Table 2

Themes describing the factors affecting the user-related changes with exemplary citations from the study findings

Main themeSubthemeExemplary citations from the study findings
The checklistChecklist contentThe binary (yes/no) response system was ambiguous and confusing.68
Execution process did not merge with existing processes… duplication with existing processes that already covered several of the items in the surgical checklist.68
Psychological ownership… they [surgeons] did not necessarily agree with it, albeit this protocol was endorsed by the College of Surgeons.62
staff should have been involved in adapting and implementing the SSC as a means of fostering ownership.74
The implementation processEducation and trainingMany participants said that they did not receive information or training on how to use the SSC…. 74
Unclear guidelinesMany participants said that staff were uncertain about how to use the SSC and who was responsible for leading it.74
Surgeons commitmentPhysician's support and motivation were crucial for implementing the checklist.63
The local contextExecutive leadership… lack of clarity and agreement with protocol specifics, and inadequate executive leadership primarily resulted in reduced ownership and acceptance of the protocol by physicians.68
Hospital leadership was not seen as involved in either promoting or actively implementing the SSC.74
Organisational cultureThe same proportion of staff held the perception that the culture within their hospital was that of a general resistance to the introduction of change, whatever form it takes, particularly from more senior members of staff.76
Communication and teamworkWe often talk about being one team, but it is in itself three teams. The surgeons don't see themselves as part of the team; they see the others forming the team, but they invite in so to speak.62