Table 4.

Summary of the qualitative framework analysis for the 16 NPT subconstructs with supportive evidence

NPT mechanisms and subconstructs	Coding summary	Supporting evidence
Coherence
Differentiation Mean survey score: 3.18	Clinicians often did not differentiate between normal practice and use of the AKI e-alert; checking the patient’s renal function was deemed to be routine in the clinical areas studied.	‘A doctor says that it’s a routine part of their job to check renal function and would check it anyway—this is the case even in the emergency department if a patient came in with a broken arm to check for a potential underlying condition’. (Trust 1 observation of emergency admissions, approx. 19:30 hours)
Communal specification Mean survey score: 3.29	Working with the AKI e-alert was perceived to be an individual rather than team action. The e-alert was rarely discussed or used to initiate discussion, with staff often not knowing what others thought about the e-alert.	“I don’t think we’ve had much discussion about the AKI alerts, it’s certainly not something that I’m aware of, that other people have commented on”. (F1 interview, general/vascular surgery, Trust 2) “I haven’t spoken to anyone else(about the AKI e-alert). I know just from being in the doctor’s office, with the other doctors that sometimes, you know, you see people glance at the screen, and go ‘click’ while they are still talking to you”. (ST2 interview, internal medicine/care of the elderly, Trust 2)
Individual specification Mean survey score: 3.8	AKI e-alerts often made staff consider the patient’s AKI and to double check renal function.	“I guess it’s to draw attention to it quickly rather than bloods getting lost in the system for the day, because… especially on a busy ward(…)there’ll be… I don’t know… 20 bloods sent in the morning and then if you’re busy with sick people it could go well into the afternoon before you get to check on bloods”. (F1 interview, emergency admissions, Trust 2)
Internalisation Mean survey score: 4.16	Many staff saw the potential value of the AKI e-alert and understood the need for the e-alerts.	“I think it’s probably the most useful out of the alerts. It generally comes on when the patients genuinely do have an AKI, although, that’s often sometimes not the case. Like we said before, often it does require action, so, yes, they’re pretty useful”. (F1 interview, emergency admissions, Trust 1)
Cognitive participation
Initiation Mean survey score: 2.8	Participants frequently cited a lack of initiation in relation to the AKI e-alerts. This occurred for one of two reasons: 1) the e-alerts just appeared without any training on how to use them or 2) clinicians were newly qualified (or new to the Trust) and the e-alerts were already implemented, but again no training was provided.	“Yes they just sort of bob up. We never had really any induction about them”. (F1 interview, general/vascular surgery, Trust 3)
Legitimation Mean survey score: 4.16	For the more junior doctors, the e-alerts are perceived to be a legitimate part of their role. However, for more senior doctors, particularly in surgical units, the e-alerts were a useful intervention but only for junior doctors. Some clinicians felt that there should be a specialist AKI nurse.	“We have specialist nurses who provide input for absolutely everything. So, the idea that there isn't one for an AKI, is a bit silly, in my opinion. Because, somebody coming… their purpose in my opinion would be to come around, read what they are in for, review their pathology, review the patient, and review reversible factors. Then make a recommendation to the junior and the consultant about reversible factors that hadn’t been looked at yet”. (ST1 interview, internal medicine/care of the elderly, Trust 2)
Enrolment Mean survey score: 4.24	As working with the AKI e-alert was an individual action, it often had no influence on working relationships. For the few clinicians who saw the relational value, it was beneficial by providing the AKI stage that could be easily reported.	“If one of the F1’s came to me and said, ‘this woman’s creatinine has gone up’, then yes, absolutely we would have a chat about meds, and fluid, and have they had an ultrasound scan, and what do you think we should do? But, I don’t think the alert has ever prompted me to do that”. (ST2 interview, internal medicine/care of the elderly, Trust 1) “It's good if you're doing a handover on the phone or something or talking to seniors in critical care or other hospitals. You can say this is Stage 2 AKI and that is sort of a standard term that people do understand even if we don’t use it in general day-to-day discussion in the notes as much as we should do”. (F1 interview, general/vascular surgery, Trust 3)
Activation Mean survey score: 4.06	Prolonged exposure to the AKI e-alerts impacted on clinician’s support for them; the e-alerts had more impact when new, but they became part of the milieu and lost among other e-alerts or working practices.	“Yes, I do actually. I think it's a big component of patient safety and I think it is the direction of travel of where we're going. As time goes on, looking forward, I think we're going to expect more and more of these alerts related to algorithms and severity”. (Consultant interview, emergency admissions, Trust 1)
Collective action
Interactional workability Mean survey score: 3.98	It was generally deemed easy to integrate the AKI e-alerts into normal working practices; they are there as a ‘check’ or ‘backup’ as most clinicians were routinely checking renal function. The e-alerts were perceived to speed up the process of calculating the stage of AKI. E-alerts were seen to be useful where creatinine was within normal range, but with an increase of >1.5 from baseline.	“I think if it’s not someone I already know, then yes, the alerts at least make me glance at the U&Es, which I would do anyway, but you know, just an extra reminder to check back what their previous U&Es were”. (ST7 interview, emergency admissions, Trust 1) “I think in some ways, it probably does speed things up, because you have got that alert there, and I think, when you open up a page of bloods, and it’s quite obvious, and the first thing you see is they have an AKI”. (ST3 interview, emergency admissions, Trust 3)
Relational integration Mean survey score: 3.67	The AKI e-alert did not appear to affect working relationships. Staff mostly do not refer to the e-alert when discussing AKI, and AKI care is often an isolated task. An exception is stage 3 e-alerts, which sometimes trigger discussions with renal services.	“I don’t know about the other staff and how they engage because actually I've not had a lot of feedback from them. I haven’t actually been hearing the juniors saying, ‘Oh there was an AKI alert’ on anyone so I suspect most of them are just clicking and moving on, dismissing and moving on because they probably already know what the creatinine’s doing”. (Consultant interview, general/vascular surgery, Trust 1)
Skill set workability Mean survey score: 3.27	There was a lack of training on how to best use the AKI e-alerts (also reported in initiation), and some clinicians demonstrated a lack of understanding about AKI, particularly the meaning of the different stages.	“When you come to the Trust you get—I don't know how long the sessions are and I don’t know what they cover, and I don’t know whether they cover alerts and things like that. If they do have (AKI e-alert training), I suspect it comes at the end of a very long day of induction where they’ve been told about every single problem under the sun and they’ve probably switched off”. (ST7 interview, emergency admissions, Trust 1) “And there’s ( AKI stages ) 1, 2 and 3, I can't really remember the difference between the three of them but if it flags up something I go, ‘oh, okay, there’s something different here’”. (F1 interview, general/vascular surgery, Trust 3)
Contextual integration Mean survey score: 3.32	Clinicians did not report any specific resource requirements for the AKI e-alert other than training and time. Management support (where considered in the capacity of those responsible for e-alerts; the laboratory) was not identified by participants.	“I’ve no idea(who has responsibility for the AKI e-alerts), no. I assume somebody will do but I don't know, it’s not been communicated”. (F1 interview, general/vascular surgery, Trust 3)
Reflexive monitoring
Systematisation Mean survey score: 2.5	Feedback was never provided to staff on the effect of the AKI e-alert.	“I haven’t had any feedback since the new version (of the AKI e-alert) went in actually(…) I don’t know whether there is a formal mechanism for that getting to anyone”. (Pharmacist interview, Trust 1)
Communal appraisal Mean survey score: 3.39	The e-alert was rarely (if ever) discussed among clinicians, but participants often stated they felt that others would find it worthwhile.	“Most people I'm sure would know it's a good idea having them. That's what I'd say to someone about these alerts”. (Consultant interview, emergency admissions, Trust 1)
Individual appraisal Mean survey score: 3.52	While a small minority of clinicians felt the AKI e-alert had no effect on their work, many did but placed the effect within constraints relating to edge-case scenarios where AKI was most likely to be missed. These included marginal AKI thresholds within ‘normal Cr range’, busy workloads and AKI presenting in patients with chronic kidney disease. The pop-up e-alert was sometimes perceived to be intrusive, while the passive e-alert was often described as being too easy to dismiss.	“Speaking to a doctor, they felt that the AKI alerts are very useful. He says that if he sees an alert then he’ll check the patient’s renal function. He also explains that things at handover will often get missed so doesn’t always know that the patient will have an AKI”. (Trust 1 observation of emergency admissions, approx. 19:45 hours)
Reconfiguration Mean survey score: 3.89	Clinicians often did not know who was responsible for the AKI e-alert. They would never consider providing feedback about the e-alert, and there was no formal mechanism for doing so.	“I’m not sure if there is a feedback mechanism. If there is, I’m not aware of it”. (F1 interview, emergency admissions, Trust 1) “( To provide feedback ) I would ring IT and they would probably be very unhelpful and I would give up at that point”. (ST2 interview, internal medicine/care of the elderly, Trust 1)

AKI, acute kidney injury; e-alert, electronic-alert; NPT, Normalisation Process Theory.