Theoretical framework

The theoretical framework underpinning the study was realist evaluation and qualitative realist interviews were utilised as the method of data collection (see p.64 for the rationale for this methodology and method).

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4.5 Participant selection

4.5.1 Practice recruitment

Two Practices were recruited via two different routes. Practice A was in Somerset and Practice B was in West Yorkshire. Practice A was recruited via network links of a member of the research team who was able to introduce the researcher to one of the Practice

Partners. The Practice Partner identified three GP Practices in that region who may have been appropriate to take part, provided Practices’ contact details and consented to the researcher contacting them. The researcher provided Practices with a study protocol, leading to two Practices withdrawing interest, as they did not have the capacity to take part. The remaining Practice was identified as being appropriate, they expressed the capacity to take part and the Management Partner consented to the Practice’s participation.

Practice B was recruited using an alternative method. The researcher contacted several CCGs via email, and made inquiries on Practices that had FCPs. The researcher then contacted appropriate Practices via email, outlined the research and invited them to consider participating. Alternatively, the CCG contacted Practices on the researcher’s behalf and connected them via email correspondence. A CCG in West Yorkshire expressed an interest in the research and granted the project approval with the Research and Development department. The researcher discussed the research with the Chief Executive Officer (CEO) and she consented to the Practice’s participation.

4.5.2 Sampling and Recruitment

Purposeful sampling was adopted to sample staff and patient participants; it aims to select information rich cases based on their ability to answer the research questions (Emmel, 2013). In purposeful sampling, theory is considered before data collection when selecting the sample, and not throughout data collection – as in theoretical sampling (Glaser and Strauss, 1967). Patton (2015) highlighted the pragmatism of purposeful sampling as a strategy that utilises available resources and operates within constraints. As there was only one primary researcher with time limitations, this pragmatic sampling method was

adopted.

4.5.2.1 Staff recruitment

Recruitment of both patient and staff participants were conducted simultaneously. Several different methods were adopted to recruit participants. However, inherent to all methods was the circulating of staff or patient information booklets (see Appendix 39 and Appendix 40).

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The booklet signposted staff to contact the Principal Investigator or speak to their Practice Manager if they were interested in participating. Staff participants were recruited via two methods: through the Practice Manager inviting them to participate through circulation of the staff information booklet via email; or through another member of staff, who had already been recruited, sharing the information booklet via email.

4.5.2.2 Staff participant selection criteria

In line with realist methodological underpinnings, a range of practitioners were recruited to gain different insights into the FCP role (Manzano, 2016). The following professionals were recruited in each Practice: a Medical Receptionist; the Management Partner; all practising FCPs; a General Practitioner.

4.5.2.3 Patient sample size

It was estimated that data saturation could be achieved with between 4-8 patient

interviews per Practice site; thus, 8-16 between the Practices. This estimate was formed on the basis of the contexts identified in the realist review, including patients experiencing HCP roles, patient experience of continuity of HCPs and the type of condition – chronic or acute.

Traditional qualitative studies sample use the principle of theoretical saturation, ceasing data collection if no novel themes are arising (Patton, 2015). This study implemented this principle; however, it was based on theory saturation (see section p.53 for discussion on sampling strategies in realist evaluations).

4.5.2.4 Patient recruitment

Several recruitment strategies were adopted to gain patient participants. Method one involved FCPs disseminating patient information booklets at the end of consultations (recruiting participants who had experienced the FCP role). The second method was GP dissemination of patient information booklets at the end of consultations (recruiting participants who had not experienced the FCP role)⁵. Posters were placed in the reception area of the Practice, they invited patients to pick up a patient information booklet from reception⁶ (see Appendix 41).

The booklet advised patients to contact the Principal Investigator by telephone.

Alternatively, patients were provided with a pre-addressed envelope in which they could

5 This method was adopted in Practice A only. It was decided that due to the low recruitment rates, particularly from GP recruitment, that this method was ineffective.

6 This method was adopted in Practice A only as it was reported by a member of staff that they had not been placed in the waiting area as intended.

117 return an enclosed reply slip that consented to them being contacted by the Principal Investigator (see Appendix 42).

4.5.2.5 Amendment to patient recruitment strategy

The initial recruitment strategies alone had limited success. In Practice A only one patient was recruited via these methods, and no patients were recruited in Practice B.

Consequently, the researcher made a non-substantial ethical amendment for a new recruitment method which was accepted 13^th September 2018 (see Appendix 43). The researcher disseminated patient information booklets at the end of the patient

consultations and briefly explained the research. It was stressed that the patient did not have to take part to avoid coercion.

4.5.3 Patient participant selection criteria

Participants were sampled first from Practice A and then Practice B. The protocol set out a plan to follow a sampling matrix in which certain factors were to be considered when selecting patient participants (see Table 4.1).

There were difficulties in patient recruitment and time constraints of the PhD process.

Consequently, any patient was recruited providing that they were willing to take part and did not meet any of the exclusion criteria (see the limitations of this, p.300) (Ritchie and Lewis, 2003).

4.5.4 Patient participants inclusion criteria and exclusion criteria

Participants were invited to take part if they: at the time had, or in the past had, a MSKD;

and were over 18 years old.

Participants were not able to take part if they: did not meet the inclusion criteria; were considered to be ‘vulnerable adults’; or did not speak English.

Table 4.1 - Sampling matrix

Age Practice A Practice B Gender

Contact Non-contact

Contact Non-contact

<64 1-2 1-2 1-2 1-2 Male 4-8

Female 4-8

>65 1-2 1-2 1-2 1-2

Secondary Criteria MSK condition: acute, chronic

Socio-economic status

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The study is on the FCP physiotherapy role specifically; the role’s speciality is MSKDs and therefore there is a requirement for the patient to have had, or currently have, a MSKD.

The study was focused on the adult population and not under 18s who have a different paediatric care pathway. Patients who fell within the British Medical Association (BMA) (2011) ‘vulnerable adults’ classification may have had difficulty in understanding the complex methodology of a realist evaluation; therefore, it was not appropriate for this patient group to be included. It would not have been possible to have non-English speakers participating in the study due to the limited resources of a PhD project, which is a

recognised limitation (see p.300).

4.5.5 Patient exclusions 4.5.5.1 Practice A

Following the change of recruitment strategy, uptake of participants increased. Seven further patients from Practice A replied that they consented to be contacted by the researcher, resulting in a total of eight responses from this Practice. Due to the pragmatics of time-constraints caused by the slow recruitment, the team decided to only interview those who had experienced the FCP role.

The study’s research questions included: What is the patient understanding of the FCP role before contact? What is the patient understanding of the FCP role after contact? What aspects of the FCP model are acceptable/ unacceptable to patients?

The first question had planned to be answered through interviewing those who had not experienced the role. However, this question could be answered retrospectively by those who had experienced the role. There are limitations involved in retrospective evaluation which are fully acknowledged (see the limitations of this, p.300). The study protocol had already set out plans to interview fewer patients who had not had contact with the FCP, as experience is a key component for patients to be able to evaluate a service (Campbell, Roland and Buetow, 2000). Richer data on what made the role acceptable/unacceptable was expected from those who had experienced the role.

Two of the patient replies were excluded on account of them never experiencing the FCP role. Patient 2 was screened as appropriate, however at the beginning of the interview it became evident that she had not experienced the role and she was excluded before the interview commenced (see Figure 4.1).

119 4.5.5.2 Practice B

Once the new recruitment strategy was in place, there were seven patient replies in total from Practice B. One patient agreed to participate, however, he had a busy work schedule and despite a gentle reminder from the researcher, he did not ring back to arrange the interview. Another patient was hard of hearing and had difficulty understanding the researcher in the recruitment phone call. As telephone interviews became the default data collection method due to patient recruitment issues hindering data collection, this patient was excluded on grounds of the limited time of the researcher to be able to travel. There were a total of five patients recruited in Practice B (see Figure 4.1).

4.5.6 Non-participation

None of the members of staff or patients declined participation directly to the researcher.

However, staff were approached by the Management Partner/Practice Manager and FCP 4 (Practice A/B respectively), thus the researcher would not have been aware of any non-participation. An unknown number of participants were invited to take part as there was no tracking of the number of leaflets that were disseminated by FCPs/taken from the waiting area. One patient did not follow through with booking an interview due to work commitments.

• All patients responded via patient reply slips

•7 responses from Practice A

• 8 responses from Practice B 15 indiviudals responded to

the inviation to take part

• 2 in Practice A, neither had experienced the FCP role

• 1 in Practice B due to being very hard of hearing 3 patients excluded in intial

phone call

• Patient from Practice B had the recruitment phone call and agreed to contact the researcher,

but he did not 1 patient did not book

interview

• Patient 2, from Practice A, had not experienced the FCP role

1 patient screened out in interview

10 patient interviews in total - 5 per each Practice

Figure 4.1 - selection process for both Practices

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4.5.7 Informed consent

All participants were provided with a consent form in advance of the interview. As well as clarifying confidentiality and the right to withdraw, the consent form stated that the participant had read and understood the patient/staff information booklet (see Appendix 44/Appendix 45). The Patient Partner had validated the patient consent for its patient accessibility. A discussion before commencing the telephone interview reiterated the contents of the information booklet and invited the participant to ask any questions regarding the research. Verbal consent was gained at the beginning of each staff/patient interview and it was stressed that the participant may stop the interview at any point; this was recorded on an audio device. This ensured patient awareness of their right to

withdraw at any point, a vital component of the process of gaining informed consent (Silverman, 2011; Ryen, 2004; Wiles, 2012). See p.63 for the ‘Ethical considerations in qualitative studies’ that underpinned this study.

4.5.7.1 Staff consent

Consent forms were circulated to staff by the researcher and the Practice Manager.

Consent forms were returned to the researcher via email and saved in an encrypted OneDrive folder. Paper copies were printed, signed by the researcher and stored in a locked filling cabinet on UWE premises.

4.5.7.2 Patient consent

All patients (n=10) chose to contact the researcher via the reply slip, providing their name and contact number as initial consent of their interest in participation. The researcher contacted the potential participant to discuss the project in more detail and check their suitability for the study against the exclusion criteria. Patients were invited to ask the researcher questions that they may have about the research project. If the patient was interested in taking part, the researcher sent them a consent form via email. If they did not have access to e-mail/preferred a hard copy, they were posted a copy of the consent form and a pre-paid envelope.

121 4.5.8 Forming interview topic guides

Realist evaluations have a unique way of forming topic guides through testing of specific hypotheses. This study’s topic guides were informed by a realist review carried out prior to the evaluation, received expert opinions from the supervision team and patient partner and had several iterations (see Figure 4.2).

4.5.8.1 Theoretical development

The interview topic guides were formed initially from the hypotheses (n=19) originating from the realist review. Hypotheses were condensed through reducing the number of questions, to the decrease the burden on the interviewee. The CMOs were integrated into questioning subtlety, in a way that would make sense to the respondent to teach them the theory (Pawson, 1996). For instance, rather than the topic guide stating “is patient

perceived severity of a condition a context?” the question was more open: “Have your patients with musculoskeletal disorders ever expressed not wanting to see a

physiotherapist?” The topic guide prompts for this question were: “why do they not want to see a physiotherapist; perceived severity of condition; what conditions they consider serious.” Although the questions were in lay-person terminology, the theory was still under test.

4.5.8.2 Expert opinion

There were subtle changes to the questioning of staff topic guides. The hierarchy question was re-framed to prevent it being provocative (see Appendix 46 to Appendix 49). An introductory question regarding the participant’s overview of the FCP role was added; this established the interviewee’s basic understanding and opinion of the role from the offset and, as an open question, encouraged the interviewee to talk freely. The opportunity for interviewees to share their experiences is vital, as a realist interview aims to explore the stakeholders’ awareness and experiences of the programme, including their reasoning

Theoretical Development

19

Figure 4.2 - Forming interview topic guides

In document Patient acceptability of the physiotherapy First Contact Practitioner (FCP) role in Primary Care: A realist evaluation (Page 115-122)