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Improvement Initiative study that weekly group debriefing was unlikely to be deliverable in most NHS hospitals outside of a clinical trial. The aim of this process evaluation was to review the delivery of the weekly group debriefing intervention that formed part of the CPR Quality Improvement Initiative study. It was anticipated that these data would be useful in assessing the long-term deliverability of weekly group debriefing and in

identifying challenges and barriers that may help to guide development of alternative debriefing approaches.

A process evaluation examines the interplay between an intervention, the context in which it is delivered, and how well it is delivered.205,206 _{Although rarely undertaken,} process evaluations fulfil two key roles.207-210 _{Firstly, they avoid research wastage by} ensuring that interventions are adequately described to enable replication in other institutions.211,212 _{Despite such information being a requirement of study reporting} guidelines, journal papers often do not include a detailed description of study interventions.213-217 _{Secondly, process evaluations provide important information to} explain study results.205,218,219 _{In the context of negative or neutral studies, this enables} researchers to distinguish between inherently flawed interventions and poorly

implemented interventions, sometimes termed a type III statistical error.205,218,219

Studies frequently incorporate process evaluations in the piloting / feasibility and evaluation stages of the MRC framework.205,209,220-223 _{In contrast to previous studies,} the format of this study allowed process evaluation data to be used in the development of debriefing interventions. A key challenge in undertaking process evaluations is a lack of consensus regarding terminology, methodology, and reporting.205,219,224 _{This has led} to the development of frameworks to improve both intervention reporting and

assessment of intervention delivery.207,224-227 _{For this research, the TIDieR checklist} (template for intervention description and replication) is used to describe the

intervention and its context and the framework developed by Carroll et al is used to evaluate intervention delivery.226,227 _{The 12 item TIDieR checklist facilitates the}

reporting of the intervention, the context in which it was delivered, and how well it was delivered.227 _{The checklist provides a useful framework for describing the intervention} and the context of delivery, but provides little guidance on the complexities of

evaluating intervention delivery. In contrast, the model developed by Carroll et al provides a cohesive framework to describe both what was delivered (termed

“adherence”) and factors that may have affected the impact of the intervention (termed “potential moderators”).226 _{These tools were chosen as, in combination, they cover all} the components of a process evaluation and can be used with all study designs.

Data were collected using an intervention delivery data set and two questionnaires. Questionnaires enabled the efficient collection of data from a large number of participants. This process evaluation was not defined a priori as part of the CPR Quality Improvement Initiative, but was developed as work for this research.180 However, some data are included in the CPR Quality Improvement Initiative study paper.

3.6.1 Data collection

A core data set was collected at each debriefing meeting. The data set included the name and clinical role of the facilitator and attendees, as well as details of the cardiac arrest cases discussed.

Two questionnaires were developed. The first questionnaire collected data about participant’s immediate reaction to the debriefing process (Kirkpatrick Level I- reaction). This was completed by every attendee at each meeting as it was considered that the attendee’s reaction may vary week by week. The second questionnaire collected data about the self-reported effect of debriefing on knowledge and professional practice (Kirkpatrick level II/ III). This was completed by attendees on a single occasion as it was felt that the impact on these factors would be stable over time.

In developing questionnaires, previous studies which had examined clinicians’ views of cardiac arrest debriefing were reviewed in an attempt to identify a reliable and valid questionnaire that could be used for this study. Edelson et al surveyed clinicians on the effect of debriefing on guideline knowledge, leadership skills, and usefulness.152

Subsequently, an internet survey study by Zebuhr et al assessed the effect of particular debriefing components on knowledge and practice.112 _{However, in both studies, the} breadth of collected data was limited and neither study published their questionnaire nor described how it was developed. Therefore, there was a need to develop a new questionnaire.

A key consideration in the questionnaire development process was the need to

maximise response rate in order to minimise non-response bias.228 _{To facilitate this, we} chose to develop a brief, anonymised paper-based questionnaires that could be

completed by attendees at the end of debriefing meetings. However, it was

acknowledged that there was little evidence to support this approach. For example, whilst questionnaire format seems to have little effect on response rate, research typically compares postal questionnaires and internet surveys.229,230 _{In contrast, there is} little research on the approach that we used, namely a written self-completed

questionnaire that is completed immediately. The effect of anonymity on response rate is unclear, but importantly there is no evidence that anonymity is associated with a reduced response rate.228,231-234 _{We chose to make questionnaires anonymous as there} was no plan to follow-up completed questionnaires and there was a concern that participants might be wary of making negative comments if they knew that they could be identified. There is evidence of improved response rates with shorter

questionnaires.235-237 _{By limiting the number of questions, it was possible to fit}

questionnaires on a single page of A5 paper and ensure that questionnaires could be completed quickly at the end of debriefing meetings.

To develop questionnaires, an initial pool of concepts was developed based on the systematic review findings. Concepts were then prioritised based on importance to the research question and specific questions were developed. Questionnaires fitted on a single page of A5 paper and included both closed (multiple-choice and ordinal attitude scales) and open questions to enhance breadth of collected data. They were pilot-

tested by a convenience sample of eight clinicians from a mix of clinical backgrounds (critical care outreach nurses, doctors, ward nurses, and resuscitation officers) to ensure that the question wording was understandable. Minor refinements were made based on feedback.

3.6.2 Data analysis

Data collected from the core data set and demographic data were analysed using descriptive statistics. Attitude scales are reported as median and IQR and number (percentage) of responses in each category.

It was intended to qualitatively analyse free-text responses using a thematic

analysis.238 _{However, a review of questionnaire responses found that they lacked the} richness required for qualitative analysis. Content analysis was selected as an alternative approach. Developed as a method for analysing media output in the late 19th _{century, content analysis consists of the development of a coding frame which is} then used to categorise data.239 _{Data coding was undertaken independently by two} people, and inter-rater reliability assessed using Krippendorf’s-alpha. Krippendorf’s- alpha can be used across all data types and with any number of coders and was specifically developed for use in content analysis.240,241 _{It is measured on a scale} between zero and one, with a value greater than 0.8 representing good inter-rater reliability.240,242