Diagrama general de las instalaciones del taller:

I collected data from each of the four teams by non-participant observation at weekly MDT meetings, semi-structured interviews with MDT professionals, and semi-structured interviews with patients under the care of the four cancer teams I observed. A summary of the data collected is provided in Table 4.

77 Table 4: Summary of data collected

Team Meetings

Non-participant observation at weekly MDT meetings

Before I began data collection I attended two MDT meetings at each site. This was to enable the team to get used to my presence and to pilot the quantitative data collection tools used for the MDT Study. Following on from these ‘pilot’ meetings, I collected non-participant observation data at 122 weekly MDT meetings (these were consecutive with the exception of weeks where I was unable to attend, for example due to annual leave). On four occasions out of 122 meetings the

observation data were collected by another Research Associate, Caoimhe Nic a Bháird, on my behalf.

During observation I made free-form field notes, audiotaped the meetings and collected data on who attended the meeting and their profession. I also collected quantitative data on each of the patients who were discussed during the

observation period using an observation proforma.

Field notes

My field notes were initially free-form, and recorded significant events and interactions that I observed. Within 24 hours of each meeting, I organised these according to a qualitative observation coding sheet (Appendix 5). This was designed in collaboration with clinical co-applicants and patient advisors for the MDT Study prior to the start of data collection. It was based on an adaptation of an Inputs-Process-Outcome model (McGrath, 1964, Cohen and Bailey, 1997, Lemieux-Charles and McGuire, 2006). It included sections on the meeting environment (e.g. the size of room and seating arrangements), mention of national or local policies, features of the team and task, levels of participation, and mediators of team processes and

78 outcomes. This provided a framework to map out features of the meeting context and decision making processes.

Audio recordings

Following each meeting, I re-listened to the audio recordings within 24 hours, adding further information to my field notes and documenting the timing of key events on the recording for future reference.

Attendance data

MDT co-ordinators in each of the teams provided me with ‘sign in sheets’ that were used to record attendance at each meeting. I used this to augment my observation field notes on meeting attendance and profession (e.g. at the beginning of the observation period when I was not familiar with all the team members, or when a new member attended a meeting).

Quantitative data

I used a standard proforma to collect quantitative data on each of the 1469 patients discussed during the observation period (Appendix 6). This proforma was initially developed by the clinical co-applicants for the MDT Study, but was subsequently amended based on feedback from me and another Research Associate following the pilot phase. Quantitative data collection included information on patient features such as diagnosis, comorbidities and whether patient preferences were mentioned during the discussion. I also used the proforma to record discussion features (e.g.

whether the presenter was questioned), and decision features (e.g. the decision made by the team).

These quantitative data will not be described in detail in my PhD analysis, but they will be used to provide background information on patient and team characteristics as an additional source of context.

79 Interviews

Interviews were carried out at the end of the observation period to avoid sensitising teams to the primary outcome measure for the MDT Study. This was decision implementation (whether or not teams implemented the decisions made during the MDT meeting) and the aim was to minimise the impact of the observation on the behaviour of MDT members. Participants were informed that the study was related to the decision making process, but they were not given specific details of which aspects.

Interview topic guides

In collaboration with the other research associates and under the supervision of the Principal Investigator on the MDT Study, I drafted topic guides for the MDT

professional and patient interviews. These were based on reviews of the literature and the research aims of the MDT Study. We revised these based on emerging issues identified during non-participant observation and suggestions from the MDT Study steering group.

The MDT professional interview topic guide included open-ended prompts about how different professional groups interacted in the team, and the information needed to make a decision, in addition to questions about things that did not get discussed enough in the meeting (Appendix 7). I piloted the interview topic guide with a clinical co-applicant from the MDT Study and amended it on the basis of their feedback.

The patient topic guide covered issues such as whether patients were aware of the MDT meeting, and what issues they believed should be considered when the MDT was making decisions about their care (Appendix 8). This topic guide was piloted by another researcher with two patient representatives and amended on the basis of their comments.

80 Sampling and recruitment of MDT professionals

I used purposive sampling to select participants for interview. This is an approach commonly adopted by qualitative researchers when the emphasis is on exploring different accounts of the issue of interest (O’Reilly and Parker, 2013). For this study, my aim was not to generate a representative sample, but to intentionally

incorporate the views of a diverse group of MDT professionals and patients and to explore these in depth (Barbour, 2001). I therefore selected MDT professionals on the basis of professional group, seniority, and level of participation in the MDT meeting as these issues were most salient to the decision making process, and to understanding interaction between team members. A summary of the number of interviewees from each professional group and team is presented in Table 5.

Table 5: Number of interviews by professional group and team Profession Gynae Haem 1 Haem 2 Skin Total

Surgeon¹ 3 - - 0 3

Medical doctor² - 2 1 2 5

Diagnostic doctor³ 1 1 1 0 3

Psychologist 1 - - - 1

CNS 1 1 1 1 4

StR 1 1 1 0 3

Total 7 5 4 3 19

1 includes Consultant Gynaecologists and Plastic Surgeons

2 includes Consultant Haematologists, Dermatologists, and Oncologists

3 includes Consultant Radiologists, Pathologists, and Nuclear Medicine

I approached interviewees after observation for each team was complete. This was done either in person or by email, and individuals were provided with an

information sheet and consent form. While I recommended we arrange a one hour appointment, the interviews lasted on average around 38 minutes, ranging from 20 minutes (when a clinician was called away) to 64 minutes.

The interviews were all conducted at the place of work of the participants and were audiotaped. Information sheets were provided in advance, and written consent obtained on the day of the interview (Appendix 3 and Appendix 4). I wrote

81 reflective field notes following each interview, including comments on setting, the main issues discussed, and areas to follow up in subsequent interviews.

Sampling and recruitment of patients

I also used purposive sampling to select patients under the care of the four cancer teams for interview. To increase the likelihood that interviewees would still be under the care of the team at the point of interview, I initially selected the thirty patients who had been most recently discussed by each team at the end of the observation period. I purposively sampled from this group in terms of disease type, gender and age.

There were five exclusion criteria for the patient interviews, which are detailed in Box 2. I used medical records to assess patients against criteria 1 to 3, and asked a clinician in each team to highlight any cases where they thought the interview would present a risk to the patient or to the interviewer (criteria 4 and 5). These patients were not approached for interview.

Box 2: Exclusion criteria for recruiting patients to interview Exclusion criteria:

1. Non-English speaker 2. Not living in England

3. No longer under the care of a participating team 4. Clinician deems a risk to interviewer

5. Clinician deems too vulnerable for interview

Following this, I asked the lead clinician or a Clinical Nurse Specialist in each team to contact the selected patients in the first instance, as this was a condition of our ethics approval. These clinicians were asked to provide patients with a study information sheet and consent form, and to seek permission for a researcher to contact them directly to discuss the study further. Patients who agreed to be contacted were telephoned, either by me or by another member of the research

82 team, to confirm participation, address any questions they had, and arrange the interview.

Patient interviews took place in the hospital or at the patient’s home and were audiotaped. The length of the interviews ranged from 21 minutes to 67 minutes, with an average time of 34 minutes. As with the professional interviews,

information sheets were provided in advance (Appendix 9), and written consent obtained on the day of the interview (Appendix 10). I wrote reflective field notes directly after each interview I conducted (I recruited and interviewed 4 of the 7 cancer patients included in this sample). We also trained and supervised two Masters students and a medical student to conduct the remaining patient interviews.

There were some specific recruitment challenges for the patient interviews. Initially, the plan had been to conduct 24 interviews with patients under the care of the four cancer MDTs. However, strict time constraints and deadlines imposed by the MDT Study meant that this figure was revised, and it was agreed with the funders that a total of 20 patient interviews would be conducted across the 12 teams recruited (i.e. including mental health, memory clinic and heart failure MDTs). In addition to this, the need for clinicians in each team to generate the initial contact with each patient meant I had less control over the process, and was reliant on busy clinicians taking time out of their schedule to introduce the study to patients on my behalf. As a result of these factors, only seven cancer patients were recruited and interviewed from three of the four teams I observed (there were no patient interviews

conducted with patients under the care of the Skin team due to time constraints).

However, despite the small numbers these interviews provide an opportunity to explore an alternative perspective - both to the views of MDT clinicians, and to the data I captured during observation (O’Reilly and Parker, 2013). For example, the patient interviews gave an insight into patients’ views about what information they shared with different team members, and who they felt should best represent their views in the MDT meeting. For this reason I have decided to include it in my

83 analysis, whilst being mindful of the limitations inherent in such a small number of cases.