Table IV.

Working together: illustrative quotations.

Theme 2: Working together
Category	Illustrative quotes
Getting everyone on board involves engaging HCPs across the patient pathway in the study to help: 1) identify patients; 2) prevent early treatment recommendations; and 3) enable staff to support one another.	1) Identify patients: If everyone was thinking the same thing about CRAFFT we wouldn’t be so anxious that we’re going to miss a patient. I feel if everyone was a bit more up with the research, and on the delegation log, and knew about it, it would be less easy for them to slip through the net and less pressure on us – we can’t miss them. (RN19)
	2) Prevent early treatment recommendations: If the orthopaedic team have seen patients before we have spoken to them about CRAFFT, then they’re already on that path to “I need surgery”. Then, you’ve got to try and pull them back from the abyss knowing that actually they’re an orthopaedic surgeon - but they’re misinformed. You’re trying to not undermine that clinical relationship and that trust, because you are basically coming in and going “yes, I know what the surgeon said, but they are kind of wrong”. That’s tricky to navigate. (Clincian10) Often what’s happening is that the emergency department doctors are seeing the patients and referring them through to us (orthopaedic surgeon). It would be the emergency department junior doctors on-call, the Senior House Office grade, seeing the patient and parents; … If they say “Oh crikey, that’s a very bent wrist - they need an operation, so we’d better call the orthopaedic surgeons”, there’s difficulty in trying to unpick that expectation made by a very junior doctor, who’s the first person they see. (Clinician13)
	3) Enable staff to support one another: I do feel a bit alone in recruitment because these children always come ‘out of hours’ - so it’s me doing the approach, consent and all the work…because we have to decide whether they’re going to go through an operation or not. (Clincian14) Recruitment has been difficult because we’re all over the place and there’s multiple people involved. Because it’s difficult to recruit, it takes effort. Trying to get people on board and doing the actual work has been hard, but it has been helped immensely by the support from instant messaging and the Chief Investigator and so that’s been a useful tool. (Clinician10)
Reaching an agreement involves: 1) ED and orthopaedic trauma teams negotiating how the study will work in their site; 2) sharing their expertise; and i3) managing tension and disagreements between the teams.	1) ED and orthopaedic trauma teams negotiating how the study will work in their site: We’ve spent a lot of time in the multidisciplinary teams really pushing it and having some top-down discussions about how and what we’re happy to randomize. I think now the orthopaedic registrars are coming on board a bit more with the studies. (RN3)
	ii) Sharing their expertise: I think it has to be a mix between emergency department and orthopaedics. Emergency department have good experience, but they don’t have the same background. I think it should be a mix and so definitely emergency department are really important to be involved. They are the first to see the patient but sometimes it’s really hard for them and it’s unfair to put all the load on them to sell it to the patients. For example, last week I was on call and there was a child who was eligible, and emergency department spoke to the parents and apparently, they declined it but when I went again to speak to the parents I answered more questions, I’ve elaborated more and they have agreed to go for it. (Clincian18)
	3) Managing tension and disagreements between the teams: It’s taken a really long time to get buy in from the orthopaedic teams. Our Principal Investigator (PI) is emergency department and our co-PI is orthopaedic - as opposed to it being an orthopaedic lead with a co-PI in the emergency department. We feel like we have ‘butted heads’ a bit trying to get orthopaedic teams on board because of the idea of not manipulating … it’s taken a lot of time and energy but I think that we’ve feel we’ve got on top of that now. (RN3)