Application of the critical incident technique in refining an initial programme theory

Abstract Introduction As realist methodology is still evolving, there is a paucity of guidance on how to conduct theory driven interviews. Novice realist researchers can therefore struggle to collect interview data that can make a meaningful contribution to refining their initial programme theory (IPT). In addition, researchers often face challenges when trying to conduct interviews with healthcare staff due to their busy work schedules. In this case study of team interventions in acute hospital contexts, we explore the benefits of using the Critical Incident Technique (CIT) in order to build and refine an IPT. Methods The five steps of the CIT were mapped against realist methods guidance and adapted into an interview framework. Specifications to identify an incident as “critical” were agreed. We embedded probes in the interview framework to confirm, refine and/or refute previous theories synthesised from the literature and to extrapolate new theories. Seventeen key informants were interviewed and recordings were transcribed and imported for analysis into NViVo software. Using RAMESES guidelines, Context-Mechanism-Outcomes configurations were extrapolated from a total of 31 incidents. Results We found that the CIT facilitated construction of an interview format that allowed KIs to reflect on specific positive or negative team interventions. We demonstrate how the CIT strengthened initial programme theory development as it facilitated the reporting of the specifics of team interventions and the contexts and mechanisms characteristic of those experiences. As new data emerged, it was possible to evolve previous theories synthesised from the literature as well as to explore new theories. Conclusions Utilising a CIT framework paid significant dividends in terms of the relevance and usefulness of the data for refining the IPT. Adapting the CIT questioning technique helped to focus the KIs on the specifics relating to an incident allowing the interviewers to concentrate on probes to explore theories during the interview process. The CIT interview format therefore achieved its

ensuring that the subject matter under evaluation -the programme theory -remains the focus of the interview (7). For the novice realist researcher, this can be a demanding task and there is limited guidance in the literature. Manzano's methods (8) of theory gleaning, refining and consolidation have important application to theory testing in realist evaluation, however collecting data for the purpose of building and refining an IPT, is less well explored.

Case study
We employ a case study for the purposes of illustrating how the critical incident technique may be applied in realist methods. This study examines the contextual conditions for team interventions in acute hospital contexts and more specifically, the enablers and barriers to team intervention success. It builds on previous work which involved a systematic search of the literature using realist synthesis (9).
For the purpose of this research, a multi -disciplinary team intervention is defined as: An intervention where a team of two or more disciplines is trying to improve how the team delivers patient care-for example: quality improvement, service improvement or change initiatives; process re-design or team training events.
These interventions are considered as complex social interventions (1) and realist evaluation was therefore considered an appropriate methodology having already been used in similar studies (10)(11)(12). The process commenced with a systematic search of the literature which was driven by the researcher's own experiential knowledge and assumptions (9). Five plausible hypotheses were extrapolated using realist synthesis and are presented in the form of Context, Mechanism, and Outcome Configurations (CMOCs).
Using these hypotheses as a foundation for the programme theory, during interviews with hospital staff who had been involved in team interventions (KIs), the authors sought to explore the conditions in which these interventions were introduced (Contexts-C); how the resources on offer in these particular contexts permeated into the reasoning of KIs involved in the team intervention (Mechanisms-M) and the intended and un-intended consequences of the intervention (Outcomes-O).
Please refer to Fig 1 for an overview of the IPT development process.
Difficulties for the realist researcher in conducting research have already been cited (10).
In this case study, the busyness of the acute hospital had potential to further impact the fieldwork process. Scheduling interviews during daily routines meant KIs would have to consciously shift their mind-set from clinical or operational activity to the more reflective mode required for research interviews. Semi-structured interviews were first conducted; however, this approach did not extract the necessary detail to meaningfully contribute to programme theory development.
KI experiences before, during, and after a team intervention/programme is implemented are particularly relevant in order to explore contextual conditions for programme theory building (13). In order to increase the quality and value of KI data, the authors therefore considered use of Flanagan's Critical Incident Technique (CIT) (14). This technique has already been adapted to explore contextual detail in incidents deemed of critical importance to individuals (15,16). As Creswell had already placed CIT in a qualitative framework (17), it had potential to extend its application to realist methods. Indeed, Woolsey (18) had previously recognised its usefulness in the early stages of research as a foundational exploratory tool and for its role in building theories. We hypothesised therefore that this method could also have potential in this case study if an intervention was deemed of critical importance to a KI. As the CIT allows for in-depth exploration of the antecedents and consequences to a specific incident, it should align closely to the configuration of context, mechanism and outcomes within the realist evaluation framework.
Flanagan describes CIT as "a flexible set of principles that must be modified and adapted to meet the specific situation at hand" (14) p. 335. Specifically, "CIT research takes place in a natural setting; the researcher is the key instrument of data collection; data are collected as words through interviewing, participant observation, and/or qualitative open-ended questions; data analysis is done inductively; and the focus is on participants' perspectives" (19) p 16.
CIT includes five steps in the form of procedures: determination of the general aim of the activity; development of plans and specifications for collecting factual incidents regarding the activity; collection of the data; analysis of the data and interpretation and reporting of the statement of the requirements of the activity. It is apparent from its use in other healthcare studies that these steps can be tailored to specific situations (11,20). We sought to explore however whether it was possible to maintain its procedural integrity within the more flexible, open and iterative processes required for realist methods.

1.
Explores use of CIT within a realist methods framework 2.
Determines if CIT has potential to be used in refining an IPT

3.
Demonstrates application of the CIT via this case study of team interventions in acute hospital contexts.

Methods
Prior to consideration of the CIT, trial interviews using a semi-structured interview (SSI) format had been piloted with two purposively sampled staff members -one female Operations Manager and one female Therapist both of whom had led on team interventions. These SSIs included open ended questions for example: "Tell me about an intervention that you have been involved in" and "How did the team operate?" The research team reviewed the data that emerged from these interviews and agreed that significant portions of the narrative consisted of tangential generalities about teams rather than specific information related to the intervention. Data were therefore not relevant to programme theory development (i.e., insufficient data relevant to context and mechanisms) and a different format was required. The CIT was subsequently considered.
In order to ensure rigour, the authors mapped and compared the five CIT procedures against the characteristics and features of realist methods (Table 3).

CIT Procedure 1-Development of plans and specifications
The research team clarified the purpose of the critical incident interview technique (as relevant to the case study described) and how to unpick the relevance of the team intervention that the key informant was describing. The objective of the CIT interviews was to obtain information relevant to: team descriptors; contextual conditions (C); the objective of the intervention; outcomes (O) and would also include probes with regard to how and why an intervention worked in order to elicit the mechanisms enacted (M). The interview guide would be designed to give specific attention to the five CMOCs already synthesised from the literature whilst also allowing other contextual enablers and barriers to emerge and the subsequent mechanisms and outcomes generated by those conditions.

CIT procedure 2-Determination of the general aim of the activity
Incidents described would be considered "critical" if KIs deemed them to be significant in terms of their experience and if they could be relied on as relatively accurate accounts of specific events. A "critical incident" for the purpose of this study was defined as: "a team intervention recalled by the KI as either a significant positive or negative experience that meets research criteria in terms of multi-disciplinary team and team intervention and therefore has potential to contribute to building the IPT".
As per the CIT, interviews would commence with an introductory statement to advise KIs of the purpose of the exercise (Please refer to Appendix 1. p.1 for complete protocol).
Following some background questions regarding professional roles and experience, KIs would then then be asked to recall a critical incident as follows: Following an initial question as to why they selected this experience, they would then be asked a series of questions with probes embedded to elicit more factual data specific to the intervention experience. This process was followed in asking participants to recall a significant event /situation/time that they were particularly proud of, and subsequently, one there were not so proud of (See Appendix 1 Interview).

Pilot tests
The CIT interview format was piloted on two KIs by the primary researcher (UC) and minor changes were made for example interviewers were reminded where to probe for detail with regard to the existing CMOCs by including triggers for these in a different colour. As per the CIT, it was agreed that interviewer remarks should be neutral and permissive (23) and should demonstrate that the interviewee was the expert. However, if specifics were not emerging, clarifications would be sought for example: "So what you are saying is….?" or "Can you give me more detail on that?" Similarly, if information was ambiguous, interviewers might say… "I am not sure I understood that point, am I correct in saying….?" Following the pilot tests, probes for data to confirm, refute or refine theories that had worked well were discussed by all authors and agreement was reached on the final format for the interview.

Interviews
Fifteen KIs who had been involved in team interventions were purposively sampled by either the Chief Operating Officer or General Manager of each participating organisation to reflect a range of disciplines; gender balance and healthcare experience across 4 acute hospitals in one Irish Hospital Group. Demograhics information of participants is presented in Table 4.
KIs were invited to participate in the process by e-mail correspondence one week in advance of the interviews. The e-mail correspondence included an information sheet (See Appendix 2} and consent form. Participants were advised that participation was voluntary and that their responses would be confidential. Interviews were conducted over a period from May-September, 2018 by two members of the research team (UC & ADB). Interviews were audio-recorded with the KIs' consent and transcribed verbatim. One interviewee did not consent to audio recording and therefore notes were taken by the interviewer during the interview process.

CIT Procedure 4 Analysing the data
Fifteen interviews (N= 29 incidents, as one KI could not recall a negative experience and 2 interviews took place at a later stage) were transcribed, anonymised and imported into NViVO software (23) in order to manage the analysis. This was conducted in three phases and included deductive, inductive and retroductive approaches to data analysis.
See Table 5 Summary of data analysis Data were analysed against the five existing theories (CMOCs) that had been extrapolated from the literature in the form of plausible hypotheses. Deductive logic was employed to test these 5 CMOCs in order to see whether associations matched the expectations.
Using inductive logic, narratives were also reviewed to extrapolate evidence that suggested the emergence of new theories. As programme theory development is an iterative process, the co-authors and the realist researcher methodology support group* were consulted to provide advice and feedback at each phase of the evaluation process.
Please refer to Table 6 for overview of consultation sessions.

Phase 1 data analysis: Scanning transcripts-Induction and Deduction
Using the 5 CMOCs that had emerged from the literature as parent nodes, phase 1 analysis involved an initial scanning of the transcripts. Pieces of narrative were coded according to parent nodes "team descriptors"; "CMOCs 1-5" or if there was the possibility of "a new CMOC" emerging. In parallel to the coding process in NViVO, a programme theory template was also developed with each phase of the analysis colour coded to demonstrate the evolving theories and /or new emerging theories. (Available on request from primary author UC).

Phase 2 Data Analysis: Building and refining theories-Retroduction
Data that were coded under the 5 original CMOCs were re-analysed and re-coded against 3 child nodes: support/ refute/ refine to allow for transparency of the process. Please refer to Narratives coded under "New CMOC" in Phase 1 were re-analysed under 8 emerging theories. How and why they resulted in an intended or un-intended outcome was queried.
During this process, evidence to support, refute or refine the enabling condition was first extrapolated. For transparency of the process, each of the 8 emerging CMOCs were used as parent nodes and narrative was coded if there was evidence specific to Context, Mechanism and Outcome.
Please refer to Table 9-Phase 2b NViVo coding

Phase 3 analysis
As part of the iterative process of data analysis, additional notes were made if there was evidence of moderating influences, rival mechanisms and inter-dependencies. Where refinement of the theory appeared to be indicated, a note was made as to how and why the judgment for same was made. Where a judgment call could not be made by the primary researcher, a note was written for discussion with co-authors and the realist support group.
Both groups suggested further exploration specific to one possible theory -"in the moment learning". Two additional interviews were therefore undertaken in December 2018 with purposively sampled interviewees who had specific expertise in delivering team interventions using simulation. Two additional positive experiences of team interventions (N= 2 incidents) were analysed following the same three phase analysis (Total N= 31 incidents). Following this iterative process of data analysis, co-authors agreed and finalised the IPT.

CIT procedure 5-Interpreting and reporting the data.
As per the CIT, it is "imperative" that interpretation and reporting of data "is objective" (23). For this purpose, Realist and Meta-narrative, Evidence Synthesis, Evolving Standards (RAMESES) for realist evaluation were followed (24). In addition, the consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist was adhered to (25) . In order to understand and agree the underpinning cause of the outcomes observed, data were presented to co-authors and the realist support group on two separate occasions so that the chains of inferences (CMOCs) made by the primary researcher could be challenged. This helped to maintain objectivity and rigour in the process of developing insights.

Semi-Structured Interviews
During trials of semi-structured interviews, KIs found it difficult to construe the intervention, speaking about the team in an abstract and sometimes detached way, as evidenced in one response: "I am not even sure of who was involved in that one…some members were only pulled in when they were needed to solve that piece of the puzzle…" [SSI 2] KIs demonstrated poor recall of specifics about the team or the context in which they were operating focussing instead on the process, problem or issue for which the intervention was designed. In addition, significant tangential information was collected relating to individual work patterns, relationships and practices which had limited relevance for programme theory refinement: The five procedures of CIT were therefore considered as a different approach was warranted.

Exploration of CIT within a realist methods framework
CIT procedures 1 and 2 helped to focus the researchers on the purpose of the interview and that questions must relate to teamwork and building of programme theory (See These triggers helped to marry the purpose of the interview which was to refine the initial programme theory (realist methods) with KI responses relating to events and facts, i.e., team behaviours and actions associated with the events (CIT) .

Potential of CIT in refining the IPT
This technique was successfully used to refine the IPT. Seven patterns of occurrence of CMOCs were elicited from KI narratives. Two consequential CMOCs in the form of "ripple theories" (ie where the outcome of one CMOc became a contextual condition to generate a subsequent CMOc) also occurred with regularity. These chains of inference are presented in the form of nine "If-then" statements below -See Table 10 below New enabling or disabling conditions were also considered during the first phase of data analysis (CIT Procedure 4) and coded as "possible" theories relating to: competing demands; supportive function of the team; in the moment learning or source of drive for the intervention. However, authors did not find a regular pattern of occurrence across the KI narratives to support these chains of inference. During the iterative processes of programme theory development in Phase 2 and 3 (CIT Procedure 4), these contextual variables were either discounted; judged to be intrinsic to another CMOC or judged to be a moderating function to one of the 7 confirmed theories or 2 ripple theories. KIs did not refute any theories synthesised from the literature thus perhaps strengthening them further.

How CIT benefitted IPT refinement in the study of team interventions in acute hospital contexts.
New information that had not been synthesised from the literature emerged from KI narratives. By specifically focussing on the antecedents to interventions and seeking the detail on how and why they impacted outcomes, prior working relationships (CMOC 6) emerged as a key contextual enabler across 6 incidents. By specifically asking for examples of negative experiences Inter-professional tensions emerged as a barrier to intervention success across seven incidents (CMOC 7). For some KIs, this was conceptualised as specific individuals having the power to de-rail an intervention process (K5, K7, K11). On more objective analysis however (CIT procedure 5) and discussion of the detail of narratives with the realist support group, it was agreed that the barrier was more likely to result from the broader issue of inter-professional tensions and rivalries and thus CMOC 7 and CMOC 7a chains of inference were made.
The flexibility of the CIT meant that interviewers could explore existing theories in more detail thus allowing refinement of theory to occur. For example, in Question 5 relating to the structure and function of the team, interviewers were encouraged to probe in relation to physician engagement PH 5. From this, a pattern emerged across 6 narratives relating to the mechanism enacted. PH 5 therefore required refinement. For KIs it was the enactment of a perception of power and influence by physician engagement that results in legitimacy of the intervention and yielded the better outcome for the intervention.
[ Where inter-dependencies between theories seemed to be suggested, the flexibility of the CIT allowed interviewers to explore how and why in subsequent interviews. In the absence of the specific detail that CIT encourages, this important information might not have emerged.

Discussion
Engaging in a social construction of a narrative about team interventions in acute hospital contexts is challenging and the importance of both the interview process and the interviewer as the 'prime research instrument' cannot be under-estimated (7,13). As opposed to a positivist approach, where the assumption is that "the researcher is independent of and neither affects nor is affected by the subject of the research" (26) p33, during the realist interview process, the interviewer is considered integral in the development of the theory (5,8). In the early stages of programme theory development, the realist interviewer needs to be mindful however that they do not lead the KIs who are considered the experts in the subject matter and striking this balance can be a challenge.
For this case study, busy hospital workers were required to detach themselves from their daily operational routine in order to get into the reflective mode of the interview and this proved difficult. During the semi-structured interviews, the KIs required repeated redirection to the topic by the interviewer (SSI 1 & SSI2). Qu (27) demonstrates how this can jostle with the interviewees thoughts: "the flow of the interviewee's story can be inadvertently disrupted by the interviewer, such as by redirecting the narrative or interrupting it…" p.248 In comparison, during the CIIs, the interviewer guided KIs towards one positive and one negative experience of a team intervention at a time. Rather than general impressions and trying to access their memory of the event, KIs focussed on the specifics of that particular incident. In this way, use of CIT allowed the interviewee to focus their attention on telling their experiences of the positive or a negative incident, allowing detail to emerge organically whilst enabling the interviewer to probe for data that would support, refute or refine theories and/ or probe for new theories. This contributed to the quality, richness and usefulness of the data for refining the IPT.
Little has been published on the efficiency of interviewing and the importance of this for healthcare workers in busy acute hospital contexts. Using the CIT, we found that as interviewers we could help the KIs access their memories of contextual conditions and outcomes in an efficient manner helping memories to re-surface by stimulating a "deep dive" on their thoughts as to how and why these things happened. Stimulating recall of specific incidents created an efficiency in the process. The average interview lasted fortyfive minutes as opposed to over an hour for SSIs. In contrast to the SSIs, the majority of data retrieved had relevance for IPT building, giving a concomitant efficiency when it came to the analysis phase for the researcher.
CIT literature (26) has demonstrated its evolving application "to focus more on thoughts, feelings, and why participants behaved as they did… in order to build on the practice of focusing on what a person did, why he/she did it, the outcome" p490. In this study, authors sought to understand the subjective reality of KIs involved in team interventions in acute hospital contexts in order to gain insights into their motives, actions and intentions in a way that is meaningful. The CII format allowed interviewers to make connections between contexts (antecedents) and outcomes (consequences) of team interventions. Sometimes these emerged organically and on occasions through carefully embedded probes. Causal explanations of how and why team members choose as individuals and as a collective to behave the way they do under different contextual conditions could therefore be inferred. Realist researchers are often challenged trying to find mechanisms to connect contexts and outcomes. From the CIIs, insights into generative causations were reasonably easy to develop. KIs on occasions un-consciously linked the contexts to outcomes and identified the mechanisms enacted themselves in these situations.
CIT therefore aligns well to Pawson's theory driven Teacher-Learner style interviews (7) and complements Manzano's (8) interview methods which are more directive and tailored towards theory evaluation or testing. The advantage of CIT has previously been cited (28) as "its capacity to explore differences or turning points; its utility as both a foundational/exploratory tool in the early stages of research and its role in building theories or models" p480. CIT is particularly "suited to the exploration of dilemmas or looking at two sides of behaviour-good and bad; effective and ineffective; avoidable and By sharing our experience of the use of CIT in developing an initial programme theory and developing a guide for the novice realist researcher, (Please refer to Appendix 3, we hope this provides some practical advice and guidance for researchers who may face similar challenges.

Limitations
In this case study, CIT was used to interview a purposively sampled group of hospital workers. The characteristics of this homogenous group from one hospital group in Ireland which had recently engaged in improvement work may have influenced their propensity to recall relevant material. Future research might therefore explore the application of CIT in realist methods in other healthcare contexts or with healthcare staff not involved in improvement work.

Conclusions
It was possible to adapt Flanagan's five CIT procedures as a technique to help refine an IPT. In particular, the CIT helped to stimulate clearer memories with regard to antecedents and consequences of specific team interventions and enabled data to be collected in a time efficient manner. CIT offered a balanced method of eliciting data from KIs, allowing detail to emerge organically whilst still allowing flexibility for interviewers to probe for data relating to previous theories extrapolated from the literature. The CIT procedure should therefore be considered for use more widely within realist methodology and the authors have developed a practical guide to support other researchers in application of this approach.

Contributions To The Literature
For the novice realist researcher, there is a paucity of data on how to conduct interviews for the purpose of refining an initial programme theory.
Although Flanagan's Critical Incident Technique has been adapted for use in several domains, to our knowledge, its application to realist methods has not been explored.
Findings contribute to the literature by demonstrating that it is possible to maintain the integrity of the five procedures described in CIT whilst placing the technique into a realist framework. A practical guide on how to apply CIT in refining an IPT is presented.  Tables   Table 1 Definitions How the resources on offer permeate into the reas participants.

Outcome (O)
The intended and un-intended consequences of te Because of the variation in context and mechanism to be different outcomes from teamwork.

Table 3 Mapping Critical Incident Technique against Realist Methodology
Critical incident technique Adapting for building IPT as part of Realist Evalua process Incident-any human observable activity that is sufficiently complete in itself to permit inferences and predictions to be made about the persons performing the act.
Incident-team intervention recalled by KI as either a po or negative experience that meets the criteria in terms o team and intervention descriptors and as specified in th research therefore has potential to contribute to buildin IPT CIT-A set of procedures for collecting direct observations of human behaviour-to facilitate their usefulness in solving practical problems and developing broad psychological principles.
CIT applied-A set of questions in interview format to el factual data to answer my question, what works for who what conditions, why, to what extent and how? Deemed useful as it will help identify patterns of regularity in the CMOCs Critical incidents obtained from interviews can be relied on to provide a relatively accurate account of job performance.
Specific accounts of positive and negative experiences interventions obtained from interviews and can be relied provide a relatively accurate account of team interventio A set of procedures for analysing and synthesising into a number of relationships that can be tested in more controlled conditions. A set of procedures for analysing and synthesising into a number of chains of inferences (CMOCs) that can be tes IPT will form the basis for further testing Obtains a record of specific behaviours.
Obtains a record of contexts, mechanisms and outcome relating to the team intervention.
From those in the best position to make the necessary observations and evaluations From Key informants-healthcare workers working in mu disciplinary teams with experience of team intervention acute hospital context. Incident deemed to be critical-where the purpose or intent of the act seems to be fairly clear to the observer and where consequences are sufficiently definite to leave little doubt concerning its effects.

Recall of factual incidents Recall of factual incidents
Principal objective of job analysis procedures should be the determination of critical requirements Ie those that have made the difference between success and failure in carrying out an important part of the job Principal objective of the analysis procedures in this inst will be the determination of critical enablers and barrier team interventions Essentially a procedure for gathering certain important facts concerning behaviour in defined situations Essentially a procedure for gathering certain important f concerning behaviour in defined situations.
Certain more difficult judgments are required regarding the relevance of various conditions and actions on the observed success in attaining the defined purpose of the activity.
Certain more difficult judgments will be required and Co research team, Co-lead advisory team, and realist supp group will be "used" to help in the judgment process of relevance of various conditions on enactment of mechan and outcomes The incidents must be studied in the light of relevant established principles of human behaviour and of the known facts regarding background factors and conditions operating in the specific situation. From this total picture, the total hypotheses are formulated.
The incidents must be studied in the light of relevant established principles of human behaviour and of the kn facts regarding background factors and conditions opera the specific situation. The interaction of the key informa the resources on offer by the various contextual conditio impacts their reasoning and mechanisms enacted and subsequent outcomes-From this total picture, CMOCs ar extrapolated and can be interpreted as plausible hypotheses/theories Establishing the general aim of the activity Introductory statement explaining the purpose of the study.
Request for general aim What would you say is the primary purpose? Request for summary In a few words, how would you summarise the general aim of a specific activity Establishing the general aim of the activity "We are making a study of multi-disciplinary team interv to improve patient care in acute hospital contexts". "The primary purpose is to help understand enablers an barriers to success of these interventions" In a few words, how would you summarise the general the team intervention? What were the objectives?

Purpose and specifications
Situation Relevance to aim Persons to collect the data need to be familiar with activity. Behaviours to be observed Detail to be extrapolated Information relating to contextual conditions and outcom the team intervention and how and why KIs as individua as a collective in the team behaved the way they did in circumstances. Sample questions as follows;

Purpose and Specifications
Rationale for asking for incidents to be recalled as opposed to direct observation-if suitable precautions are taken, recalled incidents can be relied upon to provide adequate data for a fairly satisfactory for a first approximation to a statement of requirements for the activity.
Direct observations are to be preferred but the efficiency, immediacy and minimum demands on co-operating personnel which are achieved by using recalled incident data frequently make their use the more practical procedure.
Key informants extremely busy and the idea of observin conditions over the prolonged period of a team interven not be practical…a lot of observation could be wasted ti there may be only a couple of critical incidents during a period of time relating to the research question…this wa KIs can be asked for detail of the intervention it relates t research question and building of programme theory-Someone known and respected by the observer has suggested the interview Purposeful sampling by CEO/ General Managers in 4 hos They will select candidates that they think will be able t contribute to the research question ie those who had so experience of team interventions either leading or being involved in the team intervention process.
Questions should be trialled Questions to be trialled.
Interviewer remarks should be neutral and permissive and should demonstrate that he accepts the observer as the expert. Important to get unbiased events Interviewer remarks should be neutral and permissive a should demonstrate that he accepts the observer as the Important to get unbiased incidents If only giving part of story he should be encouraged by restating the essence of his remarks. This will encourage and help him to bring out many of the details of the incident that the interviewer did not know details of the situation to ask for Analysing the data and Interpreting and reporting the data. Imperative reporting is objective.
Analysing the data and Interpreting and reporting data. RAMESES guidelines used-inductive, deductive and retr logic. Use of co-authors and realist support group to help judgment calls and challenge thinking.

If
There is genuine leadership support in the form of tangible resources and positive acknowledgeme nt of staff and alignment of team goals with organisational goals through effective engagement and dialogue Then this: Motivates, empowers and engages staff, Enacts a sense of team efficacy; a perception of sense making and a shared sense of responsibility and accountability resulting in: Team pride and camaraderie; Connectedness and confidence in the broader system; Easier implementation and sustainability of the intervention [1,3,4,5,6,7,9,10,11,12,13,14,15] 4 Characteris tics of interventio n that give credibility

Interprofession al tensions
If there are interprofessional tensions, rivalry and mis -trust Then this enacts: Feelings of frustration; lack of respect; disempowerment, perceptions of lack of psychological safety and cynicism resulting in: Failure to progress the intervention, lack of support for the intervention and/or withdrawal from the process [1,5,6,7,8,10,11,12] 7a Escalating mechanis ms

If
There is failure to progress an intervention, lack of support for the intervention and/or withdrawal from the process because of interprofessional tensions Then this enacts: further escalating mechanisms of dissatisfaction, depletion of energy and resilience and perception of powerlessness resulting in: Greater silo mentality among professions [5,7,14] Figures Figure 1 Overview of IPT development process Supplementary Files