Slaying the dragon myth: an ethnographic study of receptionists in UK general practice

Background

General practice receptionists fulfil an essential role in UK primary care, shaping patient access to health professionals. They are often portrayed as powerful ‘gatekeepers’. Existing literature and management initiatives advocate more training to improve their performance and, consequently, the patient experience.

Aim

To explore the complexity of the role of general practice receptionists by considering the wider practice context in which they work.

Design and setting

Ethnographic observation in seven urban general practices in the north-west of England.

Method

Seven researchers conducted 200 hours of ethnographic observation, predominantly in the reception areas of each practice. Forty-five receptionists were involved in the study and were asked about their work as they carried out their activities. Observational notes were taken. Analysis involved ascribing codes to incidents considered relevant to the role and organising these into related clusters.

Results

Receptionists were faced with the difficult task of prioritising patients, despite having little time, information, and training. They felt responsible for protecting those patients who were most vulnerable, however this was sometimes made difficult by protocols set by the GPs and by patients trying to ‘play’ the system.

Conclusion

Framing the receptionist–patient encounter as one between the ‘powerful’ and the ‘vulnerable’ gets in the way of fully understanding the complex tasks receptionists perform and the contradictions that are inherent in their role. Calls for more training, without reflective attention to practice dynamics, risk failing to address systemic problems, portraying them instead as individual failings.     

Domestic violence: knowledge,attitudes, and clinical practice of selected UK primary healthcare clinicians

Background

Domestic violence affects one in four women and has significant health consequences. Women experiencing abuse identify doctors and other health professionals as potential sources of support. Primary care clinicians agree that domestic violence is a healthcare issue but have been reluctant to ask women if they are experiencing abuse.

Aim

To measure selected UK primary care clinicians’ current levels of knowledge, attitudes, and clinical skills in this area.

Design and setting

Prospective observational cohort in 48 general practices from Hackney in London and Bristol, UK.

Method

Administration of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), comprising five sections: responder profile, background (perceived preparation and knowledge), actual knowledge, opinions, and practice issues.

Results

Two hundred and seventy-two (59%) clinicians responded. Minimal previous domestic violence training was reported by participants. Clinicians only had basic knowledge about domestic violence but expressed a positive attitude towards engaging with women experiencing abuse. Many clinicians felt poorly prepared to ask relevant questions about domestic violence or to make appropriate referrals if abuse was disclosed. Forty per cent of participants never or seldom asked about abuse when a woman presented with injuries. Eighty per cent said that they did not have an adequate knowledge of local domestic violence resources. GPs were better prepared and more knowledgeable than practice nurses; they also identified a higher number of domestic violence cases.

Conclusion

Primary care clinicians’ attitudes towards women experiencing domestic violence are generally positive but they only have basic knowledge of the area. Both GPs and practice nurses need more comprehensive training on assessment and intervention, including the availability of local domestic violence services.     

Attitudes towards domestic violence in Lebanon: a qualitative study of primary care practitioners

Background

Domestic violence (DV) is highly prevalent in the developing and developed world. Healthcare systems internationally are still not adequately addressing the needs of patients experiencing violence.

Aim

To explore physicians’ attitudes about responding to DV, their perception of the physician’s role, and the factors that influence their response.

Design and setting

Qualitative study using individual interviews among primary care practitioners working in Lebanon.

Method

Primary care clinicians practising for >5 years and with >100 patient consultations a week were interviewed. Physicians were asked about their practice when encountering women disclosing abuse, their opinion about the engagement of the health services with DV, their potential role, and the anticipated reaction of patients and society to this extended role.

Results

Physicians felt that they were well positioned to play a pivotal role in addressing DV; yet they had concerns related to personal safety, worry about losing patients, and opposing the norms of a largely conservative society. Several physicians justified DV or blamed the survivor rather than the perpetrator for triggering the violent behaviour. Moreover, religion was perceived as sanctioning DV.

Conclusion

Perceived cultural norms and religious beliefs seem to be major barriers to physicians responding to DV in Lebanon, and possibly in the Arab world more generally. Financial concerns also need to be addressed to encourage physicians to address DV.     

Improving the uptake of pulmonary rehabilitation in patients with COPD:: qualitative study of experiences and attitudes

Background

Pulmonary rehabilitation can improve the quality of life and ability to function of patients with chronic obstructive pulmonary disease (COPD). It may also reduce hospital admission and inpatient stay with exacerbations of COPD. Some patients who are eligible for pulmonary rehabilitation may not accept an offer of it, thereby missing an opportunity to improve their health status.

Aim

To identify a strategy for improving the uptake of pulmonary rehabilitation.

Design of study

Qualitative interviews with patients.

Setting

Patients with COPD were recruited from a suburban general practice in north-east Derbyshire, UK.

Method

In-depth interviews were conducted on a purposive sample of 16 patients with COPD to assess their concerns about accepting an offer of pulmonary rehabilitation. Interviews were analysed using grounded theory.

Results

Fear of breathlessness and exercise, and the effect of pulmonary rehabilitation on coexisting medical problems were the most common concerns patients had about taking part in the rehabilitation. The possibility of reducing the sensation of breathlessness and regaining the ability to do things, such as play with their grandchildren, were motivators to participating.

Conclusion

A model is proposed where patients who feel a loss of control as their disease advances may find that pulmonary rehabilitation offers them the opportunity to regain control. Acknowledging patients'' fears and framing pulmonary rehabilitation as a way of ‘regaining control’ may improve patient uptake.     

Exception reporting in the Quality and Outcomes Framework: views of practice staff �C a qualitative study

Background

Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a ‘gaming’ mechanism.

Aim

To explore GP and practice staff views and experiences of exception reporting in the QOF.

Design of study

Qualitative semi-structured interviews.

Setting

Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.

Method

Semi-structured interviews, analysed using open explorative thematic coding.

Results

Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an ‘exception to the rule’ that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by ‘other’ practices. Only two GPs admitted to occasional inappropriate exception reporting.

Conclusion

Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism.     

Novice to Expert Practice via Postprofessional Athletic Training Education: A Grounded Theory

Objective:

To discover the theoretic constructs that confirm, disconfirm, or extend the principles and their applications appropriate for National Athletic Trainers'' Association (NATA)–accredited postprofessional athletic training education programs.

Design:

Interviews at the 2003 NATA Annual Meeting & Clinical Symposia.

Setting:

Qualitative study using grounded theory procedures.

Patients and Other Participants:

Thirteen interviews were conducted with postprofessional graduates. Participants were purposefully selected based on theoretic sampling and availability.

Data Collection and Analysis:

The transcribed interviews were analyzed using open coding, axial coding, and selective coding procedures. Member checks, reflective journaling, and triangulation were used to ensure trustworthiness.

Results:

The participants'' comments confirmed and extended the current principles of postprofessional athletic training education programs and offered additional suggestions for more effective practical applications.

Conclusions:

The emergence of this central category of novice to expert practice is a paramount finding. The tightly woven fabric of the 10 processes, when interlaced with one another, provides a strong tapestry supporting novice to expert practice via postprofessional athletic training education. The emergence of this theoretic position pushes postprofessional graduate athletic training education forward to the future for further investigation into the theoretic constructs of novice to expert practice.     

The Quality and Outcomes Framework and self-management dialogue in primary care consultations: a qualitative study

Background

Two key elements to improve the quality of care for people with long-term conditions in primary care are improved clinical information systems to support delivery of evidence-based care, and enhanced self-management support. Although both elements are viewed as necessary, their interaction is not well understood.

Aim

To explore the use of computer-based ‘disease management’ templates and their relevance to self-management dialogue within clinical encounters.

Design and setting

Qualitative study of general practices located in three primary care trusts in the north of England.

Method

A qualitative mixed methods study was conducted that included comparative analysis of (1) observations of general practice consultations (n = 86); and (2) interviews with health professionals in general practice (n = 17).

Results

The analysis suggested that use of the computer templates reinforced a checklist approach to consultations, which included professionals working through several self-management topics framed as discrete behaviours. As a consequence, conversation tended to become focused on the maintenance of the professional-patient relationship at the expense of expansion in self-management dialogue. The computer templates also shaped how patient-initiated self-management dialogue was managed when it arose, with a shift towards discussion around medical agendas.

Conclusion

In order to enhance the management of long-term conditions in primary care, the design and implementation of clinical information systems to improve evidence-based care need to take into account their potential impact on supporting self-management.     

GPs' views in five European countries of interventions to promote prudent antibiotic use

Background

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context.

Aim

To explore GPs'' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries.

Design and setting

Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK.

Method

Fifty-two semi-structured interviews explored GPs'' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis.

Results

Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing.

Conclusion

The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.     

��I didn't want her to panic��: unvoiced patient agendas in primary care consultations when consulting about antidepressants

Background

Patient participation in primary care treatment decisions has been much debated. There has been little attention to patients'' contributions to primary care consultations over a period of time, when consulting about depression and its treatment with antidepressants.

Aim

To explore: (1) what issues remain unsaid during a primary care consultation for depression but are later raised by the patient as important during a research interview; (2) patients'' reasons for non-disclosure; (3) whether unvoiced agendas are later voiced; and (4) the nature of the GP–patient relationship in which unvoiced agendas occur.

Design of study

Qualitative interview study.

Setting

Primary health care.

Method

Patients were recruited through six general practices in the south west of England. Qualitative interviews were carried out with 10 ‘pairs’ of GPs and patients who presented with a new or first episode of moderate to severe depression and were prescribed antidepressants. Follow-up patient interviews were conducted at 3 and 6 months. Throughout the 6-month period, patients were invited to record subsequent consultations (with GPs'' consent), using a patient-held tape recorder.

Results

Twenty-three unvoiced agendas were revealed, often within decision-making relationships that were viewed in positive terms by patients. Unvoiced agendas included: a preference for immediate treatment, a preference to increase dosage, and the return or worsening of suicidal thoughts. In some cases, patients were concerned that they were ‘letting the GP down’ by not being able to report feeling better.

Conclusion

Unvoiced agendas are not necessarily an indication that ‘shared decision making’ is absent but may in some cases represent patients'' attempts to ‘protect’ their GPs.     

Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study

Background

Staying in work may benefit patients with chronic pain, but can be difficult for GPs to negotiate with patients and their employers. The new fit note is designed to help this process, but little is known of how it is operating.

Aim

To explore GPs'' views on the fit note, with particular reference to sickness certification for patients with chronic pain.

Design and setting

Qualitative study using semi-structured interviews in eight primary care trusts in south-west England.

Method

In-depth interviews with 13 GPs.

Results

GPs reported that the rationale behind the fit note is sound and that it may help patients with chronic pain to return to work earlier. However, GPs also reported barriers to successful fit note use, including the need to preserve doctor–patient relationships, inconsistent engagement from employers, GPs'' lack of specialist occupational health knowledge, issues with fit note training, and whether a new form can achieve cultural shift.

Conclusion

While doctors agree that good work improves health outcomes, they do not think that fit notes will greatly alter sickness-certification rates without more concerted initiatives to manage the tripartite negotiation between doctor, patient, and employer.     

Exploring patients' reasons for declining contact in a cognitive behavioural therapy randomised controlled trial in primary care

Background

The difficulties of recruiting individuals into mental health trials are well documented. Few studies have collected information from those declining to take part in research, in order to understand the reasons behind this decision.

Aim

To explore patients'' reasons for declining to be contacted about a study of the effectiveness of cognitive behavioural therapy as a treatment for depression.

Design and setting

Questionnaire and telephone interview in general practices in England and Scotland.

Method

Patients completed a short questionnaire about their reasons for not taking part in research. Semi-structured telephone interviews were conducted with a purposive sample to further explore reasons for declining.

Results

Of 4552 patients responding to an initial invitation to participate in research involving a talking therapy, 1642 (36%) declined contact. The most commonly selected reasons for declining were that patients did not want to take part in a research study (n = 951) and/or did not want to have a talking therapy (n = 688) (more than one response was possible). Of the decliners, 451 patients agreed to an interview about why they declined. Telephone interviews were completed with 25 patients. Qualitative analysis of the interview data indicated four main themes regarding reasons for non-participation: previous counselling experiences, negative feelings about the therapeutic encounter, perceived ineligibility, and misunderstandings about the research.

Conclusion

Collecting information about those who decline to take part in research provides information on the acceptability of the treatment being studied. It can also highlight concerns and misconceptions about the intervention and research, which can be addressed by researchers or recruiting GPs. This may improve recruitment to studies and thus ultimately increase the evidence base.     

Understanding of family medicine in Africa: a qualitative study of leaders’ views

Background

The World Health Organization encourages comprehensive primary care within an ongoing personalised relationship, including family physicians in the primary healthcare team, but family medicine is new in Africa, with doctors mostly being hospital based. African family physicians are trying to define family medicine in Africa, however, there is little clarity on the views of African country leadership and their understanding of family medicine and its place in Africa.

Aim

To understand leaders’ views on family medicine in Africa.

Design and setting

Qualitative study with in-depth interviews in nine sub-Saharan African countries.

Method

Key academic and government leaders were purposively selected. In-depth interviews were conducted using an interview guide, and thematically analysed.

Results

Twenty-seven interviews were conducted with government and academic leaders. Responders saw considerable benefits but also had concerns regarding family medicine in Africa. The benefits mentioned were: having a clinically skilled all-rounder at the district hospital; mentoring team-based care in the community; a strong role in leadership and even management in the district healthcare system; and developing a holistic practice of medicine. The concerns were that family medicine is: unknown or poorly understood by broader leadership; poorly recognised by officials; and struggling with policy ambivalence, requiring policy advocacy championed by family medicine itself.

Conclusion

The strong district-level clinical and leadership expectations of family physicians are consistent with African research and consensus. However, leaders’ understanding of family medicine is couched in terms of specialties and hospital care. African family physicians should be concerned by high expectations without adequate human resource and implementation policies.     

Assessing physical activity in general practice: a disconnect between clinical practice and public health?

Background

GPs comply poorly to public health recommendations to routinely assess their patients'' physical activity. The reasons for this disconnect between recommended practice and GPs'' actual practice are unclear.

Aim

To investigate GPs'' perceptions of assessing physical activity, and to explore how GPs assess their patients'' physical activity.

Design of the study

Qualitative study.

Setting

General practice.

Method

Semi-structured interviews were performed with 15 randomly selected southern Tasmanian GPs, with stratification to include GPs with a range of demographic characteristics. Each interview was recorded, transcribed in full, and analysed using an iterative thematic approach to identify major themes.

Results

GPs recognised the importance of assessing physical activity, but rather than assessing every patient, they target at-risk patients and those with conditions likely to benefit from increased physical activity. Depth of assessment and GPs'' definition of sufficient physical activity varied according to the clinical and social context of each patient. Major barriers were the time needed to perform an adequate assessment and lack of time to deal with physical inactivity in patients once it was identified.

Conclusion

GPs'' assessment of physical activity is a complex and highly individualised process that cannot be divorced from the issue of managing physical inactivity once it is identified. Expectations that GPs will assess physical activity levels in all their patients are unlikely to be met. This must be taken into account when developing strategies to improve physical activity assessment in general practice, and should be considered in policy decisions about approaches to take to improve physical activity levels at a population level.