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Table 4 Narrative descriptions and an example of each source of evidence and knowledge depicted in Fig. 2

From: How are evidence and knowledge used in orthopaedic decision-making? Three comparative case studies of different approaches to implementation of clinical guidance in practice

Evidence and knowledge types Narrative description Example from the data
Macro
 External evidence created by healthcare regulators, e.g. CQC and GMC The wider delivery of healthcare in England is governed by the UK Health and Social Care Regulators such as the Care Quality Commission. In orthopaedics, surgeons have to be registered with the General Medical Council and with their Royal College. Regulators are responsible for ensuring that surgeons are included in an up-to-date registry of qualified doctors and practice according to established standards An inspection report from the Care Quality Commission
 The media and the influence of ‘the press’ The mass media (or press) is a diversified collection of resources who reach a large audience via mass communication An article in a newspaper describing ‘good’ or ‘bad’ hip implants
 The opinion of leaders and professional societies An opinion leader was an eminent individual who had the ability to influence the opinion of the orthopaedic community on a subject matter for which they well known. The professional societies were larger organisations who represented the groups and sub-groups of surgeons An opinion leader could be a principal investigator of a large clinical trial in orthopaedics. The professional societies were the British Orthopaedic Association and the Hip Society
 Formal codified knowledge Evidence or knowledge that is written down can be shared and is easy to access and available to the public A NICE guideline or article published in a journal
 Culture, norms and political influence of the sector The standards and accepted way of practicing in the UK healthcare context. Including the public delivery of services and formal and informal methods in which healthcare is organised in the NHS The hierarchical structure of the healthcare system. Political factors included strategies enforced by government and the medico-legal challenges to practice
Meso
 Managerial knowledge Each hospitals’ business organisational processes which underpin day to day routines and capabilities of the Trust NHS hospital resource issues such as time, cost and safety or quality of services
 Organisational knowledge An extension of managerial knowledge which has a wider structural emphasis. It is embedded in the processes of healthcare organisations and influences the behaviour of staff A hospitals’ internal processes which are not written down. Anecdotally referred to as “the way we do things around here”
 The structure and location of the hospital The physical location of the hospital buildings and departments and the structure of the hospital wards The number of elective orthopaedic theatres available to use
 Evidence from implant manufacturing companies Information that came directly from manufacturer’s representatives located in the hospital or indirectly through marketing Leaflets about a hip implant from a manufacturer’s representative
 Socialisation and association with colleagues Knowledge that came from the inside and spread within the defined clinical group, in this case the orthopaedic community Evidence of the outcome of a surgery from a colleague or knowledge that a mentor had passed on
Micro
 Informal experiential knowledge Tacit knowledge that surgeons ‘know’ regarding how to behave and perform as an orthopaedic surgeon Represents a surgeon’s lifetime’s work, and in turn their identity as a surgeon
 Informal experiential knowledge built up over time The tacit knowledge that surgeons ‘know’ which has built up over time working in the specific hospital but which can be difficult to describe Knowing which colleague to refer a difficult case to when the surgeon does not have the specific expertise or experience
 Evidence from the professional hierarchy The layered social structure within the hospital which conceptualised the superior and inferior relationships between clinical staff Described as the ‘clinical pecking order’ with the consultant surgeon at the top
 Training and formal education The training and formal education of healthcare professionals which are recognised through standard academic qualifications A Master’s degree in Evidence-Based Medicine
 Apprenticeship style training and informal education Personal training which occurs during each working day with senior colleagues Training gained through fellowship programmes and practice-based learning
 Individual patient and surgeon factors Characteristics of the patient or surgeon that influenced clinical practice decisions Patients age or a surgeons years in practice
 Evidence linked to the innate ‘feel’ of surgery A description of the surgeon’s judgement, skill, craft and instinct A surgeon not knowing exactly what will occur during an operation until they started the surgery and can see and feel the operation takes place