Table 2

Paradoxical effect subthemes and illustrative quotations

1. FIT identify gap—TPB normative belief: norms for identified group ‘I think you kind of have a concept in your mind of what your level is at and who you should be, what group you should be in.’ (P9)
‘When I look at other endoscopists they always seem to be a little bit higher than mine. There was also one of our other nurse endoscopist colleagues who was always the same as me and we did a lot of endoscopy, us two, and I wondered whether it was because we did so many that that had an effect and that the people who were actually higher detection rates did very few colons… the ones who actually had higher detection rates than me were actually, I thought personally, not as good endoscopists.’ (P10)
‘You want to see where you stand within the group and everyone else. So, for me, it reinforced to do what I was doing. I don't think I made any particular changes, to be honest.’ (P17)
2. FIT identify gap—TPB normative belief: seeing others’ underperformance reassurance ‘I guess if your performance is not so good but everybody else’s is similar then you're a bit like, “Well that’s probably okay,” and that’s probably not quite the right way to go about it.’ (P3)
‘I would want to see more people at my level, on the report, to know if I’m as crap as the report is making out or if this is reality of where I fall.’ (P16)
3. FIT cognitive interference: reduced confidence ‘Probably I would but I don’t want to bog myself down with [KPI]. Because I know there are some endoscopists who get bogged down with completion rates and things like that and you know at the end of the day if you can't manage to get where and you’ve tried every avenue to get that caecum you have to accept that.’ (P10)
‘It was all quite negative feedback and all not positive, which I came back from the course seriously reconsidering whether I should actually continue in endoscopy. I lost a lot of confidence and I think by giving that sort of feedback without any positives … can actually destroy your confidence and I think to do this job you need to be confident in what you’re doing … [since the feedback] I struggled with a lot of different things. Things I had been doing naturally, I had been doing what I had been taught I was very hesitant to do, because it had not worked on the course, and all the crappy feedback I got.’ (P2)
‘I feel quite confident and competent, although I suppose, like everybody, you get dips and peaks and troughs, which is the world, especially, of colonoscopy…Or you get a run, which you tend to, of incomplete colonoscopies, and you think, ”What am I doing here?”’ (P14)
4. FIT goal hierarchy: task motivation processes ‘So you’re busy thinking “get to the caecum”, what am I going to do, change position, withdraw some air, put some water in, what can I do to optimise my position and you’re thinking all these things in your head.’ (P12)
‘I tend to break operations up into lots of little steps, that have to be achieved, before you proceed to the next one. So, I would achieve it by saying, the first step is intubation, … check the patient’s position, check you’ve given them the correct medications and then you can start the second part, which is withdrawal and detection and resection.’ (P4)
‘It’s quite a nice technical challenge…Using the force and I use that in the “Star Wars” thing to work out how you’re going to coax the scope round. So, hope the force is with you and you can be like Luke with the helmet off, dropping the scope just down into the middle of the Death Star.’ (P19)
5. FIT cognitive interference: feedback’s ulterior motives ‘I think initially I'll often be like, “I'm not doing enough. Why am I not doing enough? Am I being got at?”’ (P3)
‘I think what you need to be very careful of is that you don’t move beyond monitoring to ensure safe standard and to drive up and improve standards into persecution, … making more of an issue for an individual than is actually the case when perhaps that individual needs time just to settle in and let things calm down, rather than actually that individual is not competent at doing what they are doing.’ (P11)
‘I know that there is concern amongst my colleagues that this kind of data is used against you and I think there’s some people that feel that it may be used to stop you doing certain procedures, which I think is worrying and I hope that’s not the intention of it.’ (P8)
‘If [my performance] dropped then I guess there is always a worry of whether they will stop me doing this.’ (P15)
6. FIT cognitive interference: leading to gaming ‘I think the danger is not having people get too bogged down in [KPI] so they start gaming their numbers.’ (P3)
‘I mean that a lot of my biggest concern about these KPI’s is they’re either encouraging people to lie, or they are encouraging people to attempt to do something which is maybe to the detriment of the patient, because they are concerned about their outcomes. … We didn’t want [endoscopists] to feel that they were under pressure to do these or to go the extra mile if the patient had comorbidity or was finding discomfort.’ (P5)
‘We’re all aware of the goals of the unit but they’re not shoved down our throats, so we’re not made to do things that make us feel uncomfortable to hit these targets. We’re told what our data is and have the opportunity to discuss that with the endoscopy lead and if there are any concerns, that would be raised but it’s not rammed down us all the time, this is what you have to achieve, not at all.’ (P8)
  • FIT, feedback intervention theory; KPI, key performance indicator; TPB, theory of planned behaviour.