To create the interview protocol, we applied the Revised Socratic Approach for Health Technology Assessment (HTA) (22). When designing the iterative data collection process, we applied the Rapid Assessment Process model (RAP) (23). We modified the methods to meet the needs of the present study. To guide the deductive qualitative content analysis (24), we applied Normalization Process Theory (NPT) (25,26). In reporting the study, we adhered to the 32-item checklist of consolidated criteria for reporting qualitative studies (COREQ), which is presented in Additional file 1 (27). The Revised Socratic Approach for HTA, the RAP and NPT are introduced in Additional file 2.
The ODP ran during the period 2009-2013. The hospital district implementing the ODP is responsible for the provision of public specialized health care services to a population of 200,000. The ODP was carried through in six psychiatric units, of which five were under the administration of the managing organization and one external. The external unit was excluded from the present study in order to focus the evaluation on intra-organizational processes and to avoid confusing the effects of inter-organizational interactions. We collected the present data in March 2015, 16 months after the end of the ODP. The time gap was because the analyses of the final summative inquiry and mixed-methods process evaluation, both administered to the frontline therapists in spring 2014, revealed a need to complement our understanding about the realization of the ODP (20,28). The present authors’ relations to ODP and the managing organization as well as their mutual professional relationships are presented in Additional file 3.
Forming the study group
To assemble the study group according to the purposeful sampling strategy of the ‘complete target population’ (29), we emailed the whole ODP project group and all team leaders of the target units, 14 individuals in total. Only one recipient involved in the project group declined the invitation due to compelling personal reasons, thus resulting in a study group of 13 individuals. We informed the study group in advance about the purpose, setting and course of the study as well as the principles for handling the data. This included information about the videotaping of the interviews and the assurance that no interviews would be transcribed due to the sensitive nature of the material and further the assurance that each participant’s identity would be protected as far as possible during processing and utilization of the information obtained. Recipients were assured that participation in the study was voluntary and would in no way affect their status within the organization. All members of the study group gave verbal consent to participate.
Description of the study group
The study group was divided into two Focus Groups (FG1 and FG2) according to each member’s relation to the ODP. The FG1 comprised the ODP project group, altogether five people, namely the clinical director of the psychiatric department, the principal designer and executive of the ODP, a professor of psychiatry, an associate designer and an executive who was a registered psychologist and two assisting research nurses. The FG2 comprised the team leaders, both psychiatrists and registered nurses, altogether eight people. All members of the study group and the researchers had been regularly employed in the organization for years before the launching of the ODP, thus their relationship was established prior to the present evaluation.
The semi-structured focus group interviews
We interviewed the FG1 twice (FGI1.1 and FGI1.2) and FG2 once (FGI2) (Figure 1). Each interview lasted three hours and was divided into two parts with a short break between them. Four members of the FG1 and five of the FG2 attended the group interviews in person. Four individuals were unable to attend the group interviews in person due to pressure of work, so they provided the desired information in alternative ways: The FG1-enrolled associate executive was interviewed separately immediately after the FGI1.1 and the information obtained was included in the relevant report. One FG2-enrolled person provided written feedback before the FGI2, and this information was presented to the FG2 during the interview. The remaining two FG2-enrolled people who were unable to attend in person had discussed the issues beforehand with their attending colleague.
The first author acted as a facilitator in the interviews with FG1 and second author took notes. The FGI2 involved only the first author also taking notes while acting as the facilitator, since second author had to be excluded due to her managerial relation to the nurse members of the FG2. Videotaping made it possible to check the notes afterwards.
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Figure 1. Setting for performing the iterative focus group interviews and creating the raw data. Abbreviations: FG1 = Focus Group 1; FG2 = Focus Group 2; FGI1.1 = the first interview with FG1; FGI2 = interview with FG2; FGI1.2 = second interview with FG1.
The interview guide
The same interview guide was used for the interviews with FGI1.1 and FGI2. It comprised five themes and nine guiding questions relevant to the ODP. We constructed the themes to encompass information of interest; they concerned underlying motives and intentions, management, the perspective of the participating units, the interests of individuals conducting the present evaluation and creating the vision for future developments. We constructed the guide by selecting relevant explanatory questions on the themes above from the Revised Socratic Approach for HTA (22). Next the original explanatory questions selected were reformulated for the purposes of the present evaluation and renamed as guiding questions. (See Additional file 4, Table A).
The interview guide for the FGI1.2 was composed so as to involve the FG1 in the process analysis of the ODP reflexively rather than as being a source of data collection only (see Additional file 4, Table B).
While creating the interview plan and guides, the first author had reflective discussions about the mission with the second author, the clinical director and the principal programme executive according to the idea of RAP (23). Due to the setting, we had no opportunity to pilot the interview guides in practice.
Creating the raw data
As a base, we had the technical data on the ODP comprising the implementation plan of ODS-I (20), the research plan of the ODS including the protocol for data collection and total executive resources in ODP (see Figure 2 for resources). We gathered the supplementary information through an iterative and collaborative process of FGIs and finally wrote one, rich narrative (in Finnish) on the realization of the ODP that comprised the raw data (in more detail see Figure 1). We organized the raw data according to the following scheme drawing on the framework proposed by Rise et al: organizational structures, management, decision-making processes, cultural change, permeation throughout the organization, anchoring responsibility, prioritizing of resources, understanding of staff involvement and hindsight (30).
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Figure 2. Programme resources allocated to the Ostrobothnia Depression Programme. Attending training was the only prerequisite for a therapist being regarded as ODP enrolled.
aOne-day training workshops for both Behavioural Activation and Motivational Interviewing.
Qualitative content analysis
The case of our study was the process of running the ODP all the way from its rationales to its completion, and the unit of analysis was the narrative formed by the raw data (29). We analysed the raw data through deductive qualitative content analysis (24) guided by NPT (see Additional file 5 for coding frame) (25,26). Our analysis and extracting the results progressed in four steps: First, we encoded the raw data using different colours and reorganized it according to the main categories. Second, we re-encoded and organized the data further according to the subcategories. We reviewed the relevancy of the encoding during the two first steps and readjusted when needed. Third, we condensed and rewrote the information contained in the encoded text pieces into a fluent narrative in terms of each subcategory. Fourth, we answered the research questions on the basis of the data analysed, thereby providing the results of the present study.
The first author performed the process of analysis and extracted the results in close consultation with the second author. Finally, we presented the results to the FG1 for appraisal and possible amendments. They suggested some refinements and, after these have been made, they accepted the results presented below. The analysis of the data was processed manually with assistance of Word for Mac 2011.