Table 2.

Existing theories and their relationships to CMO configurations in the programme theory

Theory	Explanation of relationships	CMO configurations in the programme theory (figure 2)
Receptive capacity of an organisation 22 24 58	Theories about the organisational setting elucidate the mechanisms by which organisations help or hinder quality circles in their work. Quality circles should be embedded in a system that provides training in QI and promotes it by providing explicit knowledge, valuing tacit knowledge, and ensuring that groups have competent facilitators. These features are part of an organisation’s receptive capacity: how well it values, integrates, and uses new external knowledge.	CMO configuration 1 b-c
Self-determination theory59	Self-determination theory suggests that GPs are motivated to participate in quality circles if they feel that the quality circle will satisfy their basic needs for competence, social bonding and autonomy.	CMO configurations 1 a, 1 c, 2 a-c, 3 b, 4 b and 4 e
Theories about groups 29 33 60–62	Theories about groups and facilitation describe how groups form and norm their rules, a prerequisite for building an environment of trust in which participants can exchange ideas and thoughts. The knowledge and capacity of the group may be greater than the sum of the average of each individual’s capacity. When participants share their knowledge and incorporate all perspectives, they can collectively solve problems more efficiently than they could alone.	CMO configurations 2 b-d, 3 a-c, 4 c and 4 g
Social learning theory 63 64	Social learning theory frames learning as an active cognitive process of perception and thinking in a social context. Participants in quality circles learn by observing and imitating peers. They also learn from the responses they receive, or expect to receive, when they try something new or avoid unrewarding actions. Learning depends much on individual expectations and feelings of competence to carry tasks. Organisational factors that lend support to learners, for example, by giving access to learning material, incentives or rewards, improve the process.	CMO configuration 3 f
Adult-learning theories65	Adult-learning theories suggest that adults are highly motivated: they learn things that are immediately useful to them, and prefer to do so in a self-directed, task-oriented, experience-based manner.	CMO configurations 1 c, 2 b and 3 b-d
Experience-based learning66 67	GPs prefer experiential learning, in which experience is the starting point. Reflecting on an experience enables GPs to restructure their knowledge. They turn insights gained from experience into knowledge and transfer them to other situations. They actively experiment with the new knowledge, and then report their experiences back to the group.	CMO configurations 3 b- e
Transformative learning theory 35 44	Transformative learning begins with cognitive dissonance, a negative emotional state triggered by conflicting perceptions. Generally, people want to reduce discordant feelings. In the safe environment of a quality circle, cognitive dissonance prompts GPs to reflect on and accept new arguments or revise their old ones to resolve their internal conflict.	CMO configurations 3 e and 4 g
Social interdependence theory 45 68	Social interdependence theory explains why groups may work together towards a common goal. When quality circle participants realise that they will only achieve their own goals if their peers achieve theirs, this creates a positive interdependence, which encourages participants to reassure and support each other in pursuit of those goals. Positive interdependence improves psychological well-being and raises self-esteem through cooperation and mutual appreciation.	CMO configurations 4 a and 4 c
Knowledge-creation theory 49–51	Knowledge-creation theories describe the process by which implicit knowledge becomes explicit when participants relate and combine their experiences with other explicit knowledge like evidence-based information, generating new concepts that participants integrate into their everyday clinical practice.	CMO configurations 1 b, 3 c, 4 c, e, g
Theory of planned behaviour69 70	The theory of planned behaviour describes how intentions can change behaviour: if the new behaviour makes sense, others approve and it feels easy enough to change.	CMO configuration 4 f
Automaticity 71	There are theories that support the argument that quality circles are much more successful when they repeatedly implement new knowledge, giving participants the opportunity to build confidence in innovation and their quality circle skills.	CMO configurations 5 a-b

CMO, context–mechanism–outcome; GP, general practitioner; QI, quality improvement.