Why do general practitioners not refer patients to behaviour-change programmes after preventive health checks? A mixed-method study

Background

This study was embedded in the Check-In randomised controlled trial that investigated the effectiveness of general practice-based preventive health checks on adverse health behaviour and early detection of non-communicable diseases offered to individuals with low socioeconomic positions. Despite successful recruitment of patients, the intervention had no effect. One reason for the lack of effectiveness could be low rates of referral to behaviour-change programmes in the municipality, resulting in a low dose of the intervention delivered. The aim of this study is to examine the referral pattern of the general practitioners and potential barriers to referring eligible patients to these behaviour-change programmes.

Methods

A mixed-method design was used, including patients’ questionnaires, recording sheet from the health checks and semi-structured qualitative interviews with general practitioners. All data used in the study were collected during the time of the intervention. Logistic regressions were used to estimate odds ratios for being eligible and for receiving referrals. The qualitative empirical material was analysed thematically. Emerging themes were grouped, discussed and the material was re-read. The themes were reviewed alongside the analysis of the quantitative material to refine and discuss the themes.

Results

Of the 364 patients, who attended the health check, 165 (45%) were marked as eligible for a referral to behaviour-change programme by their general practitioner and of these, 90 (55%) received referrals. Daily smoking (OR = 3.22; 95% CI:2.01–5.17), high-risk alcohol consumption (OR = 2.66; 95% CI:1.38–5.12), obesity (OR = 2.89; 95% CI:1.61–5.16) and poor lung function (OR = 2.05; 95% CI:1.14–3.70) were all significantly associated with being eligible, but not with receiving referral. Four themes emerged as the main barriers to referring patients to behaviour-change programmes: 1) general practitioners’ responsibility and ownership for their patients, 2) balancing information and accepting a rejection, 3) assessment of the right time for behavioural change and 4) general practitioners’ attitudes towards behaviour-change programmes in the municipality.

Conclusion

We identified important barriers among the general practitioners which influenced whether the patients received referrals to behaviour-change programmes in the municipality and thereby influenced the dose of intervention delivered in Check-In. The findings suggest that an effort is needed to assist the collaboration between general practices and the municipalities’ primary preventive services.

Trial registration

Clinical Trials NCT01979107; October 25, 2013.

Unlocking intuition and expertise: using interpretative phenomenological analysis to explore clinical decision making

BACKGROUND

Clinical decision making is a complex, but important, research area. Decision-making theories have evolved to recognise that, although heuristics and biases can lead to error, expert clinician decision makers can also use intuition to good effect. More research is needed to understand how nurses and other clinicians make sense of complexity and uncertainty.

AIM

This paper discusses the utility of interpretative phenomenological analysis to elucidate clinical decision making, expertise and intuition.

METHODS

A narrative review of published interpretative phenomenological analysis studies exploring clinical decision-making, and discussion of an exemplar study.

RESULTS

A limited number of interpretative phenomenological analysis studies have been published in this area. By seeking out descriptions of real-world decision making, interpretative phenomenological analysis research provides ecologically valid insights into what it is like to make time-critical, high-stakes decisions with limited information.

CONCLUSION

Contributing to the study of complex clinical decision making in combination with other research approaches, interpretative phenomenological analysis research has significant unrealised potential to inform education, assessment and support interventions and the development of clinical guidelines. Future applications could enhance understanding of multi-disciplinary decision-making and the development of expertise and intuition, over time.

Appraising the quality of mixed methods research in nursing: A qualitative case study of nurse researchers' views

While a growing number of works have been published about the use of mixed methods research in nursing, scarce attention has been devoted to the issue of the quality of mixed methods within the discipline. The quality appraisal of mixed methods research poses two problems to nursing science: first, current quality criteria are not nursing-specific and consequently, they might not facilitate the application of mixed methods research findings into nursing practice. Second, criteria were theoretically derived and as such, they might not faithfully account for the decisions that nurse researchers take when appraising mixed methods research studies. This qualitative, within-case study explored the views of nurse researchers about mixed methods research in general and, more specifically, the question of quality in mixed methods research. An international sample of 13 nurse researchers was interviewed via Skype and phone. Thematic analysis revealed that the participants favored universal, cross-disciplinary quality criteria, and not criteria specific to the nursing discipline, and a consensual and standardized approach to appraising the quality of mixed methods research. Recommendations are put forward to strengthen the quality appraisal of mixed methods research studies by nurse researchers, as well as future works on this topic within nursing science.

Patient Numeracy? Don’t Count on It

Low levels of patient numeracy are pervasive, yet patients are expected to use basic math skills to maintain health, avoid ill health, and make important health decisions. This article summarizes what we know about best practices when communicating numeracy-based information to patients. We offer advice to home health nurses faced with challenges of caring for patients with low numeracy and who are responsible for their health and safety that require quantitative reasoning. Comprehending statistical data is difficult and counterintuitive for many people (and experts), and we offer examples of widely misunderstood formats of quantitative information but clarify them in ways that will benefit the practicing home health nurse. We conclude that patients need help understanding and using numbers while nurses need help explaining them.