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Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy

Catlow, Jamie, Bhardwaj-Gosling, Rashmi, Sharp, Linda, Rutter, Matthew David and Sniehotta, Falko F (2021) Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy. BMJ Quality & Safety, 31 (10). pp. 704-715. ISSN 2044-5415

Item Type: Article


Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study.

We undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour.

Data saturation was achieved on the 19th
participant, with participants from nursing, surgical
and medical backgrounds and a median of 7 years’
experience. When performance was below aspirational targets
participants were falsely reassured by social comparisons.
Participants described confidence as a requirement
for colonoscopy. Negative feedback without a plan
to improve risked reducing confidence and impeding
performance (cognitive interference). Unmet targets
increased anxiety and prompted participants to question
messages’ motives and consider gaming.
Participants described inaccurate documentation of
subjective measures, including patient comfort, to achieve
targets perceived as important. Participants described
causing harm from persevering to complete procedures
despite patient discomfort and removing insignificant
polyps to improve detection rates without benefiting the

Our dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence.

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Depositing User: Rashmi Bhardwaj-Gosling


Item ID: 14819
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ISSN: 2044-5415
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ORCID for Rashmi Bhardwaj-Gosling: ORCID iD

Catalogue record

Date Deposited: 06 Jun 2022 10:43
Last Modified: 06 Dec 2022 13:55


Author: Rashmi Bhardwaj-Gosling ORCID iD
Author: Jamie Catlow
Author: Linda Sharp
Author: Matthew David Rutter
Author: Falko F Sniehotta

University Divisions

Faculty of Health Sciences and Wellbeing > School of Nursing and Health Sciences


Sciences > Health Sciences

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