GP interviews and the development of DCE attributes and development of DCE attributes and

levels

7.0 Chapter overview

This chapter reports the second qualitative study conducted to design and generate attributes and levels to be used within the DCE: semi-structured interviews with GPs. This represented stage 2 of the DCE design and analysis process. Finally it reports the final chosen attributes and their respective levels.

7.1 Aims and objectives

This qualitative study had four key objectives:-

 To conduct interviews with GPs to focus the characteristics and components of discharge summaries that are significant to them, identified through a previously completed survey, into attributes that can feasibly be used to describe electronic discharge summaries.

 To assign plausible levels (those that GPs can see as realistic and believable) to the attributes identified as most important.

 To refine the language to be used in the description of attributes, so that GPs would find them appropriate to convey the correct meaning, for them, within the DCE.

 To investigate reasons for the most highly ranked components and characteristics of a discharge summary in the survey being considered important to GPs.

7.2 Methods

7.2.1 Ethical approval

Approval for this study (alongside the survey described in Chapter 6) was sought from UEA Faculty of Medicine and Health Sciences Research Ethics Committee, and granted on 21^st December 2012 (Appendix 6.1).

7.2.2 Sampling strategy

Given the specificity of our research question and topic area, it was estimated that a sample of five to ten GPs would be likely to achieve a sufficiently detailed but manageable diverse dataset. It was intended that sampling would cease only when data saturation occurred, i.e. the point at which no further emergent themes or important aspects were being identified in interviews (112), and that concurrent analysis would be undertaken to judge at which point this occurred.

As the DCE was to be conducted with GPs working in the region, the attributes obtained needed to be relevant to the wider population of GPs, and therefore a sample which purposively covered the range of features of the general population of GPs was required.

The subject being investigated was GPs’ preferences for information provided in a professional context. Therefore a factor which may have altered their views on this was their own professional working environment or practice. GP requirements and priorities at discharge may have been dependent on the in-house procedures used at their own practice to process discharge information. It was therefore important to recruit a sample of GPs working at different types of GP practices.

The representation of diversity is often important in qualitative research (171). Therefore, the sample would ideally have consisted of GPs of differing seniority (based on years of experience), specialties and backgrounds, who expressed a range of views about the system within the survey. However, it was not possible to determine this information about GPs from the participation card by which they were approached, and so a wholly purposive approach to sampling was not possible to underpin this information.

Nevertheless, a sample with maximally diverse characteristics could have been constructed. When tracing contact details it was possible to identify the gender of the GP (because of their name), and the practice where they worked (because of their address), and so a purposively diverse sample of both male and female GPs employed at different practices could have been selected providing there was a sufficient number of GPs indicating interest in participating. The 173 GPs currently practicing within the area were all sent a copy of the survey (Chapter 6). Of these, the 15 GPs who had indicated an interest in involvement in further research during the survey were approached.

7.2.3 Identification

Only GPs who had expressed a willingness to be approached were contacted and invited to participate. The contact details for GPs who had expressed an interest in further research on the survey participation card were traced using their unique study reference number, allocated for the purpose of the survey and which was present on the participation card, but not on the survey itself, in order to maintain anonymity of question responses.

7.2.4 Recruitment

GPs were sent an invitation by post (Appendix 7.1), which included a participant information sheet (Appendix 7.2) and study consent form (Appendix 7.3). These provided the GP with information about the interview, including what taking part would entail and

what they would have to do; that they did not have to take part and could withdraw their consent to take part at any time; what topics would be covered; how confidentiality would be maintained and where further information could be sought. This was then followed-up with a telephone call four days after posting to allow sufficient time for the GP to read and process the information, and if GPs expressed a willingness to take part, an interview was arranged.

7.2.5 Ethical considerations

7.2.5.1 Avoiding coercion

Coercion is defined as “the persuasion of an unwilling person to do something using force or threats” (172). Historically in research, the autonomy of human participants to participate in research has often been compromised (173) leading to disastrous consequences. As a result, it is imperative to uphold an individuals’ autonomy when entering into research.

Because this study was affiliated both with CHUFT and a local University, the GP may have felt pressured to participate in the study, because of a sense of duty to the hospital or their profession. GPs may have feared that there might have been consequences of not participating, for example, to their working relationships with the hospital, or a negative impact on their working environment.

To avoid any implied coercion to participate, the GP was provided with a detailed participant information sheet, which explicitly stated that they were under no obligation to take part, and that their decision would not affect their relationship(s) with staff at CHUFT, the University or any other body. If they proved willing to participate after having read the information about the study, GPs were asked to provide their written consent to take part.

7.2.5.2 Informed consent

Informed consent, where participants freely volunteer their consent to take part in the research having been provided with full and meaningful information about the study, is necessary to respect the rights of the GP participants and to protect their well-being. A consent form (Appendix 7.3) agreeing the terms for me to interview the GP (at their practice) was sent to doctors alongside the participation information sheet, which they were asked to read in their own time and, if happy to provide consent to participate, sign before the interview took place. Signing the consent form was seen as the participant's authorisation for me to interview them, and as agreeing to the terms of the interview.

Consent could be withdrawn at any time during the study, and this was stated explicitly on the consent form and participant information sheet. One copy of the signed consent form was given to the participating GP for their records, and the original retained at the University.

7.2.5.3 Confidentiality

It was a necessary ethical principle that participating GPs were not harmed as a result of their participation in this study. It was therefore important to uphold confidentiality within this study in order to permit GPs to speak freely and unreservedly about their opinions of, and experiences with, the electronic discharge system provided by CHUFT, without risk of repercussion from colleagues, patients or hospital staff. Consequently, all data collected were processed and stored anonymously, in accordance with Cauldicott guidelines, with all identifying information relating to GPs and their practices removed. For the purpose of the study, GPs were allocated a unique study reference number, which was used when processing and analysing their interview data. Transcripts of interviews were made available to the participating GP on request.

GPs may have been identifiable (to readers who are familiar with the practices, e.g. local primary care workers and hospital staff) if they provided details about their own GP practice-specific processes or procedures, such as the processes used to reconcile information received from the hospital into patient notes, during their interviews.

However, practice-specific information was unlikely to be pertinent to generating attributes for the DCE, as it was important to construct attributes that would be applicable and relevant to all GPs practicing within the local area.

7.2.6 Trustworthiness

Measures were taken to ensure the four criteria of Lincoln and Guba [122] for establishing trustworthiness, credibility, transferability, dependability and confirmability, were upheld during the study.

To ensure credibility, I triangulated the priorities and preferences of GPs obtained from interviews with the results of the GP survey (Chapter 6) in order confirm that the most important attributes have been identified. This study adopted an interpretive approach to analysis, which, together with my pre-existing views, will have inevitably influenced the data interpretation and conclusions that were drawn. In order to avoid misrepresentation,