Data collection

I recruited three key informants for the study; one from executive level, one from a senior clinical level and one from a nursing managerial level, as shown in Table 1 below. Key informants were selected based on my insider

knowledge of the organisation and two of the three informants were known to me professionally prior to the study starting. The third was identified through discussion with these two. I, therefore, capitalised on my insider status at this early stage of the research.

Sessions for observation were identified through discussion with key informants and were part of the „facts‟ that came out of the key informant interviews. In exploring the work of the organisation as it moved towards change with the key informants, these sessions were interpreted as forming part of the organisation‟s change agenda. They were activities such as team meetings, learning sessions or governance events that addressed

organisational issues, rather than clinical issues for individual patients. Any patients were discussed anonymously. In identifying these events as suitable

62 for observation I considered a number of factors: the aim of the event within the departmental and organisational context; the likely participants and the aspects of organisational change addressed. I aimed to include a variety of events, giving an idea of the change activity taking place within the department and wider organisation. A log of these can be seen in Table 2 below.

Post observation participant interviewees included employees from a number of roles. Selection of interviewees was purposive and pragmatic. I sought to include a variety of staff members; doctors both junior and senior, midwives both junior and senior and those in a more managerial role. I approached participants following the observation sessions informally, as I was able, and asked if they would be willing to be interviewed. However, the final number selected was largely opportunistic and limited by working pattern constraints and employees leaving the Trust during the course of the study. Although I originally aimed to conduct six interviews, I was only able to arrange four. Other contemporary researchers in the NHS have commented on the difficulty of negotiating time for interview in busy clinical settings (for example Dickinson et al., 2013) and I encountered similar problems. In particular, I was unable to secure an interview with a junior doctor or a general manager. A description of the final interviewees can be seen in Table 3 below.

Texts for analysis were similarly identified during the preceding stages of the study. They were documents that were either used or referred to in the sessions observed, or discussed in interviews. A log of these can be seen in Table 4 below. In selecting texts, I purposively chose a mix of outward and inward facing material. Outward facing material, available via the internet, was used to explore how the Trust and Department represents itself to patients and external stakeholders particularly. More inward facing material, only

accessible to staff, was used to explore the department‟s representation of its goals and priorities to its staff members. I also chose a text that had been prepared on behalf of the Trust Board and which has been widely read by both external stakeholders and internal staff members. In this way, I aimed to

63 Table 1: Key informant interviews

Interviewee Role Time in organisation

A Executive Board member Less than one year B Senior clinician Greater than three years

C Nursing manager Two years

Table 2: Organisational observation events

Event title Origin of event Description and aim Frequency of event Number and type of participants Learning and sharing session Identified by gatekeeper during scoping period and by senior clinician KI Practitioner developed and led 30 minute multidisciplinary teaching session. Aim to address key clinical issues identified through analysis of recent departmental clinical incidents and learn skills to achieve different outcomes in the future. Twice weekly Consultant obstetrician : 1 (facilitator) Middle grade doctors: 3 SHO grade doctors: 4 Midwives: 3 Healthcare assistant: 1 Change project meeting Identified by nursing manager KI Organised and timetabled by project team

1 hour steering group meeting for a specified service improvement project.

Aim to review project progress and agree an ongoing project action plan. As needed, typically monthly Project midwife: 1 (chair) Senior midwives: 2 Junior midwives: 2 Junior doctors: 1 Managerial staff: 2 Maternity business meeting Identified by senior clinician KI Organised at fixed time each month and administered by general manager‟s personal assistant 1.5 hour meeting of senior staff covering departmental

management priorities and issues.

Aim to update senior staff on the

department‟s progress in line with the

organisation‟s objectives and to agree an action plan to address new and ongoing issues. Monthly Consultant obstetricians: 9 Senior midwives: 4 Managerial staff: 3 Admin staff: 1 Clinical governance meeting Identified by senior clinician KI Organised at a fixed time bi- monthly, co- ordinated by a named consultant and administered by a dedicated member of secretarial staff 2.5 hour multidisciplinary meeting with presentation and discussion of

departmental clinical audits and serious incidents.

Aim to update staff on clinical governance priorities and issues and agree an action plan for departmental learning and quality improvement. Bi-monthly Consultant obstetricians: 12 Senior midwives: 4 Project midwives: 3 Middle grade doctors: 8 SHO grade doctors: 6 Managerial staff: 3

64 Table 3: Post observation participant interviews

Interviewee Role Observation session attended Interview completed

Priya Consultant obstetrician Learning and sharing, business meeting, clinical governance

Month 2

Ranita Project midwife Learning and sharing, change project meeting

Month 3

Tracy Senior midwife Business meeting, clinical governance

Month 4

Desmond Project manager Change project meeting Month 4

Table 4: Organisational documents analysed

Document Type Description

Maternity home page on Trust website

Web page with text and image

Accessed by external visitors to the Trust website looking for information on maternity Care Quality Commission

(CQC) Investigation report into the Trust

PDF document on CQC website

Accessible by internal and external stakeholders via the CQC website

Trust response to CQC report into concerns around

maternity services

Letter to stakeholders on Trust website

Accessible by internal and external stakeholders via the Trust main website

Maternity policy for a

specified clinical area, written as part of a service

improvement project

PDF document on Trust intranet

Accessible by internal staff only