Synthesis of datasets and analysis

Drawing on the principles of analysis described by Silverman [17], synthesis across datasets developed an account of the context and culture of pain care in the ED. Our process aimed to integrate all of the data inclusive of dimensions of evidence and context [6]. Each data source was individually reviewed through close reading of transcripts of interviews, meetings, journal notes, listening to audio recordings, and exploration of creative works. Audit data were summarised using simple descriptive statistics to explore patterns. We identified key ideas and concepts of interest, areas of overlap and noted interesting points. These concepts were coded, and similar ideas grouped under the same code. As new codes were developed, existing codes were reviewed and revised [17]. Through continued evaluation and analysis three primary overarching themes were developed: rules-based pain management, command and control, and self-defeating systems (Fig. 1). A selection of verbatim quotations has been included to illustrate these findings and “bring life to the text” from the perspective of the participating families and clinicians [18].

Data analysis and synthesis. Note: Adapted from Crowe and Manley [19]

As we became immersed in these concepts, we drew on several theoretical frames to understand the prevailing culture and how pain management practices became established. In particular, given our focus on organisational change for optimising ED pain care [5], our process of evaluation and analysis was heavily influenced by systems thinking principles summarised in Table 1 [20]. Therefore, our goal was not to add more detail complexity by generating in-depth descriptive accounts of current practice, but instead to focus and plan collaborative implementation effort on those changes that might best optimise the whole system of pain care in the ED. The outcomes of this analysis provided structure and focus to inform our implementation plan.

Systems thinking for change in complex systems ([20], p. 26)