Table 7 Qualitative excerpts

The value of the observation method for learning

Clinical team learning (sub-theme)

• ‘...you can also then look at areas of good practice and areas of poor practice and see is it that the areas of poor practice can learn from areas of good practice, because these observers can pick up areas of good practice as well. So the good thing is that they would highlight both, you can then compare and say why is it that it works well in one setting and a similar setting in another specialty, why doesn’t it work so well?’, H005.

• I think it would be a good thing. I think it’s one of the most important things that we can help with, patient safety, and I think it helps us to realise areas where there’s potential to improve things. I think a lot of us are aware of things that could be improved but I think a lot of us aren’t aware of other things that other people might pick up. H006

• ‘I think that’s what we need to sort of like focus on because for too many years, it’s always been very negative. And we need to highlight there’s a lot of people out there doing a fabulous job, and they aren’t highlighted enough, and that work isn’t highlighted enough. And that’s not me saying we don’t need to look at the things that need to be improved, because that’s essential, but we don’t praise where praise is due. H009

Student learning (sub-theme)

‘I think it makes you more vigilant in your own practice when you have to observe other people making those mistakes. So things like washing hands or putting patient detail away or something like that, like I feel like I’m more aware of myself in those settings because I’ve had to observe someone else.’ S004

Acceptability and impact of the observation process

Acceptable to be observed: staff/practitioner

• ‘The consultants weren’t that bothered… they’d start to have comments like ‘oh, patient safety whatever’…it was more the nurses and the ODPs who were a bit more like ‘oh my God, we have to be careful’. S004

• ‘I wasn’t aware that I was watching different grades. I mean obviously I know I am but I wasn’t, I didn’t feel any different making observations from the consultants than from the HCA [Health Care Assistant] type thing’, S001.

Acceptability of being the observer: students

• ‘…it felt in some ways like we were almost marking them which it’s sort of the paradigm…that’s essentially what it’s done to us, if someone’s standing there with a checklist, they're marking you and you can pass or fail… so there was that feeling of trying to accommodate for that, being almost overfriendly.’ S002.

• ‘…so I asked ‘are you happy for me to be around?’ and they said yes, but then I could clearly tell that they weren’t and kept making comments about the fact that I was there and I was watching– I mean obviously it was difficult for me being in that situation. I didn’t find it difficult for me but more for the other clinician she was working with because I think she was trying to sort of, she wanted someone to back her up and they were kind of ‘well no, it’s fine that she’s there’, so I could feel that there was a bit of tension there.’ S001.

• ‘I felt very awkward because I could sense the anxiety and the discomfort surrounding my observations, especially when I used to put pen to paper, everyone used to kind of just like tense up and bit and then – then they wander around trying to see what I had written….they were quite confrontational, it was just like ‘what have you noticed?’ or ‘what are writing?’ So they said to me they didn’t feel comfortable with me writing things.’ S004.

Concerns for being observed: staff/practitioner

• ‘…with someone that observes, you always associate that with being critiqued…for someone else to watch you do it it’s more nerve racking because you’re thinking ‘oh my God’ you’re double guessing what you would normally do in practice… And I think sometimes you’re more likely to make errors because you’re nervous.’ H008, Nursing staff.

• ‘Well personally I’m very used to it, having medical students in clinic sitting behind me, so that wasn’t an issue. But I think I was more aware of what I was doing. I think it formalised me a little bit.’ H001, Doctor.

• ‘…but it is a little bit nerve racking at times, you do second guess yourself and double check. But to be fair they were unobtrusive and I never felt, whether I was observed, I never really knew whether I was observed or not.’ H007, Nursing staff.

Concerns for being the observers: students

• ‘I felt like I think it was the lack of prior notice that made them feel a bit more like they were being watched. Because obviously when you say patient safety I think what they assumed would be human factors down to them which made them more hostile. There’s no other word for it really, or nervous. And so when, because one of the categories was equipment failures or shortages or understaffing and when I focused more on those things they were a lot more open about the struggles they’re facing, because they felt like they were going to make a difference.’ S004

The process of anonymity of observations

Staff views on anonymity

• ‘I presumed it was anonymous, however if they saw something that was particularly unsafe, you know, anywhere I would have hoped that they would have raised it and felt confident to raise it on the day rather than just to write it down that there was a problem.’ H002

• ‘I mean if nothing else, if it was all positive, it helps form part of your sort of professional development portfolio, it would help that, but actually if it raises some good points along the way and having it quite independent because a lot of people in their professional development portfolios, you know, it’s fairly biased, I would argue. And actually having an independent student who would look at things slightly differently is useful I think’. H004

The mechanism for recording observation

Staff views

‘At the time they had paper but they’re now trialling an electronic form. Which I think may have pros and cons. I think an iPad is quite acceptable. If they’re doing it on their phone I think people think that they’re texting and things like that. So phones don’t go down very well…An iPad I think is generally more accepted as a learning tool. All the students now have iPads and it’s more thought of if you’re on an iPad that you’re actually working’.H006

Student views

‘I think in some ways it [the iPad] is more discrete. As students we have our iPads with us on placement anyway so it’s not as obvious what we’re doing. I think the clipboard itself can be quite threatening and yeah, so I think the iPads are a good idea’. S003

The use of the observation data post-collection

Staff views

• ‘I think if it raises some points, you know, generally about things that people are doing subconsciously – or not doing subconsciously – and actually I appreciate it’s anonymised but actually if someone’s able to turn round and say ‘do you realise you do this?’, or don’t do this, that’s actually quite helpful.’ H004

• ‘I would personally want it fed back to myself as a Ward Sister. Now I have responsibility for this ward so if the practice is not of an expected standard I would like to know about that personally so I could disseminate it back to my team’. H009

• ‘On the day, at the debrief, yeah, that would be great. I think that would be helpful in that situation rather than later on, when you’ve forgotten about it.’ H010

• ‘We have briefings at the beginning of every list and if anything changes, so if we have different staff in the afternoon to the morning we have another briefing before the beginning of the afternoon list…yeah, there’s plenty of time to feed it back. If it’s something that’s sort of happened during that procedure that they’ve noticed and they gave us feedback straight away, you can feed it straight back in the debrief. But if it was more that they wrote it down on their iPad and handed it in, then obviously by the time the next debrief it will be a completely different team. So more of like the trends of what they see over the two days of observing. I think we tend to have them once a month and also our consultants have a meeting as well. We also have like audit quality improvement [0:08:21] so that would be another place where students could actually come to that and present it themselves’. H006