in-depth interviews with
managers and practitioners. Subsequently, the researchers collected data by following individual patient journeys.
Practitioners and organisation of services Approach and consent of practitioners
We designed recruitment of practitioners on each site in conjunction with local collaborators. Flyers with general information about the study were handed out during researcher visits and posted on ward bulletin boards and in meeting rooms. Consent forms were distributed individually and at meetings so that staff had time to read them and decide if they wished to participate. In the case of 41 senior clinicians and managers who were purposively selected to be approached for in-depth interviews, information sheets and consent forms were delivered individually by e-mail or in person, together with a personalised letter.
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All these seniors gave their consent to be interviewed. The numbers of practitioners who consented to interview at each site is shown in Table 1.
Semistructured interviews
On each site, 9–11 interviews were conducted with key informants: frontline clinicians (acute care consultants, acute GPs, lead nurses, ED consultants), senior managers and commissioners.
We used purposive sampling to identify individuals who were named by colleagues as experienced in decision-making and influential within the local model of care. Other health workers (including some seniors) were selected on pragmatic grounds to be approached for observation or brief interviews because of their roles in the care of patients who were the focus of ethnographic or VSM patient case studies.
The overall strategy, combining purposive and pragmatic sampling, produced a broad sample of professionals that spanned varied staffing levels, types of contract and specialties.
During the set-up period, key informants were identified and topic guides for interviews developed and piloted (see Appendix 10). Interviews with clinicians combined semistructured questions about
qualifications and experience of acute care settings, and open questions that explored perceptions about decision-making processes and factors influencing admission avoidance.
Participant observation of organisational processes, team composition and function (research questions 1, 3 and 4)
During set-up, we identified data-rich spaces where acute admission work could be observed. These included EDs, medical assessment and other units, and offices or clinical rooms used by patients and practitioners.
Patient journeys
Case study inclusion and exclusion criteria
Individual cases were selected on the basis of being ‘potentially avoidable’ admissions according to patient presentation. The selection of patients for ethnographic case studies was guided by the following criteria:
l Cases were to be medical (not clearly surgical, although there was some overlap).
l Cases were to be ‘uncertain’ enough for a decision to need to be made about whether or not they would be admitted (i.e. not a clear candidate for a predefined care pathway).
l Patients were excluded if their condition, treatment or cognitive ability was not conducive to being approached by a researcher (e.g. in cases of severe illness, pain, reduced consciousness or states of dementia that did not allow sufficient recall for informed consent).
TABLE 1 Number of consented practitioners by site and type of participation
Site
Practitioners recruited through ethnography (number who gave senior in-depth interviews)
Practitioners recruited through VSM
Total practitioners recruited
A: Porthaven 58 (11) 26 84
B: Churchtown 69 (9) 17 86
C: Underbridge 83 (10) 39 122
D: Waterbury 72 (11) 50 122
Total 282 (41) 132 414
Sampling
Sampling of patients was both purposive (seeking patients with particular characteristics) and pragmatic (assessing which patients who were present could be suitable and available to participate in the study).
We first checked patients who were suggested to us by staff against the inclusion and exclusion criteria listed above. We then enquired about the patient’s condition and treatment needs to avoid causing them any undue or unwanted disturbance. We purposively sought balance in sampling patients with particular types of presenting condition such as chest pain, ‘funny turn’ or collapse, shortness of breath, abdominal pain, and conditions typical of older age. We monitored our evolving sample in an ongoing way to achieve maximum variation in terms of gender, age and ethnicity. Notwithstanding South West England’s
predominantly white UK demographic profile, a degree of ethnic diversity was purposively built into the sample on each site to maximise the potential for heterogeneity of patient experience. Pragmatic sampling was used to include relatives and carers who were present when patients were being observed or interviewed.
Approach and consent Two strategies were used:
l When researchers arrived for a fieldwork session, they asked co-ordinators and other staff to alert them about patients who might be suitable for case studies.
l Researchers were guided by their own observations, which led them to identify certain patients as likely participants.
For both strategies, practitioners were asked to act as intermediaries, with the practitioner asking the patient if the researcher could make contact with them. If the patient accepted this initial contact, the researcher provided this patient with an information sheet (also available in large print) and gave further explanation as needed, using language that was comprehensible to that person. If any patients were unable to sign for themselves, relatives or carers could be asked to sign on their behalf.
Participant characteristics
As described in Table 2, 95 patients and carers gave their consent to participate in researcher observations, conversations and interviews. A further seven patients, and one carer, declined consent because they were too distressed or anxious or in too much discomfort to participate, or because they simply did not wish to participate in the study.
TABLE 2 Ethnography: number and demographic characteristics of consented participants (patients, relatives and carers) by site
Patient journeys
Ethnographic researchers documented patient journeys by making fieldnotes and holding recorded and non-recorded conversations and informal interviews with patients, carers and staff who had given consent before, during and after assessment and review of the case in question. Researchers made written
fieldnotes during participant observation and/or as soon as possible after key events. Fieldnotes included descriptions of people, scenes, dialogues and decision-making processes, as well as personal experiences and reflections. Digital audio-recorders and smartpen recorders with Livescribe software were used to make recordings (Livescribe Echo Smartpen, Oakland, CA).
Transcription
All audio-recorded conversations and interviews were transcribed verbatim and uploaded to an NVivo (Version 10, QSR International Pty Ltd, Warrington, UK) ‘project’, or file used for data coding, which also incorporated researcher fieldnotes.
Analysis of ethnographic data Coding
A framework approach63was used to develop researchers’ understanding of key concepts in the study.
The initial framework, expressed in the RQs, was based on the study proposal’s literature review. This was progressively adjusted in the light of findings that served to interrogate concepts that had formed part of the proposal, for example: How is an admission defined? Who is a senior? What meanings are given to patient waiting times?
We used two main elements from the framework approach:
1. The construction of a thematic tree that brought together categories from the project’s initial RQs, and categories that were inductively informed by coding of the initial field data. This is evidenced in Appendix 11, showing the final list of NVivo categories we used to code the ethnographic data.
2. Matrices that researchers constructed to tabulate data excerpts from specific NVivo nodes, ordered by research site, under headings referring to contexts, mechanisms and outcomes. We shared these in research team meetings and used them to elaborate context, mechanism and outcome configurations and analytical statements.
The body of data coded using NVivo 9 and included in the framework analysis consisted of ethnographic fieldnotes, interview transcripts and transcripts of audio-recorded conversations. This body of data came directly from fieldwork.
To maintain this coherence, the NVivo project did not include material that had undergone further processing by researchers, such as team meeting notes and the summaries of patient case studies, which were of two kinds: those compiled from ethnographic data, and those compiled from VSM data.
Researchers first coded their own data in separate NVivo projects, gradually adding more categories (‘nodes’) through an inductive process guided by grounded theory. The supervisors reviewed the data set and coded some data produced by each researcher. The four sets of codes were merged and, through a process of team discussion, the number of nodes was reduced to 49 (see Appendix 11); researchers then resumed coding using the agreed set. This instrument made the revised framework operational, and it enabled researchers to rapidly access and share ‘strings’ of data on particular themes. The process of opening up and redefining concepts was also informed by the reading group (see Appendix 1).
Integrated fieldwork, discussion and data analysis
Data analysis continued throughout fieldwork as an integrative part of the ethnographic method. Researchers discussed their insights and interpretations – gleaned from day-to-day field experiences, writing of fieldnotes, coding and revision of literature – in research team meetings (core team meetings, investigator meetings, fieldwork and analysis meetings, and one-to-one meetings with investigators who had specific expertise) and in activities such as the reading group, mid-project workshop, learning sets and PPI workshops. To stimulate input from the wider team, researchers presented emerging findings using visual maps incorporating illustrative quotations. Topics for analysis were chosen using the following criteria:
l frequency and intensity of their appearance in the data, for example the ‘take-all’ way in which EDs were seen to operate
l the singular impact of some occurrences, such as ‘stand-offs’ when practitioners expressed overt disagreement
l conceptual clarification, for example unpicking differences between avoidability and appropriateness or inappropriateness, which aided definition of the clinical panel’s task
l evidence of the use of divergent definitions, such as practitioners’ various different uses of the term
‘admission’, and the ‘bending’ of definitions and practices associated with breach avoidance
l need for quantification through the VSM study, through analysis of HES data, or for follow-up in future research, for example number and proportion of acute admissions on each site that decision-makers considered to be ‘social admissions’
l attention to silenced, taboo, minority-view or contentious issues, for example one stakeholder’s claim that hospitals were ‘hoovering up’ patients, especially the ‘frail elderly’, and seeking to swell their resource base with this justification.
Obvious differences and commonalities between sites were highlighted early on and these led to searches for further confirmatory or disconfirmatory data. We sought evidence of heterogeneity within sites, particularly regarding practitioners’ observed behaviour and reported beliefs and experiences.
In addition to the above procedures, the following methods were used to achieve rigour in the ethnographic data analysis:
l The semistructured interviews with patients, carers and professionals were responsive to researchers’
ongoing field observations and conversations with participants. Alternation between these activities enabled us to explore, in interviews, some emerging questions and hypotheses.
l Researchers refined their analytic statements by going from the NVivo node data excerpts ordered in framework analysis tables, back to the source transcripts, which gave greater indication of context.
l Researchers tested and revised their emerging hypotheses in discussion with groups of research partners who had similar characteristics to the study participants: the PPI group; the learning sets of managers and clinicians on the four sites; the clinical panels; and the wider meetings of stakeholders comprising representation from all the above, and including the principal site collaborators.
l In research team meetings, colleagues interrogated each other’s analytic statements and requested further examples of confirmatory and disconfirmatory evidence.
Data analysis
Researchers used the analytical method of printing and manually coding a relevant node (e.g. ‘Targets, time of day, time limits and avoiding breaches’), reading and rereading the data, highlighting phrases with particular impact and making notes on themes that became apparent. For example, a typology was developed of practitioners’ varying responses to pressure from busyness of the service and the 4-hour target. These ranged on a continuum from positive engagement to negative reaction, as staff members positioned themselves in different moments as doers and achievers, flexible team players, compliers and victims. These categorisations served to alert researchers about possible patterns to watch out for as they continued their fieldwork. When the ethnographic data set was completed, these provisional patterns were tested by seeking out tendencies within and across sites.
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Ethnographic patient case studies
During the ethnographic study, researchers started to observe each patient journey with a view to creating an ethnographic patient case study. From these data, researchers selected the cases where they had been able to observe and conduct interviews during decision-making with involvement of practitioners, patients and sometimes carers. Six or seven of these patient case studies per site were collated and analysed as ethnographic case studies (see Appendix 12). The analysis involved comparing the views of the observer, patient, carer/family member and practitioners about their experience and the process of decision-making.
The patient case studies were presented to two clinical panels (see Appendix 2) for discussion and for comments, which were incorporated into completed case studies for analysis within the main ethnography and within the synthesis. Two examples of case studies discussed by the clinical panels are provided in Appendix 2, which includes the clinical panel report.