title: Adaptation and innovation: a grounded theory study of procedural variation in the academic surgical workplace.
abstract: OBJECTIVE
  Surgical research struggles to describe the relationship between procedural variations in daily practice and traditional conceptualizations of evidence. The problem has resisted simple solutions, in part, because we lack a solid understanding of how surgeons conceptualize and interact around variation, adaptation, innovation, and evidence in daily practice. This grounded theory study aims to describe the social processes that influence how procedural variation is conceptualized in the surgical workplace.
  
  
  METHODS
  Using the constructivist grounded theory methodology, semi-structured interviews with surgeons (n = 19) from four North American academic centres were collected and analysed. Purposive sampling targeted surgeons with experiential knowledge of the role of variations in the workplace. Theoretical sampling was conducted until a theoretical framework representing key processes was conceptually saturated.
  
  
  RESULTS
  Surgical procedural variation was influenced by three key processes. Seeking improvement was shaped by having unsolved procedural problems, adapting in the moment, and pursuing personal opportunities. Orienting self and others to variations consisted of sharing stories of variations with others, taking stock of how a variation promoted personal interests, and placing trust in peers. Acting under cultural and material conditions was characterized by being wary, positioning personal image, showing the logic of a variation, and making use of academic resources to do so. Our findings include social processes that influence how adaptations are incubated in surgical practice and mature into innovations.
  
  
  CONCLUSIONS
  This study offers a language for conceptualizing the sociocultural influences on procedural variations in surgery. Interventions to change how surgeons interact with variations on a day-to-day basis should consider these social processes in their design.
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada.
authors.forename: Tavis
authors.identifier: http://orcid.org/0000-0002-4842-8247
authors.initials: T
authors.lastname: Apramian
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada.
authors.forename: Christopher
authors.initials: C
authors.lastname: Watling
authors.affiliation: Department of Medicine and Director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada.
authors.forename: Lorelei
authors.initials: L
authors.lastname: Lingard
authors.affiliation: Department of Surgery and Scientist, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada.
authors.forename: Sayra
authors.initials: S
authors.lastname: Cristancho
mesh_terms: D004059:Diffusion of Innovation; D055317:Evidence-Based Practice; D066296:Grounded Theory; D006785:Hospitals, University; D006801:Humans; D007398:Interpersonal Relations; D015279:Organizational Culture; D013514:Surgical Procedures, Operative / Q000379:methods* / Q000592:standards; D017132:Workplace / Q000458:organization & administration*
keywords: evidence-based surgery; grounded theory; innovation; practice variation; procedural variation; surgery