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Table 4 Extract from field notes: processes of recontextualisation in the trajectory of ESTEEM trial protocol in one nurse-led triage practice

From: Process evaluation for complex interventions in health services research: analysing context, text trajectories and disruptions

Stage in research process Task Texts used Researcher’s fieldnotes - verbatim Moments of vulnerability to processes of recontextualisation
Post-randomisation set up and training phase External consultant training of GP practice on how to organise triage appointments. Spreadsheet showing audit of practice’s same-day (S-D) appointment requests against available clinicians, and resources required to deliver triage. Flowchart of how S-D patients should be managed by practice. Ensure fidelity to eligibility criteria Trainer shows graphs etc. on laptop computer; best suited to smaller groups. Solutions to potential logistical,/psychological barriers are proposed/discussed. Trainer shows a sample receptionist flowchart, suggesting practices devise their own. Practice manager and senior receptionist attended. Manager reported how triage patterns could be fitted into current practice consultation pattern. Staff responses to audit critical in determining resource allocation to support triage. How receptionists respond to flowchart as text determines adherence to inclusion/exclusion criteria.
Post-randomisation set up and training phase Training of reception team on research procedures by ESTEEM team members Log sheets for recording how S-D appointment requests are managed by reception; personalized procedures for each receptionist detailing intervention process, including script when speaking to patients Trial Manager reiterated triage numbers/processes, outlining log sheet completion, arranging log sheet faxing and READ coding of triaged patients’ notes. Practice manager and senior receptionist attended. The practice manager seemed engaged/enthusiastic, the senior receptionist less so. The trial manager explicitly reiterated the importance of triaging children. The practice manager agreed [in the meeting] to do this (but to make children covert appointments, for cancellation if not needed). Log sheets emergent as text to monitor, regulate and standardize inclusion and exclusion of patient requests. Non-completion means fidelity can’t be assessed. Process of READ coding, faxing represents production of texts to show captured sample. Vulnerable to inaccuracies, missing data.
Post-randomisation set up and training phase Training of nurses on research procedures by ESTEEM team members Personalized research procedures for each nurse, emergent as text to ensure fidelity to intervention delivery. Case report ‘clinician’ forms, a key text in capturing trial outcomes Three nurses attended, 2–3 will triage. Trainer talked through triage process and completing clinician forms. Nurses understood, but [as reported] confidence with triage varied. Ability to follow procedures and accurately complete forms subject to time constraints.
Post-randomisation set up and training phase Nurse training on use of CDSS, delivered by organisation providing CDSS for trial CDSS as text, emergent out of trial philosophy of triage as means of managing demand. Observed one online 1:1 interactive software training session for 2 h with one nurse. The nurse struggled, due to limited computer skills and frequent software crashes. Nurses’ IT skills and confidence, functionality of CDSS key influences in how CDSS is used and triage delivered.
Run-in period: four week period where practices rehearsed delivering triage and completing research procedures before live data collection. Receptionists’ identification of eligible triage patients Personalised script produced by practice staff During the run-in (observed over three separate days) staff used a practice-generated script which included the terms ‘triage/clinical assessment’. Explaining these terms led them to field patients’ questions/concerns, causing stress and reducing call handling rates. Without ESTEEM materials to hand, receptionists were panicked about who to triage. Feedback of this observation led to the provision of a new version of the triage criteria. During data collection the new ESTEEM triage criteria were to hand. Receptionists were calmer, although still not totally sure about who to triage. Practice recontextualisation of script consequential for how patients receive triage and for further procedural iterations. Availability of research procedures key in how receptionists screened patients for eligibility.
‘Live’ implementation of nurse-led triage Receptionists’ use of data collection log sheets Log sheets for recording how S-D appointments are managed by reception team Receptionists were not using the provided log sheets, and had not done so since ‘going live’. The practice manager found sheets and gave them to receptionists to use. Receptionists understood how to use the sheets but did so with varied completeness under pressure on the phone to patients. The practice is triaging only the first 10 eligible patients a day, due to limited triage nurse time (3 h are set aside daily). After all nurses’ triage slots were taken, receptionists were unsure whether to fill in all log sheet columns for eligible patients. Receptionists were unsure whether to give patients approximate times for nurse call back. Triaging children: The practice is not currently triaging children, despite explicitly agreeing to do so. Potential patient avoidance: One patient asked if she could avoid the new triage system by booking in person at the reception desk. The receptionist said yes. Log sheets absent from delivery and fidelity to inclusion/exclusion criteria unclear. Process of ensuring protocol fidelity through training and provision of procedural documents failing to be enacted in delivery.