scholarly journals Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

2020 ◽  
Vol 8 (15) ◽  
pp. 1-256
Author(s):  
Alicia O’Cathain ◽  
Emma Knowles ◽  
Jaqui Long ◽  
Janice Connell ◽  
Lindsey Bishop-Edwards ◽  
...  
Keyword(s):  
General Practice ◽  
Mixed Methods ◽  
General Practitioner ◽  
Health Service ◽  
Health Services ◽  
Focus Groups ◽  
Emergency Departments ◽  
Help Seeking ◽  
Mixed Methods Study ◽  
Coping Capacity

Background There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use. Objectives To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives. Design This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking. Results From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice. Limitations Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service. Conclusions Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered. Future work There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions. Study registration This study is registered as PROSPERO CRD42017056273. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

scholarly journals Burnout, resilience, and perception of mindfulness programmes among GP trainees: a mixed-methods study

BJGP Open ◽  
2020 ◽  
Vol 4 (3) ◽  
pp. bjgpopen20X101058
Author(s):  
Petra Hanson ◽  
Amy Clarke ◽  
Manuel Villarreal ◽  
Majid Khan ◽  
Jeremy Dale
Keyword(s):  
Mixed Methods ◽  
Focus Groups ◽  
Help Seeking ◽  
High Stress ◽  
Mixed Methods Study ◽  
Mindfulness Practice ◽  
Negative Effects ◽  
High Prevalence ◽  
High Level ◽  
And Coping

BackgroundTrainee GPs are at risk of developing burnout as a result of high stress levels. Improving resilience may prevent the negative effects of stress on wellbeing, morale, and patient care, thereby supporting recruitment to general practice.AimTo explore experiences of stress and burnout among GP trainees, and their level of interest in undertaking a mindfulness programme.Design & settingA qualitative study was performed with a cohort of GP trainees in Coventry and Warwickshire.MethodThis mixed-methods study utilised a survey with validated measures to investigate the prevalence of burnout, state of wellbeing, and resilience in GP trainees. Focus groups were also used to explore experiences of stress and burnout, and perceptions of mindfulness practice.ResultsIn total, 47 (response rate 39%) trainees completed the survey and 14 participated in focus groups. There was a high prevalence of disengagement (n = 36; 80%) and emotional exhaustion (n = 35; 77%), with 29 (64%) scoring above the cut-off value for both. While 16 (34%) reported already practising mindfulness, 39 (83%) described interest in engaging in mindfulness practice. The focus groups identified a range of issues relating to how trainees recognise stress and burnout, their help-seeking and coping strategies, the perceived barriers to practising self-care, and motivations for participating in mindfulness training.ConclusionThis study confirms the degree of stress and burnout that GP trainees experience, and their desire for greater wellbeing and resilience support. It identified a high level of interest in attending a mindfulness programme, but also barriers to engagement. Results of this research shaped the Mindful Practice Curriculum programme, which was later provided to this cohort of trainees.

scholarly journals Exploring the Barriers and Levers to Hand Hygiene of Nursing and Medical Staff in Emergency Departments: A Mixed Methods Study

2021 ◽  
Author(s):  
◽  
Lorraine Rees
Keyword(s):  
Mixed Methods ◽  
New Zealand ◽  
Focus Group ◽  
Hand Hygiene ◽  
Focus Groups ◽  
Emergency Departments ◽  
Medical Staff ◽  
Healthcare Workers ◽  
Mixed Methods Study ◽  
Doctors And Nurses

<p>Background: Emergency Departments (ED) frequently host patients with undiagnosed infectious conditions and patients who are vulnerable to infection. Minimising the risk of exposure to infectious diseases is a priority in healthcare and is managed using a variety of strategies. Hand hygiene (HH) underpins these strategies, but ED have lagged behind improvement in HH compared to other units in New Zealand public hospitals. Given the consequences of healthcare associated infections (HAI), further investigation is warranted to identify barriers and levers to HH in the challenging environment of ED.  The aim of this explanatory sequential mixed methods study was to identify barriers and levers to HH practice in two ED in New Zealand.  Design: The mixed methods study was conducted in two phases. In Phase One, a questionnaire was used to survey nurses and doctors in the two ED sites. In Phase Two, follow-on focus groups were used to explore in-depth, specific aspects of the survey results.  Methods: In Phase One, doctors and nurses in the ED sites were surveyed to identify perceived barriers and levers of HH. A previously validated questionnaire from the United Kingdom was used. Following piloting, the questionnaire was circulated via email to all doctors and registered nurses. Results were analysed descriptively. Areas identified as strong barriers and levers to HH practice were identified, and used to inform development of a focus group interview guide.  In Phase Two, focus group participants were identified from a self-selected convenience sample of survey respondents. Focus groups were audio-recorded and data transcribed verbatim into NVivo Pro 11 before undergoing thematic analysis.  Results: The survey was distributed to doctors (n= 81) and nurses (n= 214). The response rate was low (11% for nurses, 12% for doctors). Two focus groups (n=6 & n=2) and one face to face interview (n=1) was held with nurses participating in each session. No medical staff participated in this phase of data collection. All respondents had worked in healthcare more than three years. Healthcare workers identified that professional role was the strongest lever for HH (93.1%, n=95), closely followed by knowledge and skills (84.3%, n=86). Healthcare workers demonstrated an awareness of benefits of HH including improving patient confidence and avoidance on infection for the patient and themselves (65.9%, n= 89). 45.6% (n=62) of responses identified a lack of encouragement or role modelling in this area of practice.  The physical environment in the ED was a major barrier (53.7%, n=73) although shorter stays in ED were not perceived as a barrier to HH (73.5%, n= 25). High patient turnover and acuity were also perceived as barriers to HH. HH initiatives were perceived to have a marginal effect (55.3%, n=57). Social influences and communication were further barriers to HH, with healthcare workers identifying discomfort when challenging others about HH.  Conclusion: Current barriers to HH including the environmental challenges, and social and cultural barriers to HH need to be addressed. Hand hygiene education that targets known challenges in, and misunderstandings about practice, need to be developed. Organisations must clearly articulate expectations of HH through policy and procedure, including a commitment to address non-compliance. Doctors and nurses should be supported in developing strategies to effectively communicate about, and challenge HH practices. With organisational support and a harnessing of the professional responsibilities that doctors and nurses hold, there is opportunity to strengthen barriers and mitigate barriers to HH.</p>

scholarly journals Exploring the Barriers and Levers to Hand Hygiene of Nursing and Medical Staff in Emergency Departments: A Mixed Methods Study

2021 ◽  
Author(s):  
◽  
Lorraine Rees
Keyword(s):  
Mixed Methods ◽  
New Zealand ◽  
Focus Group ◽  
Hand Hygiene ◽  
Focus Groups ◽  
Emergency Departments ◽  
Medical Staff ◽  
Healthcare Workers ◽  
Mixed Methods Study ◽  
Doctors And Nurses

<p>Background: Emergency Departments (ED) frequently host patients with undiagnosed infectious conditions and patients who are vulnerable to infection. Minimising the risk of exposure to infectious diseases is a priority in healthcare and is managed using a variety of strategies. Hand hygiene (HH) underpins these strategies, but ED have lagged behind improvement in HH compared to other units in New Zealand public hospitals. Given the consequences of healthcare associated infections (HAI), further investigation is warranted to identify barriers and levers to HH in the challenging environment of ED.  The aim of this explanatory sequential mixed methods study was to identify barriers and levers to HH practice in two ED in New Zealand.  Design: The mixed methods study was conducted in two phases. In Phase One, a questionnaire was used to survey nurses and doctors in the two ED sites. In Phase Two, follow-on focus groups were used to explore in-depth, specific aspects of the survey results.  Methods: In Phase One, doctors and nurses in the ED sites were surveyed to identify perceived barriers and levers of HH. A previously validated questionnaire from the United Kingdom was used. Following piloting, the questionnaire was circulated via email to all doctors and registered nurses. Results were analysed descriptively. Areas identified as strong barriers and levers to HH practice were identified, and used to inform development of a focus group interview guide.  In Phase Two, focus group participants were identified from a self-selected convenience sample of survey respondents. Focus groups were audio-recorded and data transcribed verbatim into NVivo Pro 11 before undergoing thematic analysis.  Results: The survey was distributed to doctors (n= 81) and nurses (n= 214). The response rate was low (11% for nurses, 12% for doctors). Two focus groups (n=6 & n=2) and one face to face interview (n=1) was held with nurses participating in each session. No medical staff participated in this phase of data collection. All respondents had worked in healthcare more than three years. Healthcare workers identified that professional role was the strongest lever for HH (93.1%, n=95), closely followed by knowledge and skills (84.3%, n=86). Healthcare workers demonstrated an awareness of benefits of HH including improving patient confidence and avoidance on infection for the patient and themselves (65.9%, n= 89). 45.6% (n=62) of responses identified a lack of encouragement or role modelling in this area of practice.  The physical environment in the ED was a major barrier (53.7%, n=73) although shorter stays in ED were not perceived as a barrier to HH (73.5%, n= 25). High patient turnover and acuity were also perceived as barriers to HH. HH initiatives were perceived to have a marginal effect (55.3%, n=57). Social influences and communication were further barriers to HH, with healthcare workers identifying discomfort when challenging others about HH.  Conclusion: Current barriers to HH including the environmental challenges, and social and cultural barriers to HH need to be addressed. Hand hygiene education that targets known challenges in, and misunderstandings about practice, need to be developed. Organisations must clearly articulate expectations of HH through policy and procedure, including a commitment to address non-compliance. Doctors and nurses should be supported in developing strategies to effectively communicate about, and challenge HH practices. With organisational support and a harnessing of the professional responsibilities that doctors and nurses hold, there is opportunity to strengthen barriers and mitigate barriers to HH.</p>

scholarly journals Shared Living Experiences by Physicians have a Positive Impact on Mental Health Attitudes and Stigma among Medical Students: A Mixed-Methods Study

2020 ◽  
Vol 7 ◽  
pp. 238212052096807
Author(s):  
Andrés Martin ◽  
Julie Chilton ◽  
Cecilia Paasche ◽  
Nicole Nabatkhorian ◽  
Hilary Gortler ◽  
...  
Keyword(s):  
Mental Health ◽  
Mixed Methods ◽  
Medical Students ◽  
Focus Groups ◽  
Thematic Analysis ◽  
Role Models ◽  
Help Seeking ◽  
Mixed Methods Study ◽  
Care Providers ◽  
The Impact

Introduction: Medical culture can make trainees feel like there is neither room for mistakes, nor space for personal shortcomings in the makeup of physicians. A dearth of role models who can exemplify that it is acceptable to need support compounds barriers to help-seeking once students struggle. We conducted a mixed-methods study to assess the impact of physicians sharing their living experiences with medical students. Methods: Second-year medical students participated, through synchronized videoconferencing, in an intervention consisting of 3 physicians who shared personal histories of vulnerability (e.g. failure on high-stakes exams; immigration and acculturation stress; and personal psychopathology, including treatment and recovery), followed by facilitated, small-group discussions. For the quantitative component, students completed the Opening Minds to Stigma Scale for Health Care Providers (OMS-HC) before and after the intervention. For the qualitative component, we conducted focus groups to explore the study intervention. We analyzed anonymized transcripts using thematic analysis aided by NVivo software. Results: We invited all students in the class (n = 61, 46% women) to participate in the research component. Among the 53 participants (87% of the class), OMS-HC scores improved after the intervention ( P = .002), driven by the Attitudes ( P = .003) and Disclosure ( P < .001) subscales. We conducted 4 focus groups, each with a median of 6 participants (range, 5-7). We identified, through iterative thematic analysis of focus group transcripts, active components before, during, and after the intervention, with unexpected vulnerability and unarmored mutuality as particularly salient. Conclusions: Sharing histories of personal vulnerability by senior physicians can lessen stigmatized views of mental health and normalize help-seeking among medical students. Synchronous videoconferencing proved to be an effective delivery mechanism for the intervention in a ‘virtual wellness’ format. Candid sharing by physicians has the potential to enhance students’ ability to recognize, address, and seek help for their own mental health needs.

scholarly journals An intervention to decrease burnout and increase retention of early career nurses: a mixed methods study of acceptability and feasibility

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Judy Brook ◽  
Leanne M. Aitken ◽  
Julie-Ann MacLaren ◽  
Debra Salmon
Keyword(s):  
Mixed Methods ◽  
Nursing Students ◽  
Focus Groups ◽  
Academic Staff ◽  
Skills Training ◽  
Early Career ◽  
Mixed Methods Study ◽  
Healthcare Organisation ◽  
Structured Interviews ◽  
Over Time

Abstract Aims To understand the experiences of nursing students and academic staff of an intervention to decrease burnout and increase retention of early career nurses, in order to identify acceptability and feasibility in a single centre. Background Internationally, retention of nurses is a persistent challenge but there is a dearth of knowledge about the perspectives of stakeholders regarding the acceptability and feasibility of interventions to resolve the issue. This study reports an intervention comprising of mindfulness, psychological skills training and cognitive realignment to prepare participants for early careers as nurses. Methods This is an explanatory sequential mixed methods study, conducted by a UK university and healthcare organisation. Participants were final year pre-registration nursing students (n = 74) and academics (n = 7) involved in the implementation of the intervention. Pre and post measures of acceptability were taken using a questionnaire adapted from the Theoretical Framework of Acceptability. Wilcoxon Signed Ranks test was used to assess change in acceptability over time. Qualitative data from semi-structured interviews, focus groups and field notes were thematically analysed, adhering to COREQ guidelines. Data were collected February to December 2019. Results One hundred and five questionnaires, 12 interviews with students and 2 focus groups engaging 7 academic staff were completed. The intervention was perceived as generally acceptable with significant positive increases in acceptability scores over time. Student nurses perceived the intervention equipped them with skills and experience that offered enduring personal benefit. Challenges related to the practice environment and academic assessment pressures. Reported benefits align with known protective factors against burnout and leaving the profession. Conclusion Planning is needed to embed the intervention into curricula and maximise relationships with placement partners. Evaluating acceptability and feasibility offers new knowledge about the value of the intervention for increasing retention and decreasing burnout for early career nurses. Wider implementation is both feasible and recommended by participants.

Child Health Services in England and Wales: An Overview

PEDIATRICS ◽  
1990 ◽  
Vol 86 (6) ◽  
pp. 1032-1036
Author(s):  
Shirley Goodwin
Keyword(s):  
Health Policy ◽  
General Practitioner ◽  
National Health Service ◽  
Child Health ◽  
Health Service ◽  
Health Services ◽  
Social Security ◽  
Child Health Services ◽  
England And Wales ◽  
The Impact

Child health services in England and Wales are rendered largely through the National Health Service and Social Security. The activities of local authorities are also important to child health. The structure and scope of services offered children by each of these is presented and discussed, with special attention to changes anticipated during the next 2 years. The care of children is integrated into the system serving all ages, so that services are difficult to evaluate and resources are shared with other groups. Health policy for children is fragmentary, although encouraging trends are visible in the evolution of existing policy. The impact of impending changes in hospital, community, and general practitioner services on the care of children is unclear at this time.

Student mental health and the general practitioner

1975 ◽  
Vol 13 (25) ◽  
pp. 99-100
Keyword(s):  
Mental Health ◽  
Higher Education ◽  
General Practitioner ◽  
Health Service ◽  
Health Services ◽  
Mental Health Problems ◽  
Health Problems ◽  
Student Health ◽  
Student Health Services ◽  
The University

Although most universities run a health service, students with important mental health problems are often seen by their general practitioner. There are a number of reasons for this; first, health services in the colleges of higher education outside universities are still patchy and incomplete. Second, students are on vacation for up to 24 weeks a year. Third, a student may choose to consult anyone, and may prefer someone unconnected with the university. Last, many students live at home and continue to see their general practitioner. This underlines the need for close liason between the general practitioner and student health services.

scholarly journals Women’s experiences of diagnosis and management of polycystic ovary syndrome: a mixed-methods study in general practice

2020 ◽  
Vol 70 (694) ◽  
pp. e322-e329 ◽  
Author(s):  
Sarah C Hillman ◽  
Carol Bryce ◽  
Rachel Caleychetty ◽  
Jeremy Dale
Keyword(s):  
Mental Health ◽  
General Practice ◽  
Mixed Methods ◽  
Polycystic Ovary Syndrome ◽  
Mental Health Problems ◽  
Polycystic Ovary ◽  
Mixed Methods Study ◽  
Ovary Syndrome ◽  
Women’S Experiences ◽  
Women's Experiences

BackgroundPolycystic ovary syndrome (PCOS) is a common lifelong metabolic condition with serious associated comorbidities. Evidence points to a delay in diagnosis and inconsistency in the information provided to women with PCOS.AimTo capture women’s experiences of how PCOS is diagnosed and managed in UK general practice.Design and settingThis was a mixed-methods study with an online questionnaire survey and semi-structured telephone interviews with a subset of responders.MethodAn online survey to elicit women’s experiences of general practice PCOS care was promoted by charities and BBC Radio Leicester. The survey was accessible online between January 2018 and November 2018. A subset of responders undertook a semi-structured telephone interview to provide more in-depth data.ResultsA total of 323 women completed the survey (average age 35.4 years) and semi-structured interviews were conducted with 11 women. There were five key themes identified through the survey responses. Participants described a variable lag time from presentation to PCOS diagnosis, with a median of 6–12 months. Many had experienced mental health problems associated with their PCOS symptoms, but had not discussed these with the GP. Many were unable to recall any discussion about associated comorbidities with the GP. Some differences were identified between the experiences of women from white British backgrounds and those from other ethnic backgrounds.ConclusionFrom the experiences of the women in this study, it appears that PCOS in general practice is not viewed as a long-term condition with an increased risk of comorbidities including mental health problems. Further research should explore GPs’ awareness of comorbidities and the differences in PCOS care experienced by women from different ethnic backgrounds.

scholarly journals Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study

2019 ◽  
Vol 7 (14) ◽  
pp. 1-288 ◽  
Author(s):  
John L Campbell ◽  
Emily Fletcher ◽  
Gary Abel ◽  
Rob Anderson ◽  
Rupatharshini Chilvers ◽  
...  
Keyword(s):  
Primary Care ◽  
At Risk ◽  
General Practice ◽  
Mixed Methods ◽  
Patient Care ◽  
Mixed Methods Study ◽  
Direct Patient Care ◽  
South West ◽  
Career Break ◽  
South West England

BackgroundUK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.Objectives(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.DesignThis was a comprehensive, mixed-methods study.SettingThis study took place in primary care in England.ParticipantsGeneral practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.Main outcome measuresSystematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.ResultsPast research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.LimitationsThe survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.ConclusionsThis research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.Study registrationThis study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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