The structure of the GSN and OSN groups differ. The OSN group were experienced nurses (band 6–8) working with a named orthopaedic consultant, their associated anaesthetist and designated secretary. Each OSN therefore specialised in a joint or limb area for example hip and knee. While there may be some cross cover of duties at times, there is no leader or hierarchy within the group of OSNs. The GSNs were a small group of Band 3–5 nurses led by a dynamic and experienced lead nurse on the cusp of retirement who was the point of contact for a wide range of surgical teams and anaesthetists. Regular meetings allowed information, changes and concerns to be cascaded to the more junior nursing team. They all pre-assess patients from a range of surgical specialities.
The participants represented a pragmatic sample of available pre-assessment nurses on a given day for both groups. The OSN group comprised a significant portion of the whole group with 5 nurses, while a smaller sample of 3 nurses participated from the GSN group. The lead nurse from the GSN group who had been heavily involved in development of the passport had retired at the time of interview and was therefore not in attendance.
The themes emerging from the first round of coding the OSN and GSN transcript were mainly barriers and facilitators of implementation such as lack of time. These themes mapped well onto categories from a systematic review of staff reported barriers and facilitators to the implementation hospital-based intervention (13). This provided a valuable framework to display the key areas reported by the nurses during the focus groups in the wider context of implementation within hospitals. The 12 categories identified in the systematic review are displayed, with key domains highlighted in bold within Table 1.
Environmental context, particularly staff workload and time
Culture – attitude to change, motivation, champions and role models
Staff commitment and attitude- need and ownership
Skills, ability and confidence
Similarities between groups
The themes emerging from the groups highlight the perceived strengths and weaknesses of the passport from a nursing perspective and identify the facilitators and barriers to its implementation in both pre-assessment clinics.
The areas the nurses in both groups expressed similar views or approaches on the passport were:
Quotes illustrating these areas of agreement are shown in table 2.
Differences between groups
Despite universal appreciation of the passport as beneficial and a well-designed tool, there were areas in which the groups differed in their willingness to utilise it in their routine practice.
These centred on the work required and the nurses’ ability to find time and have the resources to implement it in practice. Contrasting attitudes are highlighted in in table 2.
There were 4 key areas where groups differed:
Ease of use/ time burden
The GSN group did not feel that the passport significantly added to their workload while the OSNs expressed that this would be a duplication of some information they had in leaflets for patients with diabetes. Some felt that the additional explanations and documentation of observations in the passport could be time-consuming and patients with diabetes would therefore require longer appointments.
Culture and attitude to change
There also were differences in culture between the groups and among individuals in the OSN group in their attitude to change. The GSN group maintained their senior nurse’s openness to change as shown by her involvement in developing the passport and encouraging staff to use it. In the OSN group a nurse who offered to hand them out to her patients initially was a lone voice in the focus group.
Staff role identity
Advocacy Vs Authority
There is a contrast between the two nursing groups in the roles the nurses played in supporting the patient journey. The advocacy role is more evident from the outset with the GSN nurses.
In care settings, advocacy is a process of supporting and enabling people to express their views and concerns, access information and services, explore their options and promote their responsibilities (14). GSNs spoke a lot from a hypothetical patient perspective “if I was a patient…” and portrayed the passport as useful and informative for patients. This perhaps reflects their junior level and consequently the more limited experience they could draw on. Their role is not to explain the surgery in detail to the patient, but rather prepare them for it, giving patients an idea what to expect in hospital and signposting where necessary. It is worth noting that one of the nurses in the GSN focus group was a staff nurse with type 1 diabetes. She had not used the passport but spoke enthusiastically, sometimes from a personal viewpoint, of living with the condition and expressed she felt it was a good idea for patients. Nurses drew on empathic advocacy about patients being the expert of their disease which was likely influenced by her presence: “they’re the best people to manage their condition, aren’t they”.
The OSN group nurses had specialist knowledge in their limb or joint area and the information they give patients is tailored with some pathways structured slightly differently. They also describe a way of working which is specific to the consultant(s) they work with; consequently, information can be provided not only about the latest evidence for that type of surgery, but also about the operating surgeon’s and anaesthetist’s usual practice. “we’re going to be giving our hip and knee patients a high carb drink to take home… on the enhanced recovery programme”. This implied a different approach to patients attending pre-assessment. They take a more directive approach, informing patients what to expect and enforcing what was required of them. They appeared to carry more responsibility for ensuring perioperative readiness and had the power to delay surgery if this was not delivered. “…when I saw him at pre-admission I told him that if his …HbA1c weren’t better…we couldn’t do surgery”. Taking on this authoritative role is challenging at times: “you don’t want to tell them they need to lose loads of weight…”
Later in the focus group discussion the OSNs also mentioned their role as patient advocates. This is 35 minutes into the group compared with just 6 minutes for the GSN’s, who alluded to this role enthusiastically and frequently.
Skills, ability, confidence
The OSN group suggested that the passport was a good idea; however there was a large perceived impact on their time and workload. This is in contrast to the GSN group who felt it was quick and easy to use in everyday practice. This difference may have, in part, been a reflection of lower confidence they had in explaining diabetes care to patients in the detail that the passport appeared to require.
Changes during focus group
During the process of coding, differences in responses between the groups became apparent. Additionally, there were some themes where OSNs as a group appeared to change their position as the focus group progressed. The domains of the barriers and facilitators framework where these changes were most marked were motivation and group identity.
While the OSN group appreciated it was a useful intervention for patients, this statement was generally caveated by the question of what would be expected of them in implementing it emphasising that this would affect their workload. This perception appeared to shift after one of the nurses shared a story of a personal challenge with an aggressive patient whose surgery had to be delayed due to poor glucose control. The personal benefit to the nurses of using the passport was illustrated and there were no further objections to its utility.
The structural differences in the set-up of the two nursing groups is apparent early in their interactions. The GSNs were speaking as peers doing the same work who could ask each other for advice and support. They shared practice and affirmed each other’s statements and observations. The GSN group were quite vocal in their comradery making affirmative comments and statements throughout.
Initially, the OSN nurses spoke about their individual joint or limb practice or quirks of the surgeon they worked closely with, which did not relate to the practice of others in the group. They gave each other space to speak and respected the position of their peers, but were not seeking to support each other through the initial interactions. As the focus group progressed, the OSN group appeared to become more cohesive in emphasising and expanding on what their colleagues had just stated.
There was a noticeable difference towards the latter part of the OSN focus group. The pivot point appeared to be strong words from a senior nurse about the workload and time pressures. She expressed a collective will to help patients, but also the shared feeling of time scarcity. With this clearly and openly stated the nurses appeared able to move past their individual objections to the passport and started brainstorming how it may be implemented at other stages in the pathway to allow patients to benefit whilst limiting the impact on their own workload: “we do a hip and knee group, perhaps you could come and hand it out there”.
The behaviour change model helps categorise what is observed during the focus group. The main change appears to be centred around scenario-based risk taking. Over the course of the discussion the nurses in both groups offered issues they had encountered or noticed themselves with patient care. Finally, the single story shared in the OSN group around this challenging patient scenario was an act of storytelling or Scenario-based risk-taking. It was powerful for both groups in connecting them as a team with shared experiences and particularly with the OSN group helped address their collective concerns and provided a potential individual motivation to use the passport.