bmj open€¦ · interviews. data analysed using thematic analysis. setting: participants were...

For peer review only

Providing effective trauma care: the potential for service provider views to enhance the quality of care (Qualitative

study nested within a multicentre longitudinal quantitative study)

Journal: BMJ Open

Manuscript ID: bmjopen-2014-005668

Article Type: Research

Date Submitted by the Author: 09-May-2014

Complete List of Authors: Beckett, Kate; University of the West of England, Health & Life Sciences Earthy, Sarah; University of Surrey, Department of Sociology Sleney, Judith; University of Surrey, Department of Sociology Barnes, Jo; Loughborough University, Loughborough Design School Kellezi, Blerina; Nottingham University, Division of Primary care, School of Medicine Barker, Marcus; Nottingham University, Business School Clarkson, Julie; Nottingham University Hospitals NHS trust, Occupational Therapy Coffey, Frank; Nottingham University Hospitals NHS Trust, DREEAM

(Department of Research and Education in Emergency medicine, Acute Medicine and Major trauma) Elder, Georgina; University Hospitals Bristol NHS Foundation Trust, Emergency Department Kendrick, Denise; Nottingham University, Division of Primary care, School of Medicine

<b>Primary Subject Heading</b>:

Health services research

Secondary Subject Heading: Qualitative research, Rehabilitation medicine, Emergency medicine, Evidence based practice, Patient-centred medicine

Keywords:

QUALITATIVE RESEARCH, ACCIDENT & EMERGENCY MEDICINE, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT,

TRAUMA MANAGEMENT, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT

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Title

Providing effective trauma care: the potential for service provider views to enhance the quality of

care (Qualitative study nested within a multicentre longitudinal quantitative study)

Authors’ names:

Kate Beckett, Sarah Earthy, Jude Sleney, Jo Barnes, Blerina Kellezi, Marcus Barker, Julie Clarkson,

Frank Coffey, Georgina Elder, Denise Kendrick and the Impact of Injuries Study group.

Author addresses and positions:

• University of the West of England, Research and Innovation, University Hospitals Bristol NHS

Foundation Trust, Education Centre, Bristol BS2 8AE

Kate Beckett

Research Associate

• Department of Sociology, Faculty of Arts and Human Sciences, University of Surrey, Guildford,

Surrey, GU2 7XH

Sarah Earthy

Lecturer


Surrey, GU2 7XH

Jude Sleney

Research Fellow

• Loughborough Design School, Ashy Road, Loughborough LE1 3TU UK

Jo Barnes

Research Associate

• School of Medicine, Division of Primary Care, Nottingham University, Floor 14, Tower Building,

University Park, Nottingham, NG7 2RD

Blerina Kellezi

Research Fellow

• Nottingham University Business School, Jubilee Campus, Nottingham NG8 1BB

Marcus Barker

Research Assistant

• Nottingham University Hospitals, City Campus, Hucknall Road, Nottingham, NG5 1PB

Julie Clarkson

Occupational therapist

• DREEAM (Department of Research and Education in Emergency medicine, Acute Medicine and

Major trauma), Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG72UH

Frank Coffey

Associate Professor/Consultant in Emergency Medicine

• Emergency Department, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW

Georgina Elder

Research nurse/Senior Staff Nurse

• School of Medicine, Division of Primary Care, Floor 13, Tower Building, University Park,

Nottingham, NG7 2RD

Denise Kendrick

Professor of Primary Care Research

Correspondence to: Professor Denise Kendrick; [email protected]

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Abstract

Objective:

To explore views of service providers caring for injured people on: the extent to which services meet

patients’ needs and, their perspectives on factors contributing to any identified gaps in service

provision.

Design:

Qualitative study nested within a quantitative multicentre longitudinal study assessing longer term

impact of unintentional injuries in working age adults. Sampling frame for service providers was

based on patient reported service use in the quantitative study, patient interviews, and advice of

previously injured lay research advisers. Service providers’ views elicited through semi-structured

interviews. Data analysed using thematic analysis.

Setting:

Participants were recruited from a range of settings and services in acute hospital trusts in four

study centres (Bristol, Leicester, Nottingham and Surrey) and surrounding areas.

Participants:

40 service providers from a range of disciplines.

Results:

Service providers described two distinct models of trauma care; an ‘ideal’ model, informed by

professional knowledge of the impact of injury and awareness of best models of care, and a ‘real’

model based on the realities of NHS practice. Participants’ ‘ideal’ model was consistent with

standards of high quality effective trauma care and whilst there were examples of services meeting

the ideal model, ‘real’ care could also be fragmented and inequitable with major gaps in provision.

Service provider accounts provide evidence of comprehensive understanding of patients’ needs,

awareness of best practice, compassion and research but reveal significant organisational and

resource barriers limiting implementation of knowledge into practice.

Conclusions:

Service providers envisage an ‘ideal’ model of trauma care which is timely, equitable, effective and

holistic, but this can differ from the care currently provided. Their experiences provide many

suggestions for service improvements to bridge the gap between ‘real ‘and ‘ideal ‘care. Using service

provider views to inform service design and delivery could enhance the quality, patient experience

and outcomes of care.

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Article summary

Strengths & limitations of this study

Qualitative study exploring service providers’ perspectives on NHS trauma care nested within a large

UK multi-centre mixed methods study of the Impact of Unintended injuries

Strengths include: a wide participant base from a range of settings and services in 4 diverse UK areas

and interviews and analysis by researchers with a range of clinical and academic backgrounds

Contributes a unique perspective on NHS care generally and Trauma care in particular, identifies

gaps and inequalities in current provision and explores means to improve the safety, effectiveness

and experience of care.

The main limitations are: does not include patient and carer perspectives to permit comparison with

their experiences of care

Factors enabling some professions and individuals to sustain ideal care are not expanded upon.

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Introduction

Unintentional injury accounts for 11,000 UK deaths1 and more than 700,000 hospital admissions in

England per year.2 In the UK 5.8 million people annually attend Emergency Departments (ED)

following an unintentional injury.3 Working age adults comprise nearly 40% of unintentional injury

deaths, 38% of hospital admissions and half of all of ED attendances.3-5

Injuries are a leading cause of

Disability Adjusted Life Years (DALYs) lost, yet their impact and cost to the individual and society is

frequently underestimated.6 A large and growing body of literature demonstrates recovery can be

prolonged and incomplete for many patients and suggests many socio-economic, psychological and

physical predictors of poorer outcomes.7-10

The provision of NHS care for injured patients faces unprecedented challenges.11

Changes in

patterns of injury and improvements in medical care have increased survival after injury and an

ageing population place increasing demands on service provision.12-14

Rapid throughput and early

discharge place additional demands on community resources.15-17

In addition, the drive to improve

the quality of care in terms of safety, effectiveness and patient experience18

raises expectations and

places further demand on services. Recent public inquiries highlight a series of deficiencies in NHS

care in general19

and the National Audit Office report identifies deficiencies in trauma care in

particular.20

Although evidence-based ideal models of trauma care have been described11,20

service providers’

understanding of trauma patients’ needs, their perspectives on real world provision and how

services can better meet the needs of patients are largely unknown. We therefore undertook a

qualitative study to explore the views of those providing services for injured people on the extent to

which services meet patients’ needs, to identify gaps in service provision and views on factors

contributing to those gaps.

Method

We undertook a qualitative study, nested within a multicentre longitudinal quantitative study

assessing the longer term impact of injuries on physical, psychological, occupational and social

functioning in working age adults.21

A total of 668 adults admitted to acute NHS Trusts following an

unintentional injury in four study centres (Nottingham, Bristol, Leicester/Loughborough and Surrey)

took part in the quantitative part of the study. The qualitative component comprised interviews with

a sample of patients participating in the quantitative study, their carers and representative service

providers. This article reports on these service provider accounts. The following description of our

methodology is guided by ‘The Consolidated Criteria for Reporting Qualitative Studies (COREQ) 32

item checklist’ to ensure transparency and aid critical appraisal.22

A sampling frame for service providers was based on: 1) patient service use reported in self-

completed questionnaires at one, two and four months post injury (in the main study), 2) analysis of

22 patient interviews reporting service providers they felt had helped their recovery and 3) advice

from lay research advisers based on their experiences of recovery from injury. We created a list of

service providers and described the proportion of patients using their service and their frequency of

use. We then selected which types of service providers to invite to the study based on the highest

proportion and most frequent patient use. In addition, where patients reported less frequently used

service providers who they felt had helped (e.g. social workers, physiotherapists in private practice),

these providers were also selected. A quota sample for types of service provider and professional

role (manager or more junior) was constructed for each study centre. For hospital based services,

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managers of relevant services were approached initially to identify the most appropriate interviewee

at a senior level and to forward the invitation to more junior members of staff. A similar approach to

recruitment was adopted for non-hospital based service providers. Where there were multiple

service providers within a five mile radius of the hospital (GP practices, physiotherapists and

osteopaths in private practice) a fixed interval sampling method based on a sampling frame ordered

by distance from the hospital was trialled. However only one GP was recruited using this method. In

the other three centres, invitations were sent to all GPs within a five miles radius of the hospital.

Two private osteopaths were recruited by one centre using the same method. All potential

participants were sent an invitation including information about the study aims, objectives and

background and those who responded all agreed to participate and no-one dropped out.

We developed a semi-structured interview topic guide, based on a review of the literature and

previous use in a similar population.23

This topic guide explored the nature of the service offered and

its role in post injury care and support, factors that facilitated or hampered access to and delivery of

services, and gaps in overall provision. It was piloted with two interviews in one site, and deemed fit

for use after discussion among the research team. Further review after four interviews per site and

regular teleconference between researchers aided consistency of approach. Interviewer and

interview characteristics are detailed in Table 1 below.

[Insert table 1 here]

Interview data was coded using NVivo 10 qualitative data analysis software and thematically

analysed following the method outlined in Braun and Clarke (2006). 24

The data were reviewed by JB,

JS, KB, MB (representing all 4 study centres) and Sarah Earthy, a study principal investigator to gain

understanding of key experiences described. This was followed by independent coding of 10% of

the transcripts and development of an initial coding frame through group discussion. This process

also permitted discussion of any researcher assumptions or bias. The resultant code frame was used

by BK, JB and KB to analyse and organise the data in the remaining transcripts. After primary coding

of all 40 interviews it was determined that data saturation (the point at which no new evidence is

emerging) had been achieved and no additional interviews were required. Further cycles of coding

enabled researchers to test the codes assigned, produce broader themes, and identify relationships

and patterns in the data and any divergent cases. Continuous discussions took place to ensure

discrepancies and disagreements were identified and to refine emerging major and minor themes.

Finally three practising clinicians within the study team were asked to comment on the findings to

ensure they reflected their experience and views and further test their credibility and transferability.

Results

Forty interviews were completed with providers of a wide range of services. In accordance with the

study protocol their age and gender was not recorded however by selecting participants from

different disciplines and levels of seniority the sample demographic was representative of NHS staff.

The professional roles of service providers interviewed at each of the four sites are presented in

Table 2. Efforts to recruit representatives from social services or private physiotherapy were

unsuccessful. Study centres are identified only by a randomly assigned letter to maintain anonymity.

Between six and 15 service providers were interviewed in each site depending on levels of response.


Analysis of service provider accounts suggest the co-existence of two distinct models of care: an

aspirational or ideal model of care which participants strive towards (and would like to adhere to)

and a more haphazard, fragmented model based on the realities of NHS practice. Individuals,

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disciplines and settings differed in which model they felt able to follow, but knowledge of and

tensions between these two models permeated all service provider accounts.

Ideal Model

Participants’ ideal model of trauma care was timely, integrated, and seamless:

� “A multidisciplinary effort of managing the patient… everyone has an input into the care … what

this particular patient will need from different professional aspects.” (Junior nurse, Centre A)

Care should be effective, informative and compassionate, and endure throughout the patient’s

recovery journey:

� ”They need the right treatment and … to understand what’s happening to them and to be

listened to, questions actually answered … they need time.” (Specialist nurse, Centre B).

� ”Everything from start to finish. So the beginning of the injury when they need resuscitation right

through to rehabilitation and ongoing... management.” (Specialist nurse, Centre C)

Real model

Participants’ accounts gave many examples where individuals, settings and services met these ideal

standards. However they also acknowledged that the reality of care was sometimes less than ideal,

often due to time pressures or gaps in provision:

� ”We would like to think that we were aiming to provide a high quality of care in a very timely

way … but the reality is probably a bit different to that unfortunately.” (Senior nurse, Centre D).

� ”Staff don’t always have that time to give to the patient … the pressures are on the bed and the

staff know it … so you daren’t ask (the patient) a question in case you get held up.” (Senior

nurse, Centre C)

� ”Patients aren’t getting the right level of rehab that they need … there’s a lack of psychological

support and vocational rehab, lots of things that in an ideal world these patients should be

getting, but they’re not.” (Physiotherapist, Centre A)

Participants described a complex system in which these two models of practice coexist and give rise

to very different standards of care (See Box 1).

[Insert box 1 here]

Participants recognised and managed daily inconsistencies between ideal and real models of care.

Their accounts also provide insight into possible reasons for the divergence between models, as

described below.

1) Knowledge

Service providers demonstrated a comprehensive understanding of the potential impact of injury on

patients’ lives:

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� ”Injury involves change to a normal routine, the frustration of not being able to do what you feel you

ought to … or want to be able to do. The financial strains, the family strains, and the relationship

strains … it’s endless.” (Senior physiotherapist, Centre D)

This knowledge, gained through experience, training and research, informed their ideal model of

care:

� ”I’ll be looking at the impact on their functional activity, their work and leisure, their personal care

and the way it impacts on their lives socially and psychosocially as well … the way it’s affecting their,

… family life and relationships.” (Occupational therapist, Centre B)

Where there were gaps in knowledge, these related to difficulty keeping fully informed about the

range of NHS and other services available:

� ”Either I don’t know about the services available or it’s difficult to access them in a timely fashion...

that can be frustrating at many levels.” (General Practitioner, Centre D)

2) Research

Participants explicitly referred to research evidence that informed best models of care for their

professional role:

� ”Research suggests that good quality trauma care makes a massive difference to people’s outcome

overall, is a huge benefit to society… quite apart from being the right thing to do …it’s expensive to

provide … but on the whole it saves money.” (Consultant, Centre C)

� ”So if people have got a job open … we intervene very early with education, because it’s been found

research wise that the earlier that’s addressed, the better the outcome.” (Occupational therapist,

Centre B)

� ”Things like complex regional pain syndrome … something that can happen after an injury …picking

that up early and dealing with it early the research shows that the outcomes are so much better.”

(Specialist physiotherapist, Centre D)

Research evidence was also used pro-actively to demonstrate where care was falling below ideal

standards:

� ”There are big gaps but hopefully with the information I am gathering I can report … figures and

percentages … to say they are not meeting these people’s services.” (Specialist nurse, Centre D)

Whilst it is often considered that experiential rather than research knowledge underpins practice;

many participants demonstrated familiarity with current research and desire for additional evidence

to support improvements in care.

� ”We use the DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure … it’s got a good

evidence base… it incorporates the individual’s view of their function… I’d like to look at how we can

produce something that reflects that, but also reflects the economical advantage in the long term but

… the difficulty is people often are looking at short economical advantage, not long term.”

(Occupational Therapist, Centre B)

3) Barriers to delivery of service provider’s ideal model of care

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Participant accounts suggest that divergence between ideal and real models of care cannot be

accounted for by lack of understanding of the impact of injury or evidence of best models of care.

However they provide clear evidence of factors (variously described as ‘gaps’, ‘blocks’ or ‘holes’)

affecting implementation of this knowledge into practice:

� “There’s lots of holes for the patient to fall down depending on who has interacted with them in the

hospital, what sort of discharge plan they have got.” (Specialist physiotherapist, Centre C)

� ”There’s blocks at every stage of the process … you make all these good plans … but it just doesn't

work.” (Junior doctor, Centre D)

� “There are massive gaps in the service … for somebody who needs more care and more help …it can

clog up the system terribly …for shortage of somewhere for them to go that’s a safe environment.”

(Physiotherapist, Centre D)

Analysis of the interviews suggests six distinct types of ‘blocks’, ‘gaps’, or ‘holes’ impeding service

delivery:

a) Access to services

Study participants described significant gaps in provision and delays in access to services which

hindered recovery for the individual and caused whole system blockages and inappropriate resource

use. Particular issues were highlighted in trauma theatre capacity, resources for younger patients,

psychological services and community rehabilitation.

� “This week …I have ended up putting 12 incident forms in for patients who haven’t gone to theatre

within 36 hours.” (Specialist nurse, Centre D)

� ”We run into problems with waiting for social services and packages of care … we’ve got a patient

who’s been here for 4 weeks fit for discharge.” (Junior doctor, Centre D)

� “All those long term rehab places …particularly for younger patients … are in very short supply …

once they’ve got over the immediate injury, they need to get on with trying to rehabilitate

themselves.” (Consultant, Centre C)

� ”Some people have had to wait for 4 to 5 months before starting counselling.” (General Practitioner ,

Centre C)

� “If they need physio in their own home, the wait for an urgent referral is 18 weeks… if we’ve worked

really hard (in hospital) and got them to a really good point … that generates a lot of frustration …

and we can’t do anything about it.” (Specialist physiotherapist, Centre D)

Lack of available psychological support for patients was noted by many participants who described a

combination of strategies to manage patients’ psychological needs (avoidance, amateur psychology

or referral to General Practitioner). Some disciplines such as physiotherapy provided extensive

psychological support in the absence of formal or ‘standardised’ psychological services. However

there was general concern at how a lack of more formal specialist support might affect

rehabilitation:

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� “We see people who’ve had quite horrendous experiences … they’re making a physical recovery. But

when they talk about what’s happened… the people that you think are fine sometimes just break

down …it would be great if there was someone you could just call and say ‘… I’ve got a patient I think

you need to see’, but that isn't available to us.” (Occupational therapist, Centre B)

� “I don’t think we address the psychological aspect at all… and that would help our patient because if

they’re in the right frame of mind it will definitely improve their input into … their physio and that

sort of thing.” (Doctor/Registrar, Centre B)

b) Funding streams

Interviewees referred to further blockages caused by funding streams and restrictive access to

services. This prevented referral of patients based on individual need and created ethical dilemmas

for service providers.

� Patients with minor head injuries; “get followed up, hopefully, but only if they live within (city)… the

rest of them are left to their own devices.” (Matron, Centre C)

� “I saw a 40 year old chap today … lives on his own but he didn’t really hit the right criteria for … social

support.” (Senior physiotherapist, Centre D)

� “It becomes slightly unethical if you’ve fractured a few centimetres below (the neck of femur)... you

suddenly don’t fall into the same category…. you don’t have the same time pressure and you won’t

have the same treatment afterwards.” (Consultant, Centre A)

� “You’ve got different pathways for the different areas and that can be really frustrating … we can

send somebody home non-weight bearing … and they’ll have to wait 12 weeks for a physiotherapist.”

(Specialist nurse, Centre B)

c) Staffing and skill mix

Service providers described not only lack of staff per se as having a profound effect on service

delivery, but also reductions in the level of expertise through inadequate ‘skill mixing’ and excessive

administrative or managerial demands on senior practitioners (which reduced the potential for

improvements in quality of care). There was also a perception that external review of staffing

underestimated clinical demands on staff with resultant recommendations impacting on the quality

of care.

� “Today I’ve visited probably 9 wards by eight o’clock this morning and all of those wards were

helping each other out because they were short staffed.” (Matron, Centre A)

� “Things like intravenous pain relief are delayed … that’s ethically wrong to delay pain relief just

because a service had put on the wrong skill mix.” (Paramedic, Centre D)

� “There’s this kind of pressure to downgrade posts … to reduce the level of expertise.”

(Physiotherapists, Centre C)

� “There’s just so many things you don’t need to be a nurse to do. I don’t need to be a qualified nurse

to tick a few audits… if some of those things were taken off me I would be able to support the team

better on the ward and the patients better.” (Matron, Centre D)

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� “The trust asked for an external review on the nursing figures on the wards… it completely

underestimated the patients with dementia, the patients that came in with very poor nutritional

states… that was a massive battle and we went to a very low place in terms of nursing care.”

(Matron, Centre A)

d) Patient expectations, changing demographic & NHS use

Participants felt some patients had unrealistic expectations of recovery and made inappropriate use

of hospital services against a backdrop of increasing demands from an ageing population:

� “There’s a sort of expectation that we can just click our fingers and put a few bits of metal in and…

there you are, you’re back to normal …we are not magicians, we can’t turn everything back to how it

was before.” (Consultant, Centre A)

� “One in four people don’t need to be in ED (Emergency department). We have a high level of

inappropriate use.” (Junior nurse, Centre C)

� ”The mix has changed… we are predominantly… elderly care patients with acute confusion, with

dementia, and trauma … it is very heavy… patients are highly dependent.” (Specialist nurse, Centre

D)

e) Communication & information

Service providers acknowledged that communication between services and settings is sometimes

poor and compounded by professional boundaries and hierarchy. The complexity and demands of

service provision also make effective communication with patients and between professionals

increasingly difficult.

� “For the outlying wards, the doctors will present the patients, they won’t … necessarily know where

they are in the hospital, they might be moved around here, there and everywhere … they may miss a

patient on an outlying ward.” (Physiotherapist, Centre A)

� ”We need better working relationship with the community; the community needs to have better

working relationship with us. We don’t have that contact at all.” (Matron, Centre D)

� ”I don't have access to notes …because we (private osteopath) are on the cusp of the NHS … it

prevents me from doing something, treatment wise, technique wise… all these expensive tests … but

the person that could potentially help the patient can't get hold of them.” (Private osteopath, Centre

C).

f) Organisational values & priorities

Study participants described significant tensions between their professional and personal views on

the care that should be provided and organisational values and political and financial priorities which

could lead to an emphasis on short term finite outcomes;

� ”For society and for the patient longer term outcomes are hugely important. To my view there’s a

disconnect … because services at an earlier stage … don’t have a financial interest in the longer term

outcome. They only have an interest in the outcome of that phase.” (Physiotherapist, Centre C)

� “We have these very sort of … politically driven clinical guidelines.” (Consultant, Centre A)

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� ”I think they don’t actually collect … outcomes long enough in my view.” (General Practitioner,

Centre C)

Some service providers took a more pro-active stance in seeking to influence the commissioning of

services or in resisting management led pressures:

� “We need to get our commissioners to understand where the gaps are and what the problems are…

to get them to wake up… these patients aren’t getting the right level of rehab they need.”’

(Physiotherapist, Centre A)

� “I feel under pressure to follow the alternative care pathways, but I’ll only do that if it’s appropriate, I

won't do it because I’m supposed to.” ( Paramedic, Centre D)

� “I do go against management; I will not discharge somebody until I know (it) will be safe regardless

of the pressure on beds.” (Specialist nurse, Centre B)

Discussion

Our participants’ gave accounts of an “ideal” model of care which demonstrate a clear knowledge of

and commitment to Darzi’s (2008)18

elements of high quality care and key components of trauma

provision.11, 20

However service providers reported that their ability to adhere to this model in

practice was, at times compromised and their clinical decisions limited by factors such as insufficient

resources, gaps in communication and information, conflicting organisational values and priorities,

unrealistic patient expectations, the demands of an ageing population, and inadequate staffing

levels or skill mix. Our participants’ accounts suggest basic quality standards of safety, efficacy and

patient experience may not be universally met by current provision. Within the ‘real’ model of care,

service providers cannot always respond to the full range of patient needs following injury or

anticipate predictable sequelae such as psychological distress. Service providers are fully aware of

these limitations and consequences and strive to deliver the best care they can within increasingly

limited resources, downgraded skill mix and complex systems. However, the risk for patients is that

this may result in fragmented, inequitable and suboptimal care.

Our study draws on the views of a wide range of service providers in secondary and primary care

from four areas serving varied populations in terms of size, ethnic and socioeconomic mix. Whilst

our findings cannot be generalised to all UK primary and secondary care settings, it is unlikely that

the experiences of the service providers interviewed are restricted to the four study centres only.

Conduct of the interviews and analysis by researchers with diverse academic and clinical

backgrounds also enhanced the validity and transferability of the findings. Sample selection based

on patients’ accounts of the services used resulted in a combination of perspectives from both

frequently accessed services and those accessed by fewer patients with specific needs. We had

difficulty in recruiting some types of service providers; notably social services, counselling services

and physiotherapists working in private practice. Respondents in some staff groups were identified

by their managers, who may have chosen people who held particular views. However, the diverse

positive and negative views provided by service providers would suggest this is unlikely to have had

a large impact on our findings. Since all participants conveyed both positive and negative views;

there were no divergent cases (in which a wholly positive or negative model was described) however

the proportion of positive vs negative views varied between participants and disciplines. Future

analysis could expand on this to identify factors sustaining ideal care and analysis of IOIS patient and

carer data will permit comparison with their experiences of care.

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This study contributes to current debate on the quality of NHS care, illustrating how service provider

perspectives can improve our understanding of the current situation and inform future

improvement. Successive studies show how the gap between ‘ideal’ and ‘real’ models of care can

affect service provider wellbeing and caring25, 26

and this study demonstrates this process in action.

The recently published ‘RN4CAST study’ of hospitals in 300 European countries goes further and

demonstrates how reduction in nursing numbers and skill mix alone can be associated with poorer

outcomes and higher mortality rates.27

This study also contributes to possible solutions; practitioner

knowledge of local context is increasingly acknowledged as essential to overcome barriers to

translating evidence into practice.28

While many studies identify means to improve the effectiveness

and safety of care this study adds to understanding of the ‘aesthetics of experience’ or how services

feel (their usability and emotional content).29

These are also important determinants of best practice

and patient experience and can lead to improvements in service delivery and patient care.29

This study questions current media and policy debate exhorting service providers to be more

compassionate 30, 31

, to extend their knowledge and education18,32

and to work harder to raise

standards33

and provides alternative perspectives on factors impeding an ideal model of care. It

suggests compassion is not lacking, that service providers (across a wide range of disciplines) have a

comprehensive understanding of the impact of injury on patients’ lives and have knowledge of

evidence identifying best models of care. However, the extent to which their understanding and

knowledge informs practice is determined by factors which are frequently beyond their control.

Some services, settings and individuals clearly feel their context of care is more conducive to practice

according to an ideal model than others, for example, striking differences exist between nursing and

physiotherapy care post injury.34

Service providers’ experiences of providing care which they feel is

at odds with their ideal model of care, gives rise to a series of practical suggestions for service

improvements. These wide ranging suggestions are described in Box 2.

[Insert box 2 here]

Improving planning and organisation of trauma care can achieve better treatments and improved

outcomes.35

The views of a range of service providers across the trauma pathway are important;

they demonstrate compassion, a comprehensive understanding of patients’ needs, knowledge of the

evidence base underpinning best practice, and motivation to deliver the best possible care. Service

provider views should be routinely used to inform service design, planning and delivery, and the

impact of this on the quality of care, patient outcomes and patient experience should be evaluated

in future research. However, service provider views are only one side of the story, the views of

patients and carers also need to be collected, listened to and acted upon.

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References

1. Office for National Statistics: Mortality statistics: Deaths registered in 2011 (Series DR) Table 5.

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Accessed 11/02/14

2. Department of Health. HES online: Hospital Episode Statistics. External cause table 2011-2012.

[http://www.hscic.gov.uk/searchcatalogue?productid=9161&q=title%3a%22Hospital+Episode+Statis

tics%3a+Admitted+patient+care%22&pubdate=%2c2012&sort=Relevance&size=10&page=1#top]

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3. Department for Trade and Industry. 24th (final) report of the home and leisure accident

surveillance system, 2000, 2001 and 2002 data.

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4. Office for National Statistics. Mortality statistics. Injury and Poisoning. Series DH4 no 30. 2005.

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5. Department of Health. Hospital Episode Statistics. External cause table 2006-07.

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6. Lyons R, Kendrick D, Towner E, Christie N, Macey S, Coupland C. et al. Measuring the population

burden of injuries- implications for global and national Estimates: a multi-centre prospective UK

longitudinal study. BMC Pub Health. 2011 Dec;8 (12)

7. Polinder S, Haagsma J, Belt E, Lyons R, Eransmus V, Lund J. et al. A systematic review of studies

measuring health-related quality of life of general injury populations. BMC Public Health 2010 Dec

;10:783

8. Black J, Herbison G, Lyons R, Polinder S, Derrett S. Recovery after injury: an individual patient data

meta-analysis of general health status using the EQ-5D. J Trauma. 2011 Oct;71(4):1003-1010.

9. Wiseman T, Foster K, Curtis K. Mental health following traumatic physical injury: An integrative

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11. NHS Confederation & Ambulance Service Network. Implementing trauma systems: key issues for

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12. The intercollegiate group on trauma standards. Regional trauma systems interim guidance for

commissioners. London; The Royal College of Surgeons of England; 2009.

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Trauma Workforce. London; CFWI Regional Trauma Network Team; 2011.

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[http://www.hscic.gov.uk/catalogue/PUB13040/acci-emer-focu-on-2013-rep-V2.pdf] Accessed

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17. Edwards, N. Community services; how they can transform care. The Kings Fund, 2014

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edwards-feb14.pdf] Accessed 28/02/2014.

18. Department Of Health. High quality care for all NHS next stage review. 2008.

[http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum

_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085828.pdf] Accessed

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19. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The

stationery office, 2013. [http://www.midstaffspublicinquiry.com/report] Accessed 16/02/2014

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General. 2010. [http://www.nao.org.uk/report/major-trauma-care-in-england/] Accessed

16/02/2014

21. Kendrick D, O'Brien C, Christie N, Coupland C, Quinn C, Avis M. et al. The impact of injuries

study. Multicentre study assessing physical, psychological, social and occupational functioning post

injury - a protocol BMC Public Health. 2011 Dec;11;963

22. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a

32-item checklist for interviews and focus groups. Int J Qual Health C. 2007;19(6): 349-357

23. Sleney J, Christe N, Earthy S, Lyons R, Kendrick D, Towner E. Improving recovery - Learning from

patients experiences after injury: A qualitative Study. Injury. 2014 Jan;45(1):312-319.

24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2): 77-101

25. Glasberg A, Eriksson S, Norberg A. Burnout and ‘stress of conscience’ among healthcare

personnel. J Adv Nurs. 2007 Feb; 57(4):392-403.

26. Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience, stress of conscience and

burnout among nursing staff in residential elder care. J Adv Nurs. 2010 Aug; 66(8):1708-1718.

27. Aiken L, Sloane D, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. for the RN4CAST

consortium. Nurse staffing and education and hospital mortality in nine European countries: a

retrospective observational study. Lancet. 2014 Feb; [Published Online

http://dx.doi.org/10.1016/S0140-6736(13)62631-8] Accessed 03/03/2014

28. Flottorp S, Oxman A1, Krause J, Musila N, Wensing M, Godycki-Cwirko M, Baker R, Eccles M. A

checklist for identifying determinants of practice: A systematic review and synthesis of frameworks

and taxonomies of factors that prevent or enable improvements in healthcare professional practice.

Implementation Science 2013, 8:35 http://www.implementationscience.com/content/8/1/35

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29. Bate P, Robert G. Bringing user experience to healthcare improvement: the concepts, methods

and practices of experience based design. 2007: Radcliffe Publishing. Oxford & New York

31. Department of Health: NHS Commissioning Board. Compassion in Practice: Nursing Midwifery

and care staff our vision and strategy. 2012. [http://www.england.nhs.uk/nursingvision/] Accessed

11/02/2014

32. BBC Report: Nurses in drive for more ‘compassionate care’. 2012 Dec;

[http://www.bbc.co.uk/news/health-20583115] Accessed 28/02/2014

33. Adams S, Smith R. Report: Nurses 'are losing their sense of compassion’. The Telegraph 2012 Jan

09 [http://www.telegraph.co.uk/health/healthnews/9003772/Nurses-are-losing-their-sense-of-

compassion.html] Accessed 16/02/2014

34. Royal college of Nursing. Special report: Frontline First: Running the red light. 2013.

[http://royalnursing.3cdn.net/e678a38646d8d670b1_rdm6bgu19.pdf] Accessed 16/02/2014

35. Beckett, K. Professional wellbeing and caring: Exploring a complex relationship. Br J Nurs 2013

Oct;22(19):1118-1124.

36. World Health Organisation. Guidelines for Essential Trauma Care. 2004 Jul.

[http://whqlibdoc.who.int/publications/2004/9241546409.pdf] Accessed 28/02/2014

Author contributions

DK, JS, FC, JB, BK made substantial contributions to the conception and design of the work, KB, SE,

JS, JB, BK, MB, GE made substantial contributions to the acquisition and analysis of the data; KB, SE,

MB, JS, JB, BK, JC and DK contributed substantially to the interpretation. All authors contributed to

drafting the work, revising it critically and approved the final version to be published.

Ethical approval

Ethical approval for the study was provided by Nottingham Research Ethics Committee 1 (number:

09/H0407/29).

Participant consent

All participants gave informed consent including the statement: ‘I agree that quotes from the

interview that do not identify me can be used in reports.’

NIHR Funding & disclaimer

This research was funded by the National Institute for Health Research Collaboration for Leadership

in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire (NIHR

CLAHRC NDL). The views expressed in this work are those of the authors and not necessarily those of

the NHS, the NIHR or the Department of Health.

Data Sharing

No additional data available

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Table 1: Interviewers and interview characteristics

Interviewers

Which authors conducted the

interviews

Blerina Kellezi (BK), Jo Barnes (JB), Jude Sleney (JS), Kate Beckett

(KB), Marcus Barker (MB)

Qualifications BK, JB (PhD), JS (MSc), MB (MA (Cantab)), KB (BSc)

JB, KB (Registered Nurses)

Occupation at time of study BK: Research fellow; JB, JS,KB: Research Associate, MB: Research

Assistant - all university employees

Gender BK,JS,JB,KB: Female; MB: Male

Training All have had training and experience in Qualitative research

methodology

Was the interviewer already

known to study participants?

A small number of participants were acquainted with their

interviewer through prior involvement in quantitative study

recruitment and may have been aware of their interviewers’

background.

Interviews

Setting Interviews were carried out in the participants place of work in a

quiet private space

Who was present? Participant and interviewer only

Duration Interviews lasted between 30-60 minutes

Audio-visual recording All interviews were audio recorded with participant consent

Consent Consent was obtained at the time of interview or before if

conducted by telephone

Confidentiality Interviewees were assured of anonymity and confidentiality both

for themselves and their organisation

Transcription Interviews were centrally transcribed and checked for accuracy

by site researchers

Field notes Field notes were recorded following the interview to add context

to the analysis

Repeat interviews No repeat interviews were deemed necessary

Post interview contact All participants were given contact details for any further

thoughts or comments they wanted to add after the interview

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Table 2: Numbers and types of service providers interviewed by study centre.

Study centre A B C D Total

Ambulance service – Paramedic 1 1

Ambulance service – Manager 1 1 2

Doctor - General Practitioner 2 1 3

Doctor – Junior 1 1

Doctor – Registrar 1 1

Doctor – Consultant 1 1 2

Doctor - Medical director 1 1

Nurse – Primary care 1 1

Nurse – Junior 3 1 4

Nurse – Senior/Sister 1 1 2

Nurse – Specialist 1 1 1 3

Nurse- Matron 2 1 1 4

Occupational Therapist 2 2

Physiotherapist - Junior 1 1 2

Physiotherapist – Senior 3 3

Physiotherapist – Specialist 1 2 3

Physiotherapist – Manager 1 1

Private practice – Osteopath 2 2

Psychologist – Specialist 1 1

Voluntary sector –Manager 1 1

Total 7 6 15 12 40

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Box 1: Ideal & Real Models of Care in relation to Darzi’s (2008) 18

3 elements of good quality care

Box 1: Ideal & Real Models of Care in relation to Darzi’s (2008)18


IDEAL REAL

Safety

• “Actually they’re going to be safe in our hands

and … the care they’re going to receive is good.”

(Senior nurse, Centre D)

• “That’s my patient, their safety comes first.”


• “Being able to provide a service with skilled

clinicians … the knowledge to be able to treat a

patient safely … as an emergency service you

can't ask for any more.” (Manager ambulance

service, Centre C)

• “I think when you want to get patients to theatre ... it’s full ...

sometimes you see a little bit of harm come to patients because they

don't get to theatre in time.” (Junior doctor, Centre D)

• “So whether or not the continual monitoring gets done is a different

matter... without continual monitoring you can’t say that they’re

going to remain fine.” (Junior nurse, Centre C)

• “We get a phone call maybe for some pain medication … somebody’s

got a major life event and we don’t know about it (lack of

communication) ... so there are safety issues there about prescribing

medication.” (GP, Centre D)

Effectiveness

• “Getting the patients treated at the right time

with the right services ... getting them treated

early picking up the people that need additional

services especially psychology getting them in

there quickly to … prevent future disability.”

(Occupational therapist, Centre B)

• “My role is to ensure that the patient’s care

pathway is efficient, timely and they have a

satisfaction in the service.” (Junior nurse,

Centre A)

• “We have so many ankle fractures sitting around on the ward for a

week before the operation… if you operated on them straightaway …

they would be done and out the next day.” (Junior doctor, Centre D)

• “It’s a high pressure job … you don’t feel like you can give high quality

care … that individual’s satisfaction of what you consider high quality

care isn’t always … what the department offers.” (Senior Nurse,

Centre D)

• “I would say…for the patients who need psychological support that’s

one of the main things that’s lacking …in every hospital … there’s no

access to it for patients.” (Physiotherapist, Centre A)

Patient Experience

• “Enough information about their condition to

help them not to be scared of it … they need to

understand the reasons why we have asked

them to do what they are doing … to

understand what they are feeling and

experiencing.” (Senior physiotherapist, Centre

D)

• “I suppose it’s easier just getting your head down and doing the tasks

... during busy times especially just knowing that you’ve done this,

this and this, ….It’s almost like once you’ve done the task, then it

becomes somebody else can care about the kind of emotional side of

it.” (Junior nurse, Centre C)

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Box 2 Possible improvements to care based on service providers perspectives

Box 2: Possible improvements to care based on service providers perspectives

Knowledge

• Develop practitioner capacity to utilise and collate evidence relating to standards of care

• Develop an online regularly updated directory of services for practitioner reference

Services

• Expand trauma theatre capacity to ensure appropriately timed surgical intervention

• Expand existing and develop new screening and treatment options for post injury psychological problems

• Develop capacity for community rehabilitation (residential, domiciliary or out-patient) to ensure early discharge of

medically fit patients, sustain progress made in hospital and enable early intervention to prevent longer term problems

Funding streams

• Harmonise referral criteria across geographical boundaries

• Facilitate service access for those who do not fit ‘typical’ criteria (based on clinical assessment of need)

• Remove incentivised targets for particular cohorts and equalise access based on clinical need

Staffing and skill mix

• Ensure adequate staff numbers to effectively and compassionately meet clinical demands

• Involve senior practitioners in scoping staff and skill mix requirements

• Identify non clinical tasks and devolve to additional administrative workforce

• Utilise senior clinical expertise to drive improvements in standards through direct clinical input and supervision of junior

staff

Patient expectations

• Improve patient information at all levels using a range of sources and means

• Expand public education on appropriate NHS use

• Enhance public involvement in realistic NHS goal setting and resource allocation

Communication and information

• Formalise systems to ensure outlying patients are not neglected

• Engage practitioner groups in developing initiatives to improve communication between primary and secondary care

• Develop secure means of information sharing with non NHS practitioners

Organisational values and priorities

• Ensure equal focus & resourcing for acute and rehabilitation phases of recovery

• Develop measures and means to collate evidence of longer term injury outcomes e.g. return to work

• Undertake economic research into comparative costs of short term intensive multi-disciplinary rehabilitation vs long

term disability and resource use

• Ensure individual clinical need drives care rather than political or organisational targets

• Recognise practitioner expertise and facilitate practice according to their ideal evidence based model of care

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Authors: Kate Beckett, Sarah Earthy, Jude Sleney, Jo Barnes, Blerina Kellezi, Marcus Barker, Julie

Clarkson, Frank Coffey, Georgina Elder, Denise Kendrick and the Impact of Injuries Study group.

Contributors/acknowledgements

We wish to thank the service providers and patients who participated in the study. We would also

like to thank the principal Investigators, research nurses and other staff from the emergency

departments who assisted with recruiting participants from United Hospitals Bristol NHS Foundation

Trust; North Bristol NHS Trust, Nottingham University Hospitals NHS Trust, University Hospitals of

Leicester NHS Trust, Royal Surrey County Hospital NHS Foundation Trust. We gratefully acknowledge

the support provided for recruitment by the Mental Health Research Network West Hub. We thank;

Professor Jonathan Benger from The University of the West of England, Professor Joe Dias from

Leicester University, Dr Claire O’Brien, Shireen Patel, Chris Craig, Marcus Barker, Emma Rowley from

the University of Nottingham; Emma Alderman from the Leicester Royal Infirmary, Sara Quinn and

Francesca Hole from Royal Surrey County Hospital who helped with recruitment, data collection,

prepared data for analysis or commented on drafts of papers. We would like to acknowledge the

following principal investigators who contributed to obtaining funding, study design, project

management in their centres and to interpretation of analyses and commented on drafts of papers:

Professor Elizabeth Towner, (University of the West of England); Professor Andrew Morris

(Loughborough University), Dr Nicola Christie (University College of London). We are also very

grateful to Trevor Jones, lay research adviser, who attended project management meetings, helped

draft and pilot study documentation and advised on recruitment strategies.

Conflict of Interests statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf

and declare: some authors had financial support from the National Institute for Health Research

(NIHR) for the submitted work; no financial relationships with any organisations that might have an

interest in the submitted work in the previous three years; no other relationships or activities that

could appear to have influenced the submitted work.

Copyright

The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of

all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats

and media (whether known now or created in the future), to i) publish, reproduce, distribute, display

and store the Contribution, ii) translate the Contribution into other languages, create adaptations,

reprints, include within collections and create summaries, extracts and/or, abstracts of the

Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all

subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to

third party material where-ever it may be located; and, vi) licence any third party to do any or all of

the above.

Data access statement

All authors had full access to all of the data in the study and can take responsibility for the integrity

of the data and the accuracy of the data analysis.

Guarantor statement

The lead author (the manuscript's guarantor) affirms that the manuscript is an honest, accurate, and

transparent account of the study being reported; that no important aspects of the study have been

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omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have

been explained

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Application of COREQ checklist for interviews and focus groups (Tong et al 2007) to Beckett et al (2014) "Providing effective trauma care:

the potential for service provider views to enhance the quality of care”

No Item Guide questions/description Page number in PDF

Domain 1: Research team and reflexivity

Personal Characteristics

1. Interviewer/facilitator Which author/s conducted the interview or focus group? 18

2. Credentials What were the researcher's credentials? E.g. PhD, MD 18

3. Occupation What was their occupation at the time of the study? 18

4. Gender Was the researcher male or female? 18

5. Experience and training What experience or training did the researcher have? 18

Relationship with participants

6. Relationship established Was a relationship established prior to study commencement? 18

7. Participant knowledge of the

interviewer

What did the participants know about the researcher? e.g. personal goals,

reasons for doing the research

18

8. Interviewer characteristics What characteristics were reported about the interviewer/facilitator? e.g. Bias,

assumptions, reasons and interests in the research topic

18, 12, 5

Domain 2: study design

Theoretical framework

9. Methodological orientation

and Theory

What methodological orientation was stated to underpin the study? e.g.

grounded theory, discourse analysis, ethnography, phenomenology,

5

Participant selection

10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, 4

11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email 5

12. Sample size How many participants were in the study? 5

13. Non-participation How many people refused to participate or dropped out? Reasons? 5

Setting

14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace 18

15. Presence of non-participants Was anyone else present besides the participants and researchers? 18

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16. Description of sample What are the important characteristics of the sample? e.g. demographic data 5, 19

Data collection

17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested? 5

18. Repeat interviews Were repeat interviews carried out? If yes, how many? 18

19. Audio/visual recording Did the research use audio or visual recording to collect the data? 18

20. Field notes Were field notes made during and/or after the interview or focus group? 18

21. Duration What was the duration of the interviews or focus group? 18

22. Data saturation Was data saturation discussed? 5

23. Transcripts returned Were transcripts returned to participants for comment and/or correction? 18

Domain 3: analysis and findings

Data analysis

24. Number of data coders How many data coders coded the data? 5

25. Description of the coding tree Did authors provide a description of the coding tree? 5

26. Derivation of themes Were themes identified in advance or derived from the data? 5

27. Software What software, if applicable, was used to manage the data? 5

28. Participant checking Did participants provide feedback on the findings? 5

Reporting

29. Quotations presented Were participant quotations presented to illustrate the themes / findings? Was

each quotation identified? e.g. participant number

6-11

30. Data and findings consistent Was there consistency between the data presented and the findings? 6-12

31. Clarity of major themes Were major themes clearly presented in the findings? 6-8

32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes? 8-11, 12

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STUDY PROTOCOL Open Access

The impact of injuries study. Multicentre studyassessing physical, psychological, social andoccupational functioning post injury - a protocolDenise Kendrick1*, Claire O’Brien1, Nicola Christie2, Carol Coupland1, Casey Quinn1, Mark Avis3, Marcus Barker4,Jo Barnes5, Frank Coffey6, Stephen Joseph7, Andrew Morris5, Richard Morriss4, Emma Rowley8, Jude Sleney9 andElizabeth Towner10, for Impact of Injuries Study Group

Abstract

Background: Large numbers of people are killed or severely injured following injuries each year and these injuriesplace a large burden on health care resources. The majority of the severely injured are not fully recovered 12-18months later. Psychological disorders are common post injury and are associated with poorer functional andoccupational outcomes. Much of this evidence comes from countries other than the UK, with differing health careand compensation systems. Early interventions can be effective in treating psychological morbidity, hence the scaleand nature of the problem and its impact of functioning in the UK must be known before services can bedesigned to identify and manage psychological morbidity post injury.

Methods/Design: A longitudinal multi-centre study of 680 injured patients admitted to hospital in four areasacross the UK: Nottingham, Leicester/Loughborough, Bristol and Surrey. A stratified sample of injuries will ensure arange of common and less common injuries will be included. Participants will complete a baseline questionnaireabout their injury and pre-injury quality of life, and follow-up questionnaires 1, 2, 4, and 12 months post injury.Measures will include health and social care utilisation, perceptions of recovery, physical, psychological, social andoccupational functioning and health-related quality of life. A nested qualitative study will explore the experiencesof a sample of participants, their carers and service providers to inform service design.

Discussion: This study will quantify physical, psychological, social and occupational functioning and health andsocial care utilisation following a range of different types of injury and will assess the impact of psychologicaldisorders on function and health service use. The findings will be used to guide the development of interventionsto maximise recovery post injury.

Keywords: Unintentional injury, Disability, Psychological morbidity

BackgroundWorldwide 5.8 million people die [1] and more than 45million are moderately or severely disabled followinginjury each year [2], making injuries responsibleannually for 10% of all deaths [1] and 16% of all disabil-ities [2]. Injuries were the leading cause of preventableyears of life lost between the ages of 0 and 74 years in2005 [3]. The scale of the problem is likely to increase,

as injury related deaths are projected to rise by 28%between 2004 and 2030, predominantly due to deathsfrom road traffic injury [2]. Unintentional injuries alsoplace a large burden on health care resources. Theyresult in more than 11,000 deaths in England and Wales[4], three quarter of a million hospital admissions inEngland, resulting in more than 3.6 million bed days [5]and 5.8 million Emergency Department (ED) atten-dances in the UK [6]. Working age adults comprise 40%of unintentional injury deaths, 35% of hospital admis-sions and 50% of ED attendances [5-7].

* Correspondence: [email protected] of Primary Care, Tower Building, University Park, NG7 2RDNottingham, UKFull list of author information is available at the end of the article

Kendrick et al. BMC Public Health 2011, 11:963http://www.biomedcentral.com/1471-2458/11/963

© 2011 Kendrick et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

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Several large prospective studies have examined long-term outcomes of injury [8-25]. These studies have useddifferent populations, different outcome measurementtools and different data collection methods, follow-upperiods and timings of follow-up. Despite these differ-ences a consistent picture emerges that most severelyinjured patients are not fully recovered 12 to 18 monthspost injury [10,11,26], and even amongst less severelyinjured patients, 45% are not fully recovered 12 monthspost injury [16]. Furthermore, functioning may deterio-rate in the longer term for some of those with severeinjuries [13].Recent reviews [27-30] suggest the prevalence of psy-

chological disorders post injury is high and that thesemay be associated with poorer functional and occupa-tional outcomes [10,26,31]. A review of psychiatric mor-bidity after motor vehicle collisions found the mostcommonly reported disorders were depression (21% to67% across studies), anxiety (4% to 87% across studies),driving phobia (2% to 47% across studies) and PTSD(0% to 100% across studies) [30]. A second systematicreview reported post traumatic injury rates of PTSDranging across studies from 2-30%, depression from 6-42%, with up to half of those with PTSD also having co-morbid depression. Anxiety disorders were reported torange from 4-24%, with up to 60% of those with PTSDalso having co-morbid anxiety disorders. Specific travelphobias for those injured in motor vehicle collisionswere reported to range from 4-29% [28]. A third reviewfound rates of PTSD to range from 2% to 50% acrossstudies [29].Few large prospective studies have measured psycho-

logical morbidity following injury in the UK. Psychiatricdisorders were found to be common in injured male EDattenders in the short (48% at 6 weeks) and medium(43% at 6 months) term [32]. A second study of roadtraffic injured ED attenders found 8% had developedPTSD by 3 months, and nearly a quarter had psychiatriccomplications at one-year [33]. A third study by thesame authors in a similar study population found 36%reported psychological problems at 3 months and 32%at 1 year, with PTSD being reported in 23% at 3 monthsand 17% at 1 year [16]. The generalisability of the find-ings of these studies to wider population groups and tothose suffering a range of injuries is unclear. Although arecent large UK prospective study of injury related dis-ability has been undertaken [34], this does not measurepsychological outcomes.Evidence suggests that screening tools may be useful

in health care settings for identifying those at risk [35],and early interventions can be effective in treating psy-chological morbidity following injury. Individual trauma-focused cognitive behavioural therapy (TFCBT), stressmanagement and group TFCBT are effective in the

treatment of PTSD [36] and pharmacotherapy, particu-larly selective serotonin reuptake inhibitors (SSRIs) areeffective in reducing symptoms of PTSD and associateddepression [37]. There is also limited evidence that psy-chosocial interventions may not help prevent physical,psychological and social disability post injury but thatan intervention based on complex collaborative caremay do so [38]. Current UK guidelines propose thatheath and social care workers should understand thepsychological impacts of trauma and, as an immediateresponse, offer practical, social and emotional support.In addition the guidance supports the use of TFCBTand the use of antidepressants [39]. A health servicemodel has been proposed for identifying those who maybenefit from such interventions [28], but in order todesign such a service, the prevalence of such morbidityand its impact on functioning and costs, must beknown. The importance of, and need for qualitativeresearch in establishing the needs of injured patients,areas of unmet need, gaps in service provision and bar-riers and facilitators to accessing services for the pur-poses of informing service provision has also beenhighlighted [40-44]. Further exploration of the experi-ences of service users, carers and service providers inthe UK is required in order that services can bedesigned which will maximise recovery post injury.

AimsThe aim of the study is to measure and characterisephysical, psychological, social and occupational out-comes post unintentional injury and identify service use,gaps in service provision and information needs, andbarriers and drivers to accessing services.

ObjectivesThe objectives of this study are to:• Measure physical, psychological, social and occupa-

tional outcomes post unintentional injury• Measure health and social care provision, use and

cost• Quantify the impact of psychological problems on

recovery from a range of unintentional injuries• Identify service use, gaps in service provision and

information needs, and barriers and drivers to accessingservices from the perspective of those with injuries,their carers and service providers.

Methods/DesignParticipantsThis is a longitudinal multi-centre study with a nestedqualitative study recruiting participants admitted to hos-pital with a wide range of unintentional injuries from 4UK study centres (Nottingham, Leicester/Loughborough,Bristol, and Surrey). A stratified sampling frame (Table


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1) will be used to guide recruitment to ensure a range ofcommon and less common injuries will be included andto allow comparison with other studies of injury mor-bidity [20,22,34]. Participants will be recruited in Emer-gency Departments (EDs), on hospital wards, inoutpatient departments (OPDs), or by post followinghospital discharge. Participants with upper and lowerlimb injuries and those with multiple injuries, and theircarers along with representative service providers, willbe eligible for, and recruited by post to the qualitativestudy.

Centres for recruitmentRecruitment will be undertaken in NHS Trusts at the 4study centres: Nottingham University Hospitals NHSTrust Queens Medical Centre campus, Leicester RoyalInfirmary, Bristol Royal Infirmary, Frenchay Hospital(Bristol), and the Royal Surrey County Hospital.

Exclusion/Inclusion CriteriaInclusion criteria: patients aged between 16 and 70years, who are admitted to hospital in one of the partici-pating centres following an unintentional injury, whichoccurred up to 3 weeks prior to the date of recruitment,

and who are able to give consent will be eligible to par-ticipate in the longitudinal study. Participants withupper and lower limb injuries and those with multipleinjuries and their carers and service providers will beeligible for the qualitative study.Exclusion criteria: patients will be excluded if they are

below the age of 16 and above the age of 70 at the timeof their injury, do not have an address (due to inabilityto follow-up these patients), are not admitted to hospi-tal, do not allow access to their medical notes, or areunable to give consent. Patients with significant headinjuries (defined as loss of consciousness, amnesia or aGlasgow coma scale of < 15 at presentation) will be alsoexcluded due to the difficulty of distinguishing betweenthe sequelae of even mild head injury and psychologicalmorbidity [45,46].

MeasuresAt baseline (day of recruitment to the study) partici-pants will be asked to complete a questionnaire coveringcircumstances surrounding their injury, socio-demo-graphic and occupational details, health status, quality oflife and social and occupational functioning in the 4weeks prior to their injury. The following standardisedtools will be used: the Alcohol Use Disorders Identifica-tion Test (AUDIT) [47], the Drug Abuse Screening Test(DAST) [48], the Hospital Anxiety and Depression Scale(HADS) [49], an adaptation of the Accident Fear Ques-tionnaire (AFQ) [50], the EQ5D [51], the HUI-3 [52],the Work Limitations Questionnaire [53] and the SocialFunctioning Questionnaire [54]. Participants will alsoundergo a shortened structured clinical diagnostic inter-view (SCID) [55] to determine pre-injury psychologicalmorbidity. A small incentive (£2 high street gift vou-cher) will be given to participants on receipt of com-pleted questionnaires.At 1 month, 2 months, 4 months, and 12 months post

injury [56], participants will be asked to complete fol-low-up questionnaires covering whether they are stillaffected by their injury, perceptions of recovery, factorsthat helped or hindered recovery, health and social careresource use, time off work and litigation and compen-sation. In addition, they will be asked to complete thestandardised tools used at baseline as well as the Impactof Event Scale (IES) [57], the Trauma Screening Ques-tionnaire (TSQ) [35], the Changes in Outlook Scale(CIO), [58], the Crisis Support Scale (CSS) [59], the Listof Threatening Events (LTE) [60] and a visual analoguepain scale. Participants scoring above threshold valueson the AUDIT, DAST, HADS, IES or TSQ will be con-tacted to undertake a shortened SCID administeredface-face or by telephone, containing questions relatedonly to the tool(s) for which they scored above thethreshold value. Follow-up questionnaires will be

Table 1 Sampling frame for recruitment by age, gender,and injury typei

Male Male Male Female Female Female

16-24 25-59 60-70 16-24 25-59 60-70

Facial fracture, eyeinjury

10 10 10 10 10 10

Spine, vertebraeinjury

10 10 10 10 10 10

Internal organ injury 10 10 10 10 10 10

Upper extremityfracture

10 10 10 10 10 10

Upper extremity,other injury

10 10 10 10 10 10

Hip fracture < 10 10 10 < 10 10 10

Lower extremityfracture

10 10 10 10 10 10

Lower extremity,other injury

10 10 10 10 10 10

Superficial injury,open wounds

10 10 10 10 10 10

Burns 10 10 < 10 10 10 < 10

Poisoning 10 10 10 10 10 10

Other injury 10 10 10 10 10 10

Total by age andgender

110 120 110 110 120 110

Total by gender 340 340i Where there are < 10 expected participants in any cell of the samplingframe, attempts will be made to recruit as many people as possible, but thesecells have not been included in the total number of participants


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administered by post, phone, or via email depending onparticipant preference. Non-responders will be followedup by 2 mailed questionnaires and/or telephone remin-ders. A small incentive (£2 high street gift voucher) willbe given to participants on receipt of completedquestionnaires.Data will be extracted from the medical records to

allow injury severity scoring using the AbbreviatedInjury Scale (AIS) [61]. Socio-economic status will bebased on area deprivation scores derived from the post-code of residence using the 2010 Index of MultipleDeprivation [62]. Aggregated data on age group, genderand injury type will be collected for a 6 month periodfrom patients who do not consent to the study toexplore the generalisability of findings.Qualitative studySemi-structured interviews will explore participantsexperience of their injury and their post injury careincluding factors that facilitate or hinder recovery suchas access to healthcare and social support and issuessurrounding the effects of litigation and compensation.Interviews will be conducted in the patient’s homes orby telephone and will be audio recorded and tran-scribed. A maximum of 48 interviews will be undertakenin total across the 4 study centres. Maximum variationsampling will be used to obtain a sample of injured par-ticipants with injuries of varying types and severities,varying degrees and types of psychological morbidities,levels of deprivation, social support, age and gender.Interviewed participants will also identify carers andrepresentative service providers to be interviewed. Amaximum of 32 carers will be interviewed to exploreperceptions of the recovery process and factors thatfacilitate or hinder recovery from a carer’s perspective.A minimum of 32 service providers will be interviewedto explore factors that facilitate or hinder recovery fromthe perspective of people who deliver services. Addi-tional interviews will be undertaken with managers orcommissioners of services where these exist.Ethical ConsiderationsThe study has multi-centre research ethics committeeapproval from the Nottingham Research Ethics Commit-tee 1 (number: 09/H0407/29).AnalysisBaseline characteristics of participants will be describedusing frequencies and percentages for categorical vari-ables and means (and standard deviations (SD)) or med-ians (and inter-quartile ranges (IQR)) depending on theshape of their distributions, for continuous variables.At each follow-up time-point the prevalence of binary

and categorical physical, psychiatric, social and occupa-tional outcomes will be described using percentages(and 95% Confidence Intervals). Scores for standardisedscales will be described using means (and SDs) or

medians (and IQRs) depending on the shape of theirdistributions. Changes from baseline pre-injury healthstatus, quality of life, social and occupational functioningwill be calculated and described using means (and SDs)or medians (and IQRs) depending on the shape of theirdistributions. As the use of a multi-centre study designwill affect the precision of estimates of prevalence andmeans, this will be accounted for in the estimation of95% confidence intervals.Random-effects generalised linear models will be used

to quantify the association of psychological morbiditywith EQ5D, HUI, work limitations, time off work due toinjury and social functioning. This analysis will userepeated measures of both the outcomes and the psy-chological morbidity variables at 1, 2, 4 and 12 months,with participant as a level 2 unit (cluster) and measure-ment occasion as a level 1 unit, to allow for correlationsof measurements within patients. The exposure variablesof interest are psychiatric diagnoses, defined as meetingthe Diagnostic and Statistical Manual (DSM) criteria foreach disorder measured by the SCID. Analyses will beadjusted for study centre (Nottingham, Bristol, Surrey,Loughborough/Leicester). Causal diagrams will bedrawn to identify confounders for inclusion and effectmediators for exclusion from models. Follow-up timewill also be included in the models. Tests of interactionwill be carried out between having a psychiatric diagno-sis and confounding variables using likelihood ratiotests, to examine whether any association between hav-ing a psychiatric diagnosis and each outcome of interestdiffers according of the level of the confounding vari-able. Tests of interaction will also be carried outbetween psychiatric diagnosis and follow-up time to seewhether the associations change with time after injury.

Checks of assumptionsWe will assess multicollinearity through calculation ofcorrelations and VIF values. We will calculate residualsat both levels and assess these for normality; if they donot show an approximately normal distribution thentransformations will be applied. We will compare resultswith and without excluding observations with large stan-dardised residuals (< - 3 or > 3 standard deviations fromthe mean of a normal or normalised random variable).

Additional analysesFactors associated with psychiatric diagnoses will beexplored using univariate and multivariate random-effects generalised linear models This analysis will userepeated measures of the psychiatric diagnosis variablesat 1, 2, 4 and 12 months, with participant as a level 2unit (cluster) and measurement occasion as a level 1unit, to allow for correlations of measurements withinpatients. The main outcome variable will be a binary


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variable for any psychiatric diagnosis, Further analysesfor specific diagnoses will only be undertaken where thesample size is sufficient.

Economic AnalysisThe economic analysis will be carried in accordancewith the statistical analysis outlined above: random-effects generalised linear models will be used to quantifythe association of psychological morbidity with resourceuse and costs from the NHS, Personal Social Services(PSS) and societal perspectives. Subject to sufficient sta-tistical power being established a posteriori, resourceuse and costs will be compared across several a priorisub-groups, including• With depression/not• With PTSD/not• With anxiety disorders/not• With alcohol misuse disorders/not• With substance misuse disorders/not• With travel fear and avoidance• With 2 or more psychiatric diagnoses (at any time

over the follow-up period)• With previous history psychiatric diagnosis (prior to

or at time of injury)Separate analyses will be undertaken from each of the

perspectives. Costs will be derived by assigning unitcosts to units of patient-reported resource use; unitcosts will be collected from published sources: the BNF;NHS Reference Cost Schedule and PSSRU; ONS[63-66]. This analysis will also estimate the costs attribu-table to psychological morbidity.A sub-sample of 100 patients will have their medical

records audited to compare with self-reported resourceuse, using a pre-existing data extraction form. If itappears from the sub-sample that self-reported resourceuse is biased systematically (i.e. consistently under - orover-reporting resource use), we will model this bias inthe sub-sample, then use the model to correct theresource use reported in the full sample. We will con-duct sensitivity analyses by comparing the results of theeconomic analyses using different estimates of resourceuse.

Missing dataMissing data will be subjected to sensitivity analysis withrespect to the outcome and exposure variables to deter-mine whether it is reasonable to assume missingness atrandom. If appropriate, we will use multiple imputationto replace missing values at baseline or follow-up. Wewill compare results with a complete case analysis. Ifdata are not missing at random, either sensitivity toinclusion/exclusion/imputation will be reported, orselection models will be explored.

Sample size680 participants will be recruited, with an estimated 456(67%) followed up for 1 year. This provides 80% power(alpha = 0.05) to detect differences in the EQ5D,between those with, and without the condition of inter-est, of between 0.08 (anxiety) and 0.13 (depression)assuming a standard deviation of 0.23 based on popula-tion norms [67], or differences in the EQ5D of between0.10 (anxiety) and 0.17 (depression) assuming a standarddeviation of 0.3, as the standard deviation in an injuredpopulation may be larger than that in the general popu-lation. This is illustrated in Table 2.Time scaleParticipants will be recruited from June 2010 to June2012.

DiscussionThis will be the first UK study to provide detailed esti-mates of the prevalence of psychological morbidities fol-lowing a wide range of injuries in working age adults,and to assess their effect on functioning and health andsocial care resource use. It will use a range of validatedstandardised outcome measures and unlike many pre-vious studies, will not rely solely on the use of screeningtools for measuring psychological morbidity but will usethe SCID to make psychiatric diagnoses. Measurementof physical, social and occupational functioning willallow an assessment of the contribution of psychologicalmorbidity to delayed or sub-optimal recovery. The eco-nomic analysis will allow quantification of the healthand social care costs and the contribution of psychologi-cal morbidity to those costs. Such information is vital ifservices are to be further developed to maximise recov-ery post injury. The nested qualitative study is a uniqueaddition to previous quantitative studies of psychologicalmorbidity post injury and the experiences of those withinjuries, their carers and service providers will providevaluable insights into service development.

Funding SourceThis paper presents independent research commissionedby the National Institute for Health Research (NIHR) as

Table 2 Sample size estimations based on the prevalenceof common psychological disorders at 12 months postinjury

Psychologicaldisorder

Prevalenceat 12months[16]

Difference inEQ5D assume SD= 0.23, N = 456

Difference inEQ5D assume SD= 0.3, N = 456

Depression 6% 0.127 0.166

PTSD 17% 0.081 0.105

Anxiety 19% 0.077 0.101

Travel phobia 16% 0.083 0.108


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part of the Collaboration for Leadership in Applied HealthResearch and Care – Nottinghamshire, Derbyshire andLincolnshire (CLAHRC-NDL). The views expressed arethose of the author(s) and not necessarily those of theNHS, the NIHR or the Department of Health.

The Impact of Injuries Study GroupNottingham: Isabel Allwood, Mark Avis, Marcus Barker,Julie Clarkson, Frank Coffey, Chris Craig, TraceyGeorge, Trevor Jones, Stephen Joseph, Denise Kendrick,Blerina Kellezi, Richard Morriss, Julie Moss, ClaireO’Brien, Cecily Palmer, Shireen Patel, Stephen Regel,Emma Rowley.Surrey: Nicola Christie, Sarah Earthy, Sara Quinn, Jude

Sleney.Bristol: Kate Beckett, Georgina Elder, Elizabeth

Towner.Leicester/Loughborough: Emma Alderman, Jo Barnes,

Andrew Morris.

Author details1Division of Primary Care, Tower Building, University Park, NG7 2RDNottingham, UK. 2Centre for Transport Studies, Dept of Civil, Environmentaland Geomatic Engineering, UCL, Gower Street, London WC1E 6BT, UK.3Nursing, Midwifery & Physiotherapy Department, Nottingham UniversityHospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham NG7 2UH,UK. 4Division of Psychiatry, Institute of Mental Health, B Floor, Sir ColinCampbell Building, University of Nottingham Innovation Park, Triumph Road,Nottingham NG7 2TU, UK. 5Transport Safety Research Centre, LoughboroughDesign School, Loughborough University, Ashby Road, Loughborough LE113UZ, UK. 6Emergency Department, Nottingham University Hospitals NHSTrust, Queen’s Medical Centre Campus, Nottingham NG7 2UH, UK.7Sociology & Social Policy Department, University Park, Nottingham NG72RD, UK. 8CLAHRC NDL, Sir Colin Campbell Building, University ofNottingham Innovation Park, Nottingham NG7 2TU, UK. 9Department ofSociology Faculty of Arts and Human Sciences, University of Surrey,Guildford, Surrey GU2 7XH, UK. 10Centre for Child & Adolescent Health,University of the West of England, Oakfield House, Oakfield Grove, Clifton,Bristol BS8 2BN, UK.

Authors’ contributionsDK is the chief investigator for the study and principal investigator (PI) at theNottingham site, NC is PI at the Surrey site, AM is PI at the Leicester/Loughborough site and ET is PI at the Bristol site. DK drafted the originalgrant proposal, drafted the study protocol and helped write this paper. COproduced the first draft of this paper. MA, CC, NC, AM, RM, ET contributed towriting the grant proposal. CC and CQ wrote the analysis plan thatcontributed to the protocol. SJ, SR, RM advised on outcome measurementtools for psychological and psychiatric disorders. MA, CP, ER, JS and MBdrafted the protocol for the nested qualitative study. All study groupmembers contributed to the protocol in terms of local implementation,recruitment strategies, working in the emergency department and inpatientsettings or maximising follow-up. All authors contributed to writing andapproving this paper.

Competing interestsThe authors declare that they have no competing interests.

Received: 1 December 2011 Accepted: 31 December 2011Published: 31 December 2011

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Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/963/prepub

doi:10.1186/1471-2458-11-963Cite this article as: Kendrick et al.: The impact of injuries study.Multicentre study assessing physical, psychological, social andoccupational functioning post injury - a protocol. BMC Public Health 201111:963.


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http://ideas.repec.org/p/chy/respap/172chedp.html

http://ideas.repec.org/p/chy/respap/172chedp.html

http://www.biomedcentral.com/1471-2458/11/963/prepub



Providing effective trauma care: the potential for service provider views to enhance the quality of care (Qualitative

study nested within a multicentre longitudinal quantitative study)

Journal: BMJ Open

Manuscript ID: bmjopen-2014-005668.R1

Article Type: Research

Date Submitted by the Author: 10-Jun-2014

Complete List of Authors: Beckett, Kate; University of the West of England, Health & Life Sciences Earthy, Sarah; University of Surrey, Department of Sociology Sleney, Judith; University of Surrey, Department of Sociology Barnes, Jo; Loughborough University, Loughborough Design School Kellezi, Blerina; Nottingham University, Division of Primary care, School of Medicine Barker, Marcus; Nottingham University, Business School Clarkson, Julie; Nottingham University Hospitals NHS trust, Occupational Therapy Coffey, Frank; Nottingham University Hospitals NHS Trust, DREEAM

(Department of Research and Education in Emergency medicine, Acute Medicine and Major trauma) Elder, Georgina; University Hospitals Bristol NHS Foundation Trust, Emergency Department Kendrick, Denise; Nottingham University, Division of Primary care, School of Medicine

<b>Primary Subject Heading</b>:

Health services research

Secondary Subject Heading: Qualitative research, Rehabilitation medicine, Emergency medicine, Evidence based practice, Patient-centred medicine

Keywords:

QUALITATIVE RESEARCH, ACCIDENT & EMERGENCY MEDICINE, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT,

TRAUMA MANAGEMENT, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT


BMJ Open on M

arch 24, 2021 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

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Title



Authors’ names:






Kate Beckett

Research Associate


Surrey, GU2 7XH

Sarah Earthy

Lecturer


Surrey, GU2 7XH

Jude Sleney

Research Fellow


Jo Barnes

Research Associate



Blerina Kellezi

Research Fellow


Marcus Barker

Research Assistant


Julie Clarkson




Frank Coffey



Georgina Elder



Nottingham, NG7 2RD

Denise Kendrick



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Abstract

Objective:



provision.

Design:






Setting:



Participants:


Results:









Conclusions:






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Article summary












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Introduction










The provision of UK National Health Service (NHS) care for injured patients faces unprecedented

challenges.11

Changes in patterns of injury and improvements in medical care have increased survival

after injury and an ageing population place increasing demands on service provision.12-14

Rapid

throughput and early discharge place additional demands on community resources.15-17

In addition,

the drive to improve the quality of care in terms of safety, effectiveness and patient experience has

been renewed through publication of the Darzi Report (2008).18

This raises expectations and places

further demand on services. Yet recent public inquiries highlight a series of deficiencies in NHS care

in general19

and the National Audit Office report identifies deficiencies in trauma care in particular.20








Method













22 patient interviews reporting service providers they felt had helped their recovery and 3) advice of

two lay research advisers based on their experiences of recovery from injury (both members of the

East Midlands Collaboration for Leadership in Applied Health Research and Care Public Involvement

Group who expressed interest in the project). One was involved at a preliminary stage the other

contributed throughout the study. We created a list of service providers and described the

proportion of patients using their service and their frequency of use. We then selected which types

of service providers to invite to the study based on the highest proportion and most frequent patient

use. In addition, service providers who were less frequently used but consistently described as being

helpful (e.g. private practitioners such as osteopaths and physiotherapists)were also selected. A

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quota sample for types of service provider and professional role (manager or more junior) was

constructed for each study centre. For hospital based services, managers of relevant services were

approached initially to identify the most appropriate interviewee at a senior level and to forward the

invitation to more junior members of staff. A similar approach to recruitment was adopted for non-

hospital based service providers. Where there were multiple service providers within a five mile

radius of the hospital (GP practices, physiotherapists and osteopaths in private practice) a fixed

interval sampling method based on a sampling frame ordered by distance from the hospital was

trialled. However only one GP was recruited using this method. In the other three centres,

invitations were sent to all GPs within a five miles radius of the hospital. Two private osteopaths

were recruited by one centre using the same method. All potential participants were sent an

invitation including information about the study aims, objectives and background and those who

responded all agreed to participate and no-one dropped out.










Interview data were coded using NVivo 10 qualitative data analysis software and thematically



JS, KB, MB (representing all four study centres) and Sarah Earthy, a study principal investigator to

gain understanding of key experiences described. This was followed by independent coding of 10%

of the transcripts and development of an initial coding frame through group discussion. This process










Results

We directly invited 542 staff to participate (including; Acute/ Ambulance trusts (163);

Community/Primary care (333); Private sector (29); Social services (15) and Voluntary sector (2)). 61

managers were approached who were also asked to invite their staff to participate. The numbers of

staff each manager approached is not known, but it is estimated at around 400, making 942 total

approaches. Forty interviews were completed with providers of a wide range of services (including:

NHS staff (37); private practice (2); voluntary sector (1)). Among NHS staff: 30 worked in acute care;

four in primary/community care and three in the ambulance service. See Box 3 for a brief description

of NHS structure as it relates to this article and trauma services.

[Insert Box 3 here)

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In accordance with the study protocol their age and gender was not recorded however by selecting

participants from different disciplines and levels of seniority the sample demographic was broadly

representative of NHS staff.25

The professional roles of service providers interviewed at each of the

four sites are presented in Table 2. Efforts to recruit representatives from social services or private

physiotherapy were unsuccessful. Study centres are identified only by a randomly assigned letter to

maintain anonymity. Between six and 15 service providers were interviewed in each site depending

on the numbers responding to the call for participants..




and a more haphazard, fragmented model based on the realities of NHS practice. These dominant

themes emerged through the process of analysis; participants were not specifically asked to describe

ideal and real models of care. Individuals, disciplines and settings differed in which model they felt

able to follow, but knowledge of and tensions between these two models permeated all service

provider accounts.

Ideal Model





recovery journey:





Real model








nurse, Centre C)




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[Insert box 1 here]



described below.

1) Knowledge


patients’ lives:





care:








2) Research

Participants also explicitly referred to research evidence informing best models of care for their

professional role:






Centre B)





standards:



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Additional evidence was desired to support improvements in care;



















delivery:









who’s been here for four weeks fit for discharge.” (Junior doctor, Centre D)




� ”Some people have had to wait for four to five months before starting counselling.” (General

Practitioner , Centre C)

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rehabilitation:








b) Funding streams




















of care.



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(Matron, Centre A)

�











D)














C).

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Centre C)










Discussion




provision.11, 20


















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and physiotherapists working in private practice. However these services were rarely accessed by

Impact of injuries study (IOIS) patients. Respondents in some staff groups were identified by their

managers, who may have chosen people who held particular views. However, the diverse positive

and negative views provided by service providers would suggest this is unlikely to have had a large

impact on our findings. Since all participants conveyed both positive and negative views; there were

no divergent cases (in which a wholly positive or negative model was described) however the

proportion of positive vs negative views varied between participants and disciplines. Future analysis

could expand on this to identify factors sustaining ideal care and analysis of IOIS patient and carer

data will permit comparison with their experiences of care.












While many studies identify means to improve the effectiveness

and safety of care this study adds to understanding of the ‘aesthetics of experience’ or how services

feel (their usability and emotional content).30

These are also important determinants of best practice

and patient experience and can lead to improvements in service delivery and patient care.30


compassionate 18, 31, 32



standards34




evidence identifying best models of care. Whilst it is often considered that experiential rather than

research knowledge underpins practice; many participants demonstrated familiarity with current

research and awareness of the role of scientific evidence in improving standards. However, the

extent to which their understanding and knowledge informs practice is determined by factors which

are frequently beyond their control. Some services, settings and individuals clearly feel their context

of care is more conducive to practice according to an ideal model than others, for example, striking

differences exist between nursing and physiotherapy care post injury.35

Service providers’

experiences of providing care which they feel is at odds with their ideal model of care, gives rise to a

series of practical suggestions for service improvements. These wide ranging suggestions described

in Box 2 are based on recommendations elicited through participant interviews and extrapolation

from the data. . However the following 3 priorities were most frequently identified: improving

psychological screening and support, reduction in theatre delay and improving access to early

adequate physiotherapy. Further research combining scientific evidence of the impact of injury with

practitioner knowledge of local context may assist in clarifying future priorities for action. 36

[Insert box 2 here]


outcomes.37



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References



Accessed 11/02/14




Accessed 11/02/2014









Accessed 11/02/2014

6. Lyons R, Kendrick D, Towner E, et al. Measuring the population burden of injuries- implications for

global and national Estimates: a multi-centre prospective UK longitudinal study. BMC Pub Health.

2011 Dec;8 (12)

7. Polinder S, Haagsma J, Belt E, et al. A systematic review of studies measuring health-related

quality of life of general injury populations. BMC Public Health 2010 Dec ;10:783

8. Black J, Herbison G, Lyons R, et al. Recovery after injury: an individual patient data meta-analysis

of general health status using the EQ-5D. J Trauma. 2011 Oct;71(4):1003-1010.



10. O'Donnell M, Bryant R, Creamer M, et al. Mental health following traumatic Injury: toward a



the NHS. 2010.


Accessed 28/04/2014



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28/02/2014







28/02/2014







16/02/2014





16/02/2014

21. Kendrick D, O'Brien C, Christie N, et al. The impact of injuries study. Multicentre study assessing

physical, psychological, social and occupational functioning post injury - a protocol BMC Public

Health. 2011 Dec;11;963



23. Sleney J, Christe N, Earthy S, et al. Improving recovery - Learning from patients experiences after

injury: A qualitative Study. Injury. 2014 Jan;45(1):312-319.


25. NHS: The Information Centre for health & social care. NHS Workforce: Summary of staff in the

NHS: Results from September 2012 Census [Published online

http://www.hscic.gov.uk/catalogue/PUB10394/nhs-staf-2002-2012-over-rep.pdf] Accessed

04/06/2014



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27. Juthberg C, Eriksson S, Norberg A, et al. Perceptions of conscience, stress of conscience and


28. Aiken L, Sloane D, Bruyneel L, et al. for the RN4CAST consortium. Nurse staffing and education

and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014

Feb; [Published Online http://dx.doi.org/10.1016/S0140-6736(13)62631-8] Accessed 03/03/2014

29. Flottorp S, Oxman A1, Krause J, et al. A checklist for identifying determinants of practice: A

systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable

improvements in healthcare professional practice. Implementation Science 2013, 8:35

http://www.implementationscience.com/content/8/1/35





11/02/2014









Oct;22(19):1118-1124.

36. Brussoni, M. Towner, E., Hayes, M. (2006) Injury Prevention 12, 373-377 Evidence into practice:

combining the art and science of injury prevention



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Ethical approval


09/H0407/29).

Participant consent








Data Sharing


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Table 1: Interviewers and interview characteristics

Interviewers

Which authors conducted the

interviews

Blerina Kellezi (BK), Jo Barnes (JB), Jude Sleney (JS), Kate Beckett

(KB), Marcus Barker (MB)

Qualifications BK, JB (PhD), JS (MSc), MB (MA (Cantab)), KB (BSc)

JB, KB (Registered Nurses)

Occupation at time of study BK: Research fellow; JB, JS,KB: Research Associate, MB: Research

Assistant - all university employees

Gender BK,JS,JB,KB: Female; MB: Male

Training All have had training and experience in Qualitative research

methodology

Was the interviewer already

known to study participants?

A small number of participants were acquainted with their

interviewer through prior involvement in quantitative study

recruitment and may have been aware of their interviewers’

background.

Interviews

Setting Interviews were carried out in the participants place of work in a

quiet private space

Who was present? Participant and interviewer only

Duration Interviews lasted between 30-60 minutes

Audio-visual recording All interviews were audio recorded with participant consent

Consent Consent was obtained at the time of interview or before if

conducted by telephone

Confidentiality Interviewees were assured of anonymity and confidentiality both

for themselves and their organisation

Transcription Interviews were centrally transcribed and checked for accuracy

by site researchers

Field notes Field notes were recorded following the interview to add context

to the analysis

Repeat interviews No repeat interviews were deemed necessary

Post interview contact All participants were given contact details for any further

thoughts or comments they wanted to add after the interview

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Table 2: Numbers and types of service providers interviewed by study centre.

Study centre A B C D Total

Ambulance service – Paramedic 1 1

Ambulance service – Manager 1 1 2

Doctor - General Practitioner 2 1 3

Doctor – Junior 1 1

Doctor – Registrar 1 1

Doctor – Consultant 1 1 2

Doctor - Medical director 1 1

Nurse – Primary care 1 1

Nurse – Junior 3 1 4

Nurse – Senior/Sister 1 1 2

Nurse – Specialist 1 1 1 3

Nurse- Matron 2 1 1 4

Occupational Therapist 2 2

Physiotherapist - Junior 1 1 2

Physiotherapist – Senior 3 3

Physiotherapist – Specialist 1 2 3

Physiotherapist – Manager 1 1

Private practice – Osteopath 2 2

Psychologist – Specialist 1 1

Voluntary sector –Manager 1 1

Total 7 6 15 12 40

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Box 1: Ideal & Real Models of Care in relation to Darzi’s (2008) 18


Box 1: Ideal & Real Models of Care in relation to Darzi’s (2008)18


IDEAL REAL

Safety

• “Actually they’re going to be safe in our hands

and … the care they’re going to receive is good.”

(Senior nurse, Centre D)

• “That’s my patient, their safety comes first.”


• “Being able to provide a service with skilled

clinicians … the knowledge to be able to treat a

patient safely … as an emergency service you

can't ask for any more.” (Manager ambulance

service, Centre C)

• “I think when you want to get patients to theatre ... it’s full ...

sometimes you see a little bit of harm come to patients because they

don't get to theatre in time.” (Junior doctor, Centre D)

• “So whether or not the continual monitoring gets done is a different

matter... without continual monitoring you can’t say that they’re

going to remain fine.” (Junior nurse, Centre C)

• “We get a phone call maybe for some pain medication … somebody’s

got a major life event and we don’t know about it (lack of

communication) ... so there are safety issues there about prescribing

medication.” (GP, Centre D)

Effectiveness

• “Getting the patients treated at the right time

with the right services ... getting them treated

early picking up the people that need additional

services especially psychology getting them in

there quickly to … prevent future disability.”

(Occupational therapist, Centre B)

• “My role is to ensure that the patient’s care

pathway is efficient, timely and they have a

satisfaction in the service.” (Junior nurse,

Centre A)

• “We have so many ankle fractures sitting around on the ward for a

week before the operation… if you operated on them straightaway …

they would be done and out the next day.” (Junior doctor, Centre D)

• “It’s a high pressure job … you don’t feel like you can give high quality

care … that individual’s satisfaction of what you consider high quality

care isn’t always … what the department offers.” (Senior Nurse,

Centre D)

• “I would say…for the patients who need psychological support that’s

one of the main things that’s lacking …in every hospital … there’s no

access to it for patients.” (Physiotherapist, Centre A)

Patient Experience

• “Enough information about their condition to

help them not to be scared of it … they need to

understand the reasons why we have asked

them to do what they are doing … to

understand what they are feeling and

experiencing.” (Senior physiotherapist, Centre

D)

• “I suppose it’s easier just getting your head down and doing the tasks

... during busy times especially just knowing that you’ve done this,

this and this, ….It’s almost like once you’ve done the task, then it

becomes somebody else can care about the kind of emotional side of

it.” (Junior nurse, Centre C)

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Box 2 Possible improvements to care based on service providers perspectives

Box 2: Possible improvements to care based on service providers perspectives

Knowledge

• Develop practitioner capacity to utilise and collate evidence relating to standards of care

• Develop an online regularly updated directory of services for practitioner reference

Services

• Expand trauma theatre capacity to ensure appropriately timed surgical intervention

• Expand existing and develop new screening and treatment options for post injury psychological problems

• Develop capacity for community rehabilitation (residential, domiciliary or out-patient) to ensure early discharge of

medically fit patients, sustain progress made in hospital and enable early intervention to prevent longer term problems

Funding streams

• Harmonise referral criteria across geographical boundaries

• Facilitate service access for those who do not fit ‘typical’ criteria (based on clinical assessment of need)

• Remove incentivised targets for particular cohorts and equalise access based on clinical need

Staffing and skill mix

• Ensure adequate staff numbers to effectively and compassionately meet clinical demands

• Involve senior practitioners in scoping staff and skill mix requirements

• Identify non clinical tasks and devolve to additional administrative workforce

• Utilise senior clinical expertise to drive improvements in standards through direct clinical input and supervision of junior

staff

Patient expectations

• Improve patient information at all levels using a range of sources and means

• Expand public education on appropriate NHS use

• Enhance public involvement in realistic NHS goal setting and resource allocation

Communication and information

• Formalise systems to ensure outlying patients are not neglected

• Engage practitioner groups in developing initiatives to improve communication between primary and secondary care

• Develop secure means of information sharing with non NHS practitioners

Organisational values and priorities

• Ensure equal focus & resourcing for acute and rehabilitation phases of recovery

• Develop measures and means to collate evidence of longer term injury outcomes e.g. return to work

• Undertake economic research into comparative costs of short term intensive multi-disciplinary rehabilitation vs long

term disability and resource use

• Ensure individual clinical need drives care rather than political or organisational targets

• Recognise practitioner expertise and facilitate practice according to their ideal evidence based model of care

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Box 3: UK NHS structure as it relates to this article and provision of trauma services

Services for injured patients may be provided by:

1. NHS acute, ambulance or care trusts (these are in effect public sector organisations

providing services on behalf on the NHS) – providing emergency, acute (secondary) and out-

patient care. They also provide some community services

2. NHS General Practitioners (primary care/family physicians)) and allied health professionals

who contract services for the NHS through the NHS commissioning board and clinical

commissioning groups – providing care in the community after the acute injury

3. Voluntary sector organisations providing additional services to the NHS

4. Private practitioners providing supplementary care accessed and paid for by the individual

patient

5. Local Authority Social Services providing social worker or occupational therapist support and

means tested personal care.

Trauma care may be shared between settings with separate budgets and provision criteria

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Title



Authors’ names:






Kate Beckett

Research Associate


Surrey, GU2 7XH

Sarah Earthy

Lecturer


Surrey, GU2 7XH

Jude Sleney

Research Fellow


Jo Barnes

Research Associate



Blerina Kellezi

Research Fellow


Marcus Barker

Research Assistant


Julie Clarkson




Frank Coffey



Georgina Elder



Nottingham, NG7 2RD

Denise Kendrick



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Abstract

Objective:



provision.

Design:






Setting:



Participants:


Results:









Conclusions:






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Article summary












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Introduction










The provision of UK National Health Service (NHS) care for injured patients faces unprecedented

challenges.11

Changes in patterns of injury and improvements in medical care have increased survival

after injury and an ageing population place increasing demands on service provision.12-14

Rapid

throughput and early discharge place additional demands on community resources.15-17

In addition,

the drive to improve the quality of care in terms of safety, effectiveness and patient experience18

has

been renewed through publication of the Darzi Report (2008).18

This raises expectations and places

further demand on services. Yet Rrecent public inquiries highlight a series of deficiencies in NHS care

in general19

and the National Audit Office report identifies deficiencies in trauma care in particular.20








Method













22 patient interviews reporting service providers they felt had helped their recovery and 3) advice

from of two lay research advisers based on their experiences of recovery from injury (both.

members of the East Midlands Collaboration for Leadership in Applied Health Research and Care

Public Involvement Group who expressed interest in the project). One was involved at a preliminary

stage the other contributed throughout the study. We created a list of service providers and

described the proportion of patients using their service and their frequency of use. We then selected

which types of service providers to invite to the study based on the highest proportion and most

frequent patient use. In addition, where patients reported less frequently used service providers

Formatted: Superscript

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who were less frequently used but consistently described as being helpful who they felt had helped

(e.g. social workers, physiotherapists in private practicetioners such as osteopaths and

physiotherapists), these providers were also selected. A quota sample for types of service provider

and professional role (manager or more junior) was constructed for each study centre. For hospital

based services, managers of relevant services were approached initially to identify the most

appropriate interviewee at a senior level and to forward the invitation to more junior members of

staff. A similar approach to recruitment was adopted for non-hospital based service providers.

Where there were multiple service providers within a five mile radius of the hospital (GP practices,

physiotherapists and osteopaths in private practice) a fixed interval sampling method based on a

sampling frame ordered by distance from the hospital was trialled. However only one GP was

recruited using this method. In the other three centres, invitations were sent to all GPs within a five

miles radius of the hospital. Two private osteopaths were recruited by one centre using the same

method. All potential participants were sent an invitation including information about the study

aims, objectives and background and those who responded all agreed to participate and no-one

dropped out.










Interview data wasere coded using NVivo 10 qualitative data analysis software and thematically



JS, KB, MB (representing all four 4 study centres) and Sarah Earthy, a study principal investigator to

gain understanding of key experiences described. This was followed by independent coding of 10%

of the transcripts and development of an initial coding frame through group discussion. This process










Results

We directly invited 542 staff to participate (including; Acute/ Ambulance trusts (163);

Community/Primary care (333); Private sector (29); Social services (15) and Voluntary sector (2)). 61

managers were approached who were also asked to invite their staff to participate. The numbers of

staff each manager approached is not known, but it is estimated at around 400, making 942 total

approaches. Forty interviews were completed with providers of a wide range of services (including:

NHS staff (37); private practice (2); voluntary sector (1)). Among NHS staff: 30 worked in acute care;

four in primary/community care and three in the ambulance service. See Box 3 for a brief description

Formatted: Font: (Default) +Body(Calibri), 11 pt, Font color: Auto

Formatted: Font: (Default) +Body(Calibri), 11 pt, Font color: Auto

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of NHS structure as it relates to this article and trauma services'.Forty interviews were completed

with providers of a wide range of services.

[Insert Box 3 here)

In accordance with the study protocol their age and gender was not recorded however by selecting

participants from different disciplines and levels of seniority the sample demographic was broadly

representative of NHS staff.25

The professional roles of service providers interviewed at each of the

four sites are presented in Table 2. Efforts to recruit representatives from social services or private

physiotherapy were unsuccessful. Study centres are identified only by a randomly assigned letter to

maintain anonymity. Between six and 15 service providers were interviewed in each site depending

on the numbers responding to the call for participants.levels of response.




and a more haphazard, fragmented model based on the realities of NHS practice. These dominant

themes emerged through the process of analysis; participants were not specifically asked to describe

ideal and real models of care. Individuals, disciplines and settings differed in which model they felt

able to follow, but knowledge of and tensions between these two models permeated all service

provider accounts.

Ideal Model





recovery journey:





Real model








nurse, Centre C)

Formatted: Font: (Default) +Body (Calibri)


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[Insert box 1 here]



described below.

1) Knowledge


patients’ lives:





care:








2) Research

Participants also explicitly referred to research evidence that informeding best models of care for

their professional role:






Centre B)




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standards:



Whilst it is often considered that experiential rather than research knowledge underpins practice;

many participants demonstrated familiarity with current research and desire for aAdditional

evidence was desired to support improvements in care.;



















delivery:









who’s been here for four 4 weeks fit for discharge.” (Junior doctor, Centre D)

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� ”Some people have had to wait for four 4 to five 5 months before starting counselling.” (General

Practitioner , Centre C)









rehabilitation:








b) Funding streams

















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of care.













(Matron, Centre A)

�

�











D)









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C).










Centre C)










Discussion




provision.11, 20










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and physiotherapists working in private practice. However these services were rarely accessed by

Impact of injuries study (IOIS) patients. Respondents in some staff groups were identified by their

managers, who may have chosen people who held particular views. However, the diverse positive

and negative views provided by service providers would suggest this is unlikely to have had a large

impact on our findings. Since all participants conveyed both positive and negative views; there were

no divergent cases (in which a wholly positive or negative model was described) however the

proportion of positive vs negative views varied between participants and disciplines. Future analysis

could expand on this to identify factors sustaining ideal care and analysis of IOIS IOIS patient and

carer data will permit comparison with their experiences of care.












While many studies identify means to improve the

effectiveness and safety of care this study adds to understanding of the ‘aesthetics of experience’ or

how services feel (their usability and emotional content).2930

These are also important determinants

of best practice and patient experience and can lead to improvements in service delivery and patient

care.2930


compassionate 18, 310, 312



standards334




evidence identifying best models of care. Whilst it is often considered that experiential rather than

research knowledge underpins practice; many participants demonstrated familiarity with current

research and awareness of the role of scientific evidence in improving standards. However, the

extent to which their understanding and knowledge informs practice is determined by factors which

are frequently beyond their control. Some services, settings and individuals clearly feel their context

of care is more conducive to practice according to an ideal model than others, for example, striking

differences exist between nursing and physiotherapy care post injury.345

Service providers’

experiences of providing care which they feel is at odds with their ideal model of care, gives rise to a

series of practical suggestions for service improvements. These wide ranging suggestions described

in Box 2 are based on recommendations elicited through participant interviews and

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extrapolatationextrapolation from the data. These wide ranging suggestions are described in Box 2.

However the following 3 priorities were most frequently identified: improving psychological

screening and support, reduction in theatre delay and improving access to early adequate

physiotherapy. Further research combining scientific evidence of the impact of injury with

practitioner knowledge of local context may assist in clarifying future priorities for action. 36

[Insert box 2 here]


outcomes.357









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References



Accessed 11/02/14




Accessed 11/02/2014









Accessed 11/02/2014

6. Lyons R, Kendrick D, Towner E, Christie N, Macey S, Coupland C. et al. Measuring the population

burden of injuries- implications for global and national Estimates: a multi-centre prospective UK

longitudinal study. BMC Pub Health. 2011 Dec;8 (12)

7. Polinder S, Haagsma J, Belt E, Lyons R, Eransmus V, Lund J. et al. A systematic review of studies

measuring health-related quality of life of general injury populations. BMC Public Health 2010 Dec

;10:783

8. Black J, Herbison G, Lyons R, Polinder S, Derrett S. Recovery after injury: an individual patient data

meta-analysis of general health status using the EQ-5D. J Trauma. 2011 Oct;71(4):1003-1010.



10. O'Donnell M, Bryant R, Creamer M, Carty J. Mental health following traumatic Injury: toward a



the NHS. 2010.


Accessed 28/04/2014







28/02/2014

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28/02/2014







16/02/2014





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21. Kendrick D, O'Brien C, Christie N, Coupland C, Quinn C, Avis M. et al. The impact of injuries

study. Multicentre study assessing physical, psychological, social and occupational functioning post

injury - a protocol BMC Public Health. 2011 Dec;11;963



23. Sleney J, Christe N, Earthy S, Lyons R, Kendrick D, Towner E. Improving recovery - Learning from

patients experiences after injury: A qualitative Study. Injury. 2014 Jan;45(1):312-319.


25. NHS: The Information Centre for health & social care. NHS Workforce: Summary of staff in the

NHS: Results from September 2012 Census [Published online

http://www.hscic.gov.uk/catalogue/PUB10394/nhs-staf-2002-2012-over-rep.pdf] Accessed

04/06/2014



276. Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience, stress of conscience and


287. Aiken L, Sloane D, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. for the RN4CAST

consortium. Nurse staffing and education and hospital mortality in nine European countries: a

retrospective observational study. Lancet. 2014 Feb; [Published Online

http://dx.doi.org/10.1016/S0140-6736(13)62631-8] Accessed 03/03/2014

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298. Flottorp S, Oxman A1, Krause J, Musila N, Wensing M, Godycki-Cwirko M, Baker R, Eccles M. A

checklist for identifying determinants of practice: A systematic review and synthesis of frameworks

and taxonomies of factors that prevent or enable improvements in healthcare professional practice.

Implementation Science 2013, 8:35 http://www.implementationscience.com/content/8/1/35





11/02/2014









Oct;22(19):1118-1124.

36. Brussoni, M. Towner, E., Hayes, M. (2006) Injury Prevention 12, 373-377 Evidence into

practice: combining the art and science of injury prevention








Ethical approval


09/H0407/29).

Participant consent






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Data Sharing


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Application of COREQ checklist for interviews and focus groups (Tong et al 2007) to Beckett et al (2014) "Providing effective trauma care:

the potential for service provider views to enhance the quality of care”


Domain 1: Research team and reflexivity

Personal Characteristics

1. Interviewer/facilitator Which author/s conducted the interview or focus group? 18

2. Credentials What were the researcher's credentials? E.g. PhD, MD 18

3. Occupation What was their occupation at the time of the study? 18

4. Gender Was the researcher male or female? 18

5. Experience and training What experience or training did the researcher have? 18

Relationship with participants

6. Relationship established Was a relationship established prior to study commencement? 18

7. Participant knowledge of the

interviewer

What did the participants know about the researcher? e.g. personal goals,

reasons for doing the research

18

8. Interviewer characteristics What characteristics were reported about the interviewer/facilitator? e.g. Bias,

assumptions, reasons and interests in the research topic

18, 12, 5

Domain 2: study design

Theoretical framework

9. Methodological orientation

and Theory

What methodological orientation was stated to underpin the study? e.g.

grounded theory, discourse analysis, ethnography, phenomenology,

5

Participant selection

10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, 4

11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email 5

12. Sample size How many participants were in the study? 5

13. Non-participation How many people refused to participate or dropped out? Reasons? 5

Setting

14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace 18

15. Presence of non-participants Was anyone else present besides the participants and researchers? 18

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16. Description of sample What are the important characteristics of the sample? e.g. demographic data 5, 19

Data collection

17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested? 5

18. Repeat interviews Were repeat interviews carried out? If yes, how many? 18

19. Audio/visual recording Did the research use audio or visual recording to collect the data? 18

20. Field notes Were field notes made during and/or after the interview or focus group? 18

21. Duration What was the duration of the interviews or focus group? 18

22. Data saturation Was data saturation discussed? 5

23. Transcripts returned Were transcripts returned to participants for comment and/or correction? 18

Domain 3: analysis and findings

Data analysis

24. Number of data coders How many data coders coded the data? 5

25. Description of the coding tree Did authors provide a description of the coding tree? 5

26. Derivation of themes Were themes identified in advance or derived from the data? 5

27. Software What software, if applicable, was used to manage the data? 5

28. Participant checking Did participants provide feedback on the findings? 5

Reporting

29. Quotations presented Were participant quotations presented to illustrate the themes / findings? Was

each quotation identified? e.g. participant number

6-11

30. Data and findings consistent Was there consistency between the data presented and the findings? 6-12

31. Clarity of major themes Were major themes clearly presented in the findings? 6-8

32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes? 8-11, 12

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