Competing epistemologies: a reflexive thematic analysis of research in general practice

Abstract

Background

Although most UK National Health Service (NHS) consultations take place in primary care, healthcare research is dominated by secondary care and higher education institutions. The Royal College of General Practitioners has called for increased academic activity by developing research capability in General Practice. However, little is known about the challenges for GPs involved in research. We aimed to explore general practitioners’ (GPs) experiences of using a screening tool embedded in a research study.

Method

We recruited GPs from three practises participating in the study. An independent researcher interviewed GPs virtually. The interviews were recorded, transcribed verbatim, checked against recordings, and de-identified. We used Reflexive Thematic Analysis to develop essential themes.

Results

We developed four themes giving insight into barriers to research activity: (1) it’s rare that things are black or white, (2) it’s a clinical tool, not a clinician, (3) it’s about balancing valuable time, (4) we don’t see every patient face-to-face anymore.

Conclusion

Quantitative research design, underpinned by positivist epistemology does not always align with primary care practice. Our findings highlight competing epistemologies that can make it challenging for GPs to complete standardised measures in a primary care setting. General practice involves a complex reasoning process grounded on interpretive knowledge. Closed questioning does not always comfortably align with a primary care setting where “a simple answer” is rare. Compatibility with primary care should be considered in all research design.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-03090-8.

Introduction

Although most NHS consultations occur in a primary care setting, healthcare research in the UK is dominated by secondary care and higher education institutions [1]. As such, Dickson and colleagues refer to primary care as the “sleeping giant” of the research delivery landscape [1]. Including this highly skilled workforce in research activity has huge potential to increase research capability and capacity. Primary care is a unique specialty which should be reflected in research design: this is recognise in the Consensus Reporting Items for Studies in Primary Care (CRISP) [2]. There is also increasing evidence that engaging practitioners in research has an impact on the quality of care and on job satisfaction, recruitment, and retention; for example some primary care practitioners recognise that it can be a valuable way of ‘upskilling’ the practice team [3]. Less is known about the barriers to research activity in primary care, and some regard it as “an unaffordable luxury” [1]. Increasing workload is potentially the greatest barrier to general practitioners’ (GPs) involvement in research activities [4], and this is hardly surprising at a time when “GP numbers are not rising at pace with GP workload” (chair of RCGP). The Royal College of General Practitioners has called for increased academic activity by developing research capability in general practice. In 2021, the National Institute for Health Research Clinical Research Network (NIHR) CRN launched a NIHR Clinical Research Network Primary Care Strategy. This was in response to the falling level of engagement in primary care research post-Covid [5]. The strategy aimed to develop, promote, and facilitate high quality research in the primary care setting. This is important in view of the low engagement GP trainees and trainers have with research [6]. Understanding the challenges of integrating research into a primary care setting can make an important contribution to research design in primary care. We report a qualitative exploration of a research-based activity embedded in primary care. The overarching study investigated the use of a research screening tool for osteoporotic vertebral fracture (Vfrac) in primary care [7]. We report findings that highlight epistemological challenges inherent to research activity for GPs that should be considered in future research design.

Method

Recruitment and sampling

Healthcare professionals were recruited from three general practices in the West of England who had been recruited to participate in a study testing the integration of an online clinical decision tool (called Vfrac) to screen for vertebral fragility fractures in older people within GP consultations. Healthcare professionals who had participated in this evaluation were invited by the research lead for the practice to participate in the qualitative study exploring their experiences of using the Vfrac tool [8]. The invitation to participate was sent by email with the full participant information sheet attached to the email and a hyperlink to an online consent form was included in the body of the email. The research team had access to responses from the online consent form and potential participants were given the option to have an interview in person, by telephone, or on Microsoft Teams.

Sample size: Qualitative sampling aims to generate ideas and insight: it does not aim to be statistically representative. As such, samples are chosen for their “information power” [9]: this means that the more knowledge participants have about the topic, the fewer participants are needed. Our sample and focus were highly specific to the research question and this analysis only included GP interview data. The concept of data saturation is not compatible with Reflexive Thematic Analysis and other interpretive methodologies [10].

Trustworthiness and Reflexivity: The Vfrac research team (EC, SD, TK, KB) invited an independent external qualitative researcher with more than 20 years’ experience to conduct the interviews and analyse the data. This qualitative researcher had made no earlier contribution to the design of the Vfrac tool or the embedded study. She made it clear to all participants that she was not part of the research design team, and that the team were “very keen to get frank feedback” which may allow some improvements to the design. Each unit of interview text was analysed, allowing it to remain close to the data, from which narrative exemplars could be chosen to illustrate the themes. Nvivo software for qualitative analysis facilitated organisation of the data. All members of the team were invited to discuss the themes and comment on the concept-indicator “fit” between theme and exemplar. This is in line with qualitative research methodology.

The research context

GPs working within the centres allocated to the Vfrac intervention arm were trained on how to use the Vfrac tool. Vfrac was made accessible to them from their IT systems through a Uniform Resource Locator (URL), via pop-ups, when they typed relevant words such as “back pain”. Use of the Vfrac tool was encouraged within their clinical pathways for management of older women (over 65 years of age) who consulted with back pain. This was in accordance with each practice’s service delivery model, facilitated by the research team in discussion with the clinical team. The Vfrac Tool has been described elsewhere and comprises fifteen questions covering age, weight, height, reported height loss, characteristics of pain and functional activities that either increase or decrease pain [7].

Data collection

A topic guide was developed by the study team as part of a nested qualitative evaluation and is available in the supplementary file. This was used as a guide, and the interview remained open to allow participants the opportunity to discuss their experiences of using the Vfrac tool. The qualitative interviewer shared the screen allowing visualisation of the tool and went through each question in turn, probing for any observations the participants may have. Interviews were recorded, transcribed verbatim, and checked for accuracy. Participants received a gratuity in recognition of their time.

Analysis

We used the six stages of Reflexive Thematic Analysis (RTA): familiarisation with the data; coding (a process that involves distilling meaning into concise phrases); generating initial themes (through constant comparison); developing and reviewing themes through discussion; refining and naming themes; writing up. RTA provides a method for distilling ideas from qualitative data into themes organised around a central idea [10].

Results

We conducted in-depth interviews with seven GPs (4 male and 3 female). The range of time qualified as a doctor was 11–24 years (median 18); the range of years qualified as a GP was 4–21 (median 9). The Indices of Multiple Deprivation (IMD) data based on the postcode of their practice were 9, 6, and 2, indicating they were practicing in areas that ranged from the 90% least deprived to the 20% most deprived. All interviews took place virtually (one on the telephone and others on Microsoft Teams) between April and June 2024. Interviews lasted between 40 and 80 min. We developed four reflexive themes: (1) it’s rare that things are black or white, (2) it’s a research tool, not a clinician, (3) it’s about balancing valuable time, (4) we don’t see every patient face-to-face anymore. We use narrative exemplars to illustrate these themes.

It’s rare that things are black or white

This theme highlights a tension between the skilled process of excavating key information during a primary care consultation and collecting yes/no answers for research purposes. General practice was framed as a hermeneutic (interpretive) process, not unlike “excavation”. Participants explained how effective general practice rested upon piecing together the puzzle, and sometimes working intuitively with a “best guess” based on a multiplicity of inputs [GP3]. In this way, GPs gathered information and transformed it into a working diagnosis. If the patient was uncertain about whether an answer was “yes or no”, the GP would use prompts, or their knowledge-based discretion to populate the most appropriate answer. For example, when indicating pain in the body diagram,

You tend to filter things particularly in primary care. So “I’ve got pain everywhere” … “Oh it’s all over my back”; Well, “where specifically?”; “it’s usually lower back and sometimes my right buttock”. So, you might just put lower back. there is a bit of clinician discretion in that … “It’s usually here [pointing] and it can also affect one buttock … but sometimes it can be this buttock.” So, which [answer] do you click? (laugh) [Gp1].

GPs talked about the challenge of answering fixed-answer questions when there was “no straight answer”, or where the question did not apply to the patient. For example, walking might be painful at first, ease off, and then increase later. Similarly, the movement of getting in and out of a chair might increase pain, whereas resting in a chair might decrease pain. This “dithering and thinking” [GP6] was likely to prolong consultations and leave everyone wondering, “is that a yes or a no?” [GP2]. For example,

One of the things that has been a little unclear is the timeframe for walking … initiation of movement can be quite tricky … So, are we talking kind of five minutes? … getting up to walk can be quite painful. But actually, walking itself doesn’t always cause that pain … [similarly] the act of reclining can often cause people the pain … [but when] they’re settled in a position that can then enable pain to get better [GP7].

There was a strong sense that it was often hard to pin down questions about pain to a “yes/no”. Pain varied in nature and intensity, sometimes from ache to sharp, and back again. GPs described the skill of “filtering” information if the boundaries of pain on the pain diagram were blurred, or if pain fluctuated and moved around the body over time.

It’s very rare that things are as black and white … often people say it is sharp some of the time. … we’ve spent three minutes deciding whether pain is sharp or not … we’re still left ultimately making what is effectively an arbitrary choice between whether your pain is sharp or not …. because you’re not really sure…. there is high noise ratio because the patient doesn’t even know what the answer is, it’s like you’re tossing a coin …. you are using an arbitrary word to describe pain [GP2].

Another challenge for “yes/no” questions was if the question did not apply at all. In these situations, the GP might fill in the gap, or offer an alternative scenario to help the patient to respond.

Well, some people aren’t able to stand in the kitchen and chop vegetables or wash. So, then it might not be applicable to them. So that makes that question difficult because if you don’t mark one of the answers, it won’t let you proceed … I think it might be helpful if you … have another option … if you’re standing to brush your teeth… because most people they might not do the work in the kitchen, but most will be brushing their teeth [GP1].

Complexity and length of question could also present an interpretive challenge, and some found that they had to repeat questions, or paraphrase, so that the patient understood.

It’s quite a long question… they have often lost the track of it; and it’s not because my patients are stupid or so forgetful, they’ve lost interest, … I am pretty sure that statement has five clauses in it. It’s actually very difficult to hold that in your head and to decide whether or not you agree with the statement [GP2].

It is a research tool, not a clinician

This theme describes the Vfrac as supplementary to clinical judgement: “these are clinical tools, not an absolute” [GP7]. The consultation was framed as an interaction between patient and GP to decipher the diagnostic meaning of symptoms. Some were concerned that using “closed questions” risked placing information into categories that did not necessarily reflect patients’ experiences. There was a sense that skillful use of open questions was more effective at getting to the diagnostic hub.

The [point of the] whole process …. is to interpret what the patient says… What we get when we ask open question, is a range of responses which we then interpret, and they can clarify. For these are very close questions, and they may not fit with the experiences, that the patient had … it comes back to dichotomising an issue where people may perceive that the issue is more of living in a relationship [GP2].

Some described the risks of undermining professional judgement if the tool was used to decide on a definitive course of action. The risk-to-benefit of requesting an x-ray were framed as low, in comparison to a high risk for poor outcome if a fracture was missed. GPs felt uncomfortable if the tool went against their “gut feeling”, and might find another reason for an x-ray if they felt it was indicated, even if the score indicated no risk.

There were a couple of times I felt slightly uneasy because I thought, “oh, it’s telling me not to get an x-ray”, and I definitely would have…. I have a feeling we ordered it for a different reason… I didn’t want to be clinically going against my gut feeling until I can say that this is a tool which has been validated [GP6].

Some carefully considered the long-term impact on the patient-doctor relationship, or professional “reputation”, if fractures were missed in the absence of an x-ray.

One of the phenomenal things about the general practice is that we treat people over a life course… that means you have this reputational issue … so, when the patient attends the practice … and they are told to have some paracetamol…. and then 3 weeks later they have an x-ray, and it is showing a vertebral fracture, it is an embarrassment … I might see 10,000 people in my career … [and] a failure rate of 1% means missing probably 100 people [GP2].

However, some also described “educational” [GP 7] situations where the tool prompted an x-ray where the GP had not considered osteoporotic fracture as a possible diagnosis. For example, a diagnosis of osteoporosis might be missed in male patients with back pain.

Clinically you start thinking about other things within men with persistent back pain. … things like metastatic prostate cancer can present with back pain and so.

it’s a slightly different mindset … I think your clinical suspicion of osteoporosis is typically your frail, older lady. And whereas if someone presents with back pain as a man in that age group, my mind would more likely go to metastatic disease rather than osteoporosis [GP7].

As such, some suggested that the tool might be useful if the clinician had less experience or to encourage clinicians to think “outside the box”.

In our practise we have [other clinicians] … who are very protocol based, and this would be the perfect tool to help support them …, because I don’t think otherwise, they would be thinking vertebral fractures for back pain… it has prompted them to think outside the box … I think once you’ve got quite a few years of general practise under your belt… you probably know who you x-ray, and who you don’t [GP6].

It is about balancing valuable time

This theme illustrates the time burden of research activity on top of a clinical caseload. GPs described the daily complexity of dealing with multiple morbidities where “people often come in with three or four things” [GP1]. They talked about the additional time taken to discuss questions and answers, or to remove shoes or clothing for physical outcome measurement. There was a sense that any additional activity was a “trade-off” that might impact on patient care.

Frankly the problem is that anything in general practice which adds time is difficult… all these questions takes 2–3 min here… in the context of the consultation taking 10 min you’ve added 30% to my consultation … it has to have significant added benefit … and it also has to be quick, really quick, because otherwise I am just going to request the x-ray because requesting takes me literally no time … [there is a] trade-off benefit clinically [GP2].

This raised the questions of whether a verbal proxy measurement was reliable “enough” and if there was any “room for error” [GP3]. GPs also talked about finding time to “set the scene” and talk through “an opener” to the research. In some cases, the GPs commented that patients liked this additional level of attention and were “very grateful that you’re being thorough” (GP4).

I do a good sort of opener and say that “look, this is a study tool, we’re going to do a number of measurements and we’re looking at calculating your risk … in which case we may end up doing an x-ray”. … the scene is [then] set, and they are expecting a number of measurements and a calculation at the end and a decision; do an X-ray or not [GP5].

One described the burden of “pop-up fatigue” [GP7] because of multiple (sometimes inappropriate) reminders to include research-based activity during a single clinic. Some suggested that either financial incentives, making research mandatory, or “if there’s a QOF (quality and outcomes framework) point linked to it” (GP1) might be the only way to make research viable in primary care.

A salaried doctor might legitimately say, “you’re asking me to fill all these questions, they will take me five minutes so …. I want an appointment reduced from my session… if the locum does it, very often what they will say is, “well I have to stay late” … so instead of charging you £100 I will be charging you £130, so then doing it has a genuine financial cost [GP2].

You don’t see every patient face-to-face

This final theme is underpinned by a change in primary care whereby, “doctors may not call patients in as much as they would have done” [GP3]. Several practices now offered telephone triage as a first point of call. Therefore, having to complete the screening measurements face-to-face had a direct impact on service delivery.

Sometimes nowadays I might have managed people over the phone… [but] I had to physically get people down into the room. I had to physically examine them … I would have managed over the phone and probably requested the x-ray just as routine to make sure that I was investigating it… so it did add a step [GP6].

This raised the question of whether it was necessary for a GP to complete the Vfrac, or whether a different health professional (for example a healthcare assistant, or urgent care practitioner) might be able to complete some (or all) of it. This could cause logistical issues, not only leaving patients waiting for two different appointments, but also placing additional work on reception staff.

The worry I have about delegating it to another person is the operational need in terms of how you actually set that up in practice; it actually becomes quite a lot more difficult. And then the total gain is perhaps not as much as you might think … [if I see the patient] you don’t have to sort out patient with the healthcare assistant as well as with the doctor [GP2].

It also raised a “bigger question” of who the most qualified person to triage, diagnose, and treat was. There was an underlying sense that the GP retained oversight and responsibility for an individual’s care, and that it was not always best practice, or even time/cost efficient, to devolve care to other staff.

I mean that is a big question [laugh]… who should be assessing people with back pain of undiagnosed or uncertain cause… I think that’s a complicated question … we used to have a physio … really sort of knowledgeable … their awareness of things that mimic MSK disorders that have another underlying pathology … I suspect they would be at least as accurate as us at diagnosing: quite possibly more [GP5].

Discussion

Our qualitative exploration was set within a study that explored the feasibility of the Vfrac tool in primary care. However, our findings highlight ideas that are transferable beyond this research setting. In this case, the idea that competing epistemologies can make it challenging for GPs to unambiguously complete standardised tools; a finding that resonates with research and outcome measurement in clinical practice. Similarly, Toye and colleagues argue that findings generated from qualitative research embedded in trials can stretch beyond the setting and make a valuable contribution to knowledge unrelated to the original study aim [11]. They argue that a strength of qualitative methodology is to find things that it did not intend to find. We show that general practice is underpinned by non-reductive way of knowing that does not necessarily sit comfortably in research design, and that this may impact on research conclusions. General Practice involves a complex reasoning process grounded on interpretive knowledge, and answers are “rarely black or white”. Closed questioning does not always comfortably align with a primary care setting where “a simple answer” is rare.

Lynch and colleagues propose that the unique “Craft” of the generalist (or general practitioner) cuts across physical and social sciences to incorporate both fact (positivism) and perspective (constructivism): human-beings are simultaneously “100% material (or bodily) AND 100% dynamic, social, relational, experiential and meaning-making organisms” [12]. The generalist does not reject the factual physical body, but rather, integrates biological and sociological disciplines (paraphrasing Lynch’s metaphor; just as the quantum physicist integrates the particle and wave to understand light) [12]. As such General Practice uniquely encompasses illumination (of illness experience) and definition (of disease): the Craft hinges upon a dialectic or “abductive” form of knowing that is continuously responding, moving and emerging, and that is also reflexive and humble in the face of uncertainty [13].

The general practitioner is defined by the Royal College of General Practitioners as a doctor who provides “whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide” [13]. However, reductive approaches have dominated evidence-based medicine in such a way that subjective human experiences (the reason we seek care) are framed as no more than “confounding variables” [14]. There are strong arguments that primary care is undermined by systemic reductivism [15], and Reeve asks if “it’s time to retire EBM (evidence based medicine)” [16]. For example, clinicians can be called to account for clinical judgements (in the best interest of their patients) that do not conform to evidence-based guidelines [16]. Systemic reductivism is likely to contribute to a demoralised and demotivated workforce, experiencing “an uncomfortable sense that [they] are no longer able to offer comprehensive humane care” [12]. This resonates Franks call for a “renewal of generosity” in healthcare [17], and Reeve’s call to “stand up for general practice” [18]. Study designs that do not value generalist approaches to knowledge may also contribute to GP reluctance to engage in research. From a patient perspective, Carel [19] and Lynch [12] provide a compelling argument that, by silencing voices, reductivism also risks epistemic injustice.

We highlight some of the practical challenges for GPs of completing standardised forms in a primary care setting. Our findings highlight potential burdens and trade-offs of research activity in primary care that should be considered in research design. It also highlights the value of including the perspective of primary care practitioners in research design. Healthcare research is dominated by secondary care and little is known about the barriers to research activity in primary care in the UK [1]. In a review exploring the challenges for conducting research in primary health care practice, Only 2 out of 26 studies took place in the UK [20]. Increasing workload is a barrier facing GPs [4].

Our findings confirms that research activity in primary care requires a time trade off, where GPs carefully considered the right balance of time and clinical/research activity. As population demand per GP has increased [21], the work and time pressures on GPs are clear, and research activity can add to the burden of an already pressurised system [22]. Research teams should be sensitive to the challenges and include primary care practitioners in research design teams. Bonfirm and colleagues’ highlight other challenges for conducting research in primary health care practice [20]. For example, some staff fear that research can impair productivity or have an impact on patients’ trust; some regard research as secondary to practice; lack of time dedicated to research alongside high caseloads; along with ineffective communication between research teams and primary care. Our findings also indicate that research/clinical trade-offs include the need to maintain an ongoing relationship with the patient in primary care, and to limit any damage to professional reputation where effective care hinges upon trust. Future research design in primary care should carefully consider “reputational” and relational issues in primary care. Although participants recognised the potential for “educational” opportunities from being involved in research, our findings highlight that (experienced) professional judgement should not be undervalued or usurped. Future research design should also consider recent changes in primary care whereby not all patients are seen in person, and the logistical issues for staff and patients of combining research appointments. Some participants pointed to the need for financial or QOF (quality and outcomes framework) incentives to be involved in research if it was not compulsory.

Our findings draw on open and in-depth interviews with GP volunteers involved in research activity in their daily work, giving a unique insight into research activity in primary care. Other primary care practitioners may also have given useful insight. The interviewer was an external anthropologist who was not involved in the design of the overarching study. As such, candour was strongly encouraged and trustworthiness enhanced. We did not include a GP in the analysis of the qualitative data which would have given alternative perspectives. The sample size was compatible with qualitative methodology where the power of a sample (“information power” [9]) is indicated by the richness of the data. Qualitative sample size is a moot point (amongst quantitative, and some qualitative researchers). The number or participants included in qualitative studies range widely, with very little tangible to operationalise the decision [23]. For example, in a meta-ethnography of studies (n = 77) exploring health professionals experience of treating adults with pain, the sample size from the studies ranged from 6 to 103 (average 22) [24]; these studies often include a range of healthcare professions. Information power encourages researcher to focus on the purposive (and non-representational) nature of qualitative sampling. This is in line with the homogenous sampling of Interpretative Phenomenological Analysis, where sample sizes are intentionally small to capture nuance [25]. Our findings demonstrate that small purposive sample focusing on a defined group of experts in a particular phenomenon (in this case, GPs using a screening tool) can yield valuable qualitative insights.

The innovation of our study is to highlight epistemological challenges to research that may be transferable across health settings. Our findings indicate that closed questioning did not always align comfortably with a primary care consultation. On the contrary, we found that general practice was underpinned by open questioning, and that closed questions potentially increased consultation time as GPs tried to pin-down an answer. Language is not a precision tool: it is indexical, not fixed. People talk “together”. As such, Mishler a key figure in the development of narrative psychology reminds us that “asking and answering questions is at once a simple and a subtle affair” [26]. Mishler argues that this “stimulus equals answer” model can mask true meaning. An interview is a discourse that takes place between two people, and yet this discourse is necessarily absent in fixed-response surveys or questionnaires where efforts are made to standardise questions and answers. Resonating with Mishler, our findings show that GPs incorporated dialogue in a sincere attempt to uncover a “true” response. In the commonsensical words of one GP “The [point of the] whole process …. is to interpret what the patient says”. This resonated very closely to Mishler, who noted (again, commonsensical) that “the original purpose of interviewing as a research method, [is]… to understand what respondents mean by what they say in response to our queries” (page 7).

Our findings highlight the interpretive work integral to decoding, work which hinges on “culturally shared and often tacit assumptions” (page 7) [26]. An interview is “social discourse” that cannot be decontextualized. GPs described how they changed the questions to fully grasp meaning. Although at odds with modern survey method, this decoding is likely not uncommon in survey design, even with the same interviewer [26]. Lazarsfield, a pioneer of survey research, advocated a “loose and liberal handling of a questionnaire by an interviewer” as it is “more important that the question be fixed in its meaning, than in the wording” [27] (page 32). He did not regard this as a weakness. GPs provided context that would not be provided by a stranger and in doing such, decoded data prior to collection: “Standard research practice ignores …. the process of disambiguation, sometimes unsuccessful, that takes place in discourse” (page 64) [26]. Future research design should consider the work of disambiguation and its role in uncovering meaning.

Conclusions

Quantitative research design, underpinned by positivist epistemology does not always align comfortably with General Practice where “a simple answer” is rare. Closed questioning does not always comfortably align with a primary care setting, and can even increase the time necessary for a consultation. Compatibility with primary care should be considered in all research design and primary care practitioners and members of the public should be included in research design decision-making.

We frame general practice as general praxis (defined as, “the practice … as distinct from the theory” [28]). Praxis is a practical form of knowing, or Phronesis (defined as Practical understanding; wisdom, prudence; sound judgement” [29]); it grows dialectically through experience [30]. In contrast, evidence-based medicine has become deeply vested in objective modes of knowledge, or Episteme [31]. Fifteen years ago, Greenhalgh invited us to challenge given (objective) ways of knowing in medicine, asking, ‘what is this knowledge we seek to exchange?’ [32]. This question is increasingly pertinent as Artificial Intelligence and Large Language Models become part of routine healthcare. Our findings support the value of Phronesis as an essential ally to Episteme in this new technocentric age.

Abbreviations

NHS

National health service

GP

General practitioner

NIHR

National institute for health and care research

Vfrac

Vertebral fracture screening tool

RTA

Reflexive thematic analysis

IMD

Indices of multiple deprivation

Authors’ contributions

FT made a substantial contribution to the acquisition and interpretation of data and drafted the first and final draft of the submitted manuscript. KB made a substantial contribution to the interpretation of data and revisions to the manuscript. SD, TYK, EMC made substantial contributions to the conception and design of work. All authors approved the submitted version and agreed to be accountable for accuracy and integrity of the work.

Funding

National Institute for Health and Care Research, Research for Patient Benefit Programme (NIHR203026).

Data availability

The datasets analysed are not publicly available. As it is not possible to fully anonymise participants in a qualitative interview, we did not seek ethical permission to make transcripts publicly available to protect participants’ anonymity. Anonymised data fragments used to support each theme are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This was a qualitative study using semi-structured interviews. All participants provided written informed consent before taking part in the study. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from Yorkshire & The Humber- Bradford Leeds Research Ethics Committee (reference 22/YH/0135).

Consent for publication

Not applicable.

Competing interests

The Vfrac study team (including SD, TK & EC) developed the tool that was the topic of enquiry. FT and KB have no competing interests.