Background Open-ended questions are a common addition to surveys of healthcare practice, yet the free-text responses generated are rarely integrated in substantive findings. There is currently little guidance about how they can be used to enhance survey analysis. In this study we report the qualitative analysis of free-text comments alongside the quantitative analysis of two surveys designed to elicit information from clinicians about reconstructive surgery for pressure ulcers (PU), in terms of referral, treatment, indications and barriers for surgery. The aim was to identify issues not captured by the closed-ended questions, add contextual information to the survey responses and combine quantitative and qualitative results to identify the most important issues influencing referral for surgery.

Methods The surveys were completed between June and September 2020 by 137 nurses and 43 surgeons and included 21 and 29 closed-ended questions, respectively, of which 16 (76%) and 23 (79%) had a free-text comment option. We conducted an inductive thematic analysis of the free-text responses using NVivo (QSR International).

Results A total of 99 nurses (72%) and 24 surgeons (56%) provided at least one free-text comment, generating a total of 373 and 77 comments, respectively. Themes captured by the free-text responses were grouped into two overarching themes: barriers and contraindications for referral. Barriers were defined as any factor involving the healthcare system/care pathways, while contraindications were defined as any patient-related factor that negatively influences referral. Preliminary analyses identified several barriers that were not captured in the closed-ended questions: i) difficulty in referring patients to appropriate services (nurses and surgeons); ii) surgeon reluctance to operate on/take responsibility for patients outside their direct care (nurses); iii) the current lack of evidence about the effectiveness of reconstructive surgery (nurses and surgeons). The main contraindications, already captured by the closed-ended questions, were patient comorbidities and adherence to post-surgery protocols (nurses and surgeons). Ongoing analysis will attempt to identify sub-themes and rank their relative importance for referral.

Conclusion Preliminary analyses revealed that clinicians used free-text comments to highlight barriers to patients receiving reconstructive surgery that were not addressed in the closed-ended questions and reinforce the most important contraindications for surgery. We will argue that embedding and analysing free-text responses in surveys provide further insight into aspects of the topic under investigation not captured by closed-ended questions to highlight directions for future research.