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Cummins NM, Barry LA, Garavan C, Devlin C, Corey G, Cummins F, Ryan D, Wallace E, Deasy C, Flynn M, McCarthy G, Galvin R. Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland. BMC Health Serv Res 2023; 23:1003. [PMID: 37723478 PMCID: PMC10506270 DOI: 10.1186/s12913-023-09760-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 06/28/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland. METHODS The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels. RESULTS The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites. CONCLUSIONS Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.
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Affiliation(s)
- Niamh M Cummins
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland.
- Department of Paramedicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Louise A Barry
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Carrie Garavan
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Collette Devlin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Gillian Corey
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Fergal Cummins
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Emma Wallace
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Conor Deasy
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Mary Flynn
- Emergency Medicine Programme, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gerard McCarthy
- Emergency Department, Cork University Hospital, Cork, Ireland
- Emergency Medicine Programme, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rose Galvin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
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Viktorsson L, Törnvall E, Falk M, Wåhlin I, Yngman-Uhlin P. Young adults’ needs when seeking first-line healthcare: A grounded theory design. PLoS One 2022; 17:e0263963. [PMID: 35167607 PMCID: PMC8846516 DOI: 10.1371/journal.pone.0263963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 01/31/2022] [Indexed: 11/19/2022] Open
Abstract
Background Healthcare outpatient visits have increased in recent years, and young adults are often given as an explanatory factor for many avoidable visits. Objective The objective of this study was to explore how young adults perceive seeking first-line healthcare. Design and setting The study utilized a grounded theory design with data collection at primary healthcare centres and emergency departments in southeast Sweden. Method Data were collected during individual interviews and patient observations with subsequent interviews during the years 2017–2018. The analysis was performed using grounded theory. Results The main concern when young adults are seeking healthcare is that their worries are taken seriously. It is a four-part process: becoming aware of, verifying, communicating, and receiving an opinion about one’s symptoms. The process includes external factors, clarity of symptoms, behavioural approaches, healthcare know-how, enabling self-management, and prior healthcare experience(s). When communicating symptoms, the clearer the symptoms, the less there needs to be communicated. When symptoms are unclear, the importance of different behavioural approaches and healthcare know-how increases. When receiving a medical opinion about symptoms, young adults want to learn how to self-manage their symptoms. Depending on previous healthcare experience, the healthcare visit can either harm or help the patient in their healthcare-seeking process. Conclusion This study reflects several insights in the healthcare-seeking process from a young adult perspective. Based on the results, we suggest that healthcare providers focus on the final step in the healthcare-seeking process when giving their medical opinion about symptoms. Having extra minutes to give support for future self-care regardless of diagnosis could increase positive healthcare experiences and increase future self-care among young adults.
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Affiliation(s)
- Lisa Viktorsson
- Unit for Research and Development, and Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
- * E-mail:
| | - Eva Törnvall
- Management Department in Region Östergötland, and Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | - Magnus Falk
- Primary Health Care Centre Kärna, and Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | - Ingrid Wåhlin
- Research Section, Region Kalmar County, Kalmar, Sweden
- School of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Pia Yngman-Uhlin
- Unit for Research and Development, and Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
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Viktorsson L, Törnvall E, Falk M, Wåhlin I, Yngman-Uhlin P. Young adults' healthcare utilisation and healthcare needs: Perceptions and experiences of healthcare providers. Health Expect 2021; 25:245-253. [PMID: 34624154 PMCID: PMC8849221 DOI: 10.1111/hex.13370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background Health care in many countries entails long waiting times. Avoidable healthcare visits by young adults have been identified as one probable cause. Objective The aim of this study was to explore healthcare providers' experiences and opinions about young adults' healthcare utilisation in the first line of care. Method This study used latent qualitative conventional content analysis with focus groups. Four healthcare units participated: two primary healthcare centres and two emergency departments. This study included 36 participants, with 4–7 participants in each group, and a total of 21 registered nurses and 15 doctors. All interviews followed an interview guide. Results Data were divided into eight categories, which all contained the implicit theme of distribution of responsibility between the healthcare provider and the healthcare user. Young adult healthcare consumers were considered to be highly influenced by external resources, often greatly concerned with small/vague symptoms they had difficulty explaining and unable to wait with. The healthcare provider's role was much perceived as being part of a healthcare structure—a large organisation with multiple units—and having to meet different priorities while also considering ethical dilemmas, though feeling supported by experience. Conclusion Healthcare personnel view young adults as transferring too much of the responsibility of staying healthy to the healthcare system. The results of this study show that the discussion of young adults unnecessarily seeking health care includes an underlying discussion of scarcity of resources. Patient or Public Contribution The conduct of this study is based on interviews with young adult patients about their experiences of seeking healthcare.
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Affiliation(s)
- Lisa Viktorsson
- Research and Development Unit in Region Östergötland, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Eva Törnvall
- Department of Health, Medicine and Caring Sciences, Management Department in Region Östergötland, Linköping University, Linköping, Sweden
| | - Magnus Falk
- Department of Health, Medicine and Caring Sciences, Primary Health Care Centre Kärna, Linköping University, Linköping, Sweden
| | - Ingrid Wåhlin
- Research Section, Region Kalmar County, Kalmar, Sweden.,Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
| | - Pia Yngman-Uhlin
- Research and Development Unit in Region Östergötland, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Truter P, Edgar D, Mountain D, Bulsara C. An emergency department optimized protocol for qualitative research to investigate care seeking by patients with non-urgent conditions. Nurs Open 2021; 8:628-635. [PMID: 33570278 PMCID: PMC7877135 DOI: 10.1002/nop2.667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/09/2020] [Accepted: 10/02/2020] [Indexed: 11/11/2022] Open
Abstract
AIM To describe a tailored qualitative research methodology for exploring the complex interaction of factors driving non-urgent care seeking in the emergency department. DESIGN Qualitative descriptive design with a literature informed semi-structured interview and analysis structure. Triangulation with the State-Trait Anxiety Inventory allows expedited exploration of biopsychosocial factors. Consolidated criteria for reporting qualitative research requirements integrated. METHODS With a short 10- to 15-min interview and a low-inference analysis process, this methodology offers a structured way to explore the "go to ED" decision, to understand the patient perspective on their healthcare needs and feed into the development of suitable local services that meet patient healthcare needs. RESULTS This methodology offers a structured way for clinician-researchers to explore the factors that influence patients seeking care in the emergency departments for non-urgent conditions that are specific to their local health service environment. The described methodology is accessible to novice qualitative researchers and includes the semi-structured interview, coding and analysis frameworks.
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Affiliation(s)
- Piers Truter
- School of PhysiotherapyUniversity of Notre Dame AustraliaFremantleWAAustralia
- Emergency DepartmentFiona Stanley HospitalMurdochWAAustralia
- SJOG Midland Public and Private HospitalMidlandWAAustralia
| | - Dale Edgar
- School of PhysiotherapyUniversity of Notre Dame AustraliaFremantleWAAustralia
- Fiona Wood FoundationPerthWAAustralia
| | - David Mountain
- Emergency DepartmentSir Charles Gairdner HospitalNedlandsWAAustralia
- University of Western AustraliaNedlandsWAAustralia
| | - Caroline Bulsara
- School of Nursing and MidwiferyUniversity of Notre Dame AustraliaFremantleWAAustralia
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Ingvarsson S, Augustsson H, Hasson H, Nilsen P, von Thiele Schwarz U, von Knorring M. Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians. Implement Sci 2020; 15:93. [PMID: 33087154 PMCID: PMC7579796 DOI: 10.1186/s13012-020-01052-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
Background The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. Methods Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. Results Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. Conclusions Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
| | - Mia von Knorring
- Leadership in Healthcare and Academia Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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Martin A, Manley K. Developing an integrated career and competence framework for a whole systems approach to urgent and emergency care delivery. Int Emerg Nurs 2020; 48:100784. [DOI: 10.1016/j.ienj.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/21/2019] [Accepted: 06/16/2019] [Indexed: 10/26/2022]
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Power B, Bury G, Ryan J. Stakeholder opinion on the proposal to introduce 'treat and referral' into the Irish emergency medical service. BMC Emerg Med 2019; 19:81. [PMID: 31864305 PMCID: PMC6925841 DOI: 10.1186/s12873-019-0295-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/09/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call, regardless of acuity, to an emergency department (ED). A proposal to introduce Treat and Referral, an established care pathway in some jurisdictions, is under active consideration in Ireland. This will present a significant change. Stakeholder engagement is recognised as an essential component of management of such change. This study has conducted a multicentre, cross-sectional survey exploring opinions on the introduction of Treat and Referral among key Irish stakeholders; consultants in emergency medicine, paramedics and advanced paramedics. METHODS Public-sector consultants in emergency medicine (EM), registered paramedics and advanced paramedics, in Ireland at the time of the study, were invited to complete an on-line survey. RESULTS A significant finding was that 90% of both cohorts (EM consultants and registered paramedic practitioners) support written after-care instructions being given to referred patients, that > 83% agree that Treat and Referral will reduce unnecessary ambulance journeys and that 70% are in favour of their own family member being offered Treat and Referral. Consensus was reached between respondents that Treat and Referral would improve care and increase clinical judgement of practitioners. Differences were identified in relation to the increased availability of ambulances locally, that only adults should be included, and that research was required to extend Treat and Referral beyond the index conditions. There was no consensus on whether general practitioners (GPs) should be directly informed. CONCLUSIONS This study identified that the Irish healthcare practitioners surveyed are supportive of the introduction of Treat and Referral into Ireland. It also affords healthcare policymakers the opportunity to address the concerns raised, in particular the clinical level which will be targeted for inclusion in this extended scope of practice.
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Affiliation(s)
- Brian Power
- Pre-Hospital Emergency Care Council, Beech House, Millennium Pk, Naas, Co., Kildare, W91 TK7N, Ireland.
| | - Gerard Bury
- Centre for Emergency Medical Science, University College Dublin, Dublin, Ireland
| | - John Ryan
- Emergency Department, St Vincent's University Hospital, Dublin, Ireland
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Turnbull J, Pope C, Prichard J, McKenna G, Rogers A. A conceptual model of urgent care sense-making and help-seeking: a qualitative interview study of urgent care users in England. BMC Health Serv Res 2019; 19:481. [PMID: 31299969 PMCID: PMC6624886 DOI: 10.1186/s12913-019-4332-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/08/2019] [Indexed: 11/16/2022] Open
Abstract
Background Theoretical models have sought to comprehend and conceptualise how people seek help from health professionals but it is unclear if such models apply to urgent care. Much previous research does not explain the complex interactions that influence how people make sense of urgent care and how this shapes service use. This paper aims to conceptualise the complexity of sense-making and help-seeking behaviour in peoples’ everyday evaluations of when and how to access modern urgent care provision. Methods This study comprised longitudinal semi-structured interviews undertaken in the South of England. We purposively sampled participants 75+, 18–26 years, and from East/Central Europe (sub-sample of 41 received a second interview at + 6–12 months). Framework analysis was thematic and comparative. Results The amount and nature of the effort (work) undertaken to make sense of urgent care was an overarching theme of the analysis. We distinguished three distinct types of work: illness work, moral work and navigation work. These take place at an individual level but are also shared or delegated across social networks and shaped by social context and time. We have developed a conceptual model that shows how people make sense of urgent care through work which then influences help-seeking decisions and action. Conclusions There are important intersections between individual work and their social networks, further shaped by social context and time, to influence help-seeking. Recognising different, hidden or additional work for some groups may help design and configure services to support patient work in understanding and navigating urgent care. Electronic supplementary material The online version of this article (10.1186/s12913-019-4332-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanne Turnbull
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
| | - Catherine Pope
- NIHR CLAHRC Wessex, University of Southampton, Southampton, SO17 1BJ, UK
| | - Jane Prichard
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, SO17 1BJ, UK
| | - Gemma McKenna
- NIHR CLAHRC Wessex, University of Southampton, Southampton, SO17 1BJ, UK
| | - Anne Rogers
- NIHR CLAHRC Wessex, University of Southampton, Southampton, SO17 1BJ, UK
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Turnbull J, McKenna G, Prichard J, Rogers A, Crouch R, Lennon A, Pope C. Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundPolicy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.ObjectivesTo describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.DesignMixed-methods sequential design.SettingFour counties in southern England coterminous with a NHS 111 provider area.MethodsA literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.FindingsThe literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).LimitationsThe sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.ConclusionsMuch of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.Future workA whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.Study registrationThis study is registered as UKCRN 32207.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanne Turnbull
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Gemma McKenna
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jane Prichard
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Anne Rogers
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, University of Southampton, Southampton, UK
| | - Robert Crouch
- Emergency Department, University Hospital Southampton NHS Foundation Trust (UHS), Southampton, UK
| | - Andrew Lennon
- Southern Headquarters, South Central Ambulance Service NHS Foundation Trust (SCAS), Winchester, UK
| | - Catherine Pope
- School of Health Sciences, University of Southampton, Southampton, UK
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Koce F, Randhawa G, Ochieng B. Understanding healthcare self-referral in Nigeria from the service users' perspective: a qualitative study of Niger state. BMC Health Serv Res 2019; 19:209. [PMID: 30940134 PMCID: PMC6444603 DOI: 10.1186/s12913-019-4046-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/27/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The by-pass of the primary level of care to the referral facilities has continued to raise concerns for the healthcare delivery system. About 60-90% of patients in Nigeria are reported to self-refer to a referral level of care. Thus, this study sought to identify the factors that influence service-users' decision to self-refer to the secondary healthcare facilities in Nigeria by exploring the perceptions and experiences of the service-users. METHODS Twenty-four self-referred service-users were interviewed from three selected secondary healthcare facilities (general hospitals) in Niger state, Nigeria. The interviews were tape-recorded, each lasting 20 min on average. This was subsequently transcribed and framework analysis was employed for the analysis. RESULTS Various reasons were identified to have resulted in the bypass of the primary healthcare facilities in favour of the secondary level of care. The identified themes were organised based on the predisposing, enabling and need component of Andersen's model. These themes included: patients understanding of the healthcare delivery system; perceptions about the healthcare providers; perceptions about healthcare equipment/ facilities; advice from relatives and friends; service-users' expectations; access to healthcare facilities; regulations/ policies; medical symptoms; perceptions of severity of medical symptoms. CONCLUSIONS The findings from this study call for an evaluation of the current healthcare referral system, particularly in developing settings like Nigeria and consequently the need for developing a contextual model as applicable to individual settings. Therefore, a multifaceted approach is needed to address the current concerns to ensure patients utilise the appropriate level of care. This will ensure the primary healthcare facilities are not undermined and allow the referral levels of care to live up to their mandate.
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Affiliation(s)
- Francis Koce
- Institute for Health Research,University of Bedfordshire, Putteridge Bury Campus, Hitchin Road, Luton, LU2 8LE UK
| | - Gurch Randhawa
- Institute for Health Research,University of Bedfordshire, Putteridge Bury Campus, Hitchin Road, Luton, LU2 8LE UK
| | - Bertha Ochieng
- Faculty of Health & Life Sciences, De Montfort University, Edith Murphy House, The Gateway. Leicester, Leicester, LE1 9BH UK
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Oslislo S, Heintze C, Schmiedhofer M, Möckel M, Schenk L, Holzinger F. How to decide adequately? Qualitative study of GPs' view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany. BMJ Open 2019; 9:e026786. [PMID: 30944138 PMCID: PMC6500203 DOI: 10.1136/bmjopen-2018-026786] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals. DESIGN Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis. SETTING GP practices in Berlin, Germany. PARTICIPANTS 15 GPs (female/male: 9/6; mean age 53.6 years). RESULTS The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy. CONCLUSIONS Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals. TRIAL REGISTRATION NUMBER DRKS00011930.
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Affiliation(s)
- Sarah Oslislo
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Martina Schmiedhofer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Emergency Medicine, Berlin, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Emergency Medicine, Berlin, Germany
- James Cook University, The College of Public Health, Medical and Veterinary Sciences, Townsville, Queensland, Australia
| | - Liane Schenk
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Felix Holzinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
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How do emergency nurse practitioners experience managing acutely unwell patients in minor injury units? An Interpretative Phenomenological Analysis. Int Emerg Nurs 2019; 43:99-105. [DOI: 10.1016/j.ienj.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 10/18/2018] [Accepted: 11/22/2018] [Indexed: 11/17/2022]
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Wilson DM, Devkota R. A study of nurse-based Injury Units in Ireland: An emergency care development for consideration worldwide. Int J Health Plann Manage 2018; 34:e72-e84. [PMID: 30408239 DOI: 10.1002/hpm.2700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 11/06/2022] Open
Abstract
The aim of this 2018 research study was to determine why nurse-based Injury Units were developed in Ireland and how they function in the Irish healthcare system, including what they contribute in relation to addressing the healthcare needs of Irish citizens. A document review was completed and interviews of nurse practitioners and physicians working in Irish Emergency Rooms (ERs) and Injury Units, as well as nurse managers with responsibility for Injury Units and health service executives who helped design Injury Units. A new model of emergency care was needed 20 years ago when two issues were apparent. The first was concern over unsafe care in small ERs as a result of low patient volumes and staff not having ER expertise. The second issue was long waits for ER care. Considerable opportunity for change was present, including financial imperatives and nurse, physician, and political leaders who were together ready to design and move a new-to-Ireland ER services model and nurse practitioner education forward. The Injury Unit model is based on nurse practitioners providing a defined set of services to nonurgent patients in daytime hours. This model was pilot tested and is being implemented across Ireland after it was determined that quality services were being rapidly and safely provided. Nurse practitioner education was also initiated and is now in expansion mode to gain 700 more nurse practitioners by the year 2021 over the current 240.
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Affiliation(s)
- Donna M Wilson
- Faculty of Nursing, University of Alberta, Edmonton, Canada.,Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland.,Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rashmi Devkota
- Faculty of Nursing, University of Alberta, Edmonton, Canada
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Owens C, Hansford L, Sharkey S, Ford T. Needs and fears of young people presenting at accident and emergency department following an act of self-harm: secondary analysis of qualitative data. Br J Psychiatry 2016; 208:286-91. [PMID: 26450583 PMCID: PMC4807637 DOI: 10.1192/bjp.bp.113.141242] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 01/15/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Presentation at an accident and emergency (A&E) department is a key opportunity to engage with a young person who self-harms. The needs of this vulnerable group and their fears about presenting to healthcare services, including A&E, are poorly understood. AIMS To examine young people's perceptions of A&E treatment following self-harm and their views on what constitutes a positive clinical encounter. METHOD Secondary analysis of qualitative data from an experimental online discussion forum. Threads selected for secondary analysis represent the views of 31 young people aged 16-25 with experience of self-harm. RESULTS Participants reported avoiding A&E whenever possible, based on their own and others' previous poor experiences. When forced to seek emergency care, they did so with feelings of shame and unworthiness. These feelings were reinforced when they received what they perceived as punitive treatment from A&E staff, perpetuating a cycle of shame, avoidance and further self-harm. Positive encounters were those in which they received 'treatment as usual', i.e. non-discriminatory care, delivered with kindness, which had the potential to challenge negative self-evaluation and break the cycle. CONCLUSIONS The clinical needs of young people who self-harm continue to demand urgent attention. Further hypothesis testing and trials of different models of care delivery for this vulnerable group are warranted.
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Affiliation(s)
- Christabel Owens
- Christabel Owens, PhD, Lorraine Hansford, MSc, University of Exeter Medical School, Exeter, UK; Siobhan Sharkey, PhD, RMN, Plymouth University Peninsula School of Medicine & Dentistry, Plymouth, UK; Tamsin Ford, PhD, MRCPsych, University of Exeter Medical School, Exeter, UK
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Greenfield G, Ignatowicz A, Gnani S, Bucktowonsing M, Ladbrooke T, Millington H, Car J, Majeed A. Staff perceptions on patient motives for attending GP-led urgent care centres in London: a qualitative study. BMJ Open 2016; 6:e007683. [PMID: 26769775 PMCID: PMC4735149 DOI: 10.1136/bmjopen-2015-007683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES General practitioner (GP)-led urgent care centres were established to meet the growing demand for urgent care. Staff members working in such centres are central in influencing patients' choices about which services they use, but little is known about staff perceptions of patients' motives for attending urgent care. We hence aimed to explore their perceptions of patients' motives for attending such centres. DESIGN A phenomenological, qualitative study, including semistructured interviews. The interviews were analysed using thematic content analysis. SETTING 2 GP-led urgent care centres in 2 academic hospitals in London. PARTICIPANTS 15 staff members working at the centres including 8 GPs, 5 emergency nurse practitioners and 2 receptionists. RESULTS We identified 4 main themes: 'Confusion about choices', 'As if increase of appetite had grown; By what it fed on', 'Overt reasons, covert motives' and 'A question of legitimacy'. The participants thought that the centres introduce convenient and fast access for patients. So convenient, that an increasing number of patients use them as a regular alternative to their community GP. The participants perceived that patients attend the centres because they are anxious about their symptoms and view them as serious, cannot get an appointment with their GP quickly and conveniently, are dissatisfied with the GP, or lack self-care skills. Staff members perceived some motives as legitimate (an acute health need and difficulties in getting an appointment), and others as less legitimate (convenience, minor illness, and seeking quicker access to hospital facilities). CONCLUSIONS The participants perceived that patients attend urgent care centres because of the convenience of access relative to primary care, as well as sense of acuity and anxiety, lack self-care skills and other reasons. They perceived some motives as more legitimate than others. Attention to unmet needs in primary care can help in promoting balanced access to urgent care.
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Affiliation(s)
- Geva Greenfield
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Agnieszka Ignatowicz
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Shamini Gnani
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | | | - Tim Ladbrooke
- London Central and West Unscheduled Care Collaborative, London, UK
| | - Hugh Millington
- Charing Cross Hospital Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Josip Car
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Turkish health care providers' views on inappropriate use of emergency department: Who, when and why? Int Emerg Nurs 2015; 27:31-6. [PMID: 26749206 DOI: 10.1016/j.ienj.2015.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/03/2015] [Accepted: 11/07/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Inappropriate use of emergency departments is recognized globally as a widespread problem. The study was undertaken to determine the perceptions of emergency department personnel regarding inappropriate use of this department. METHODS The study was undertaken with 124 emergency department employees from six emergency departments in a province of the Eastern Black Sea region of Turkey. Using a questionnaire form designed by the researcher, the data were gathered and analyzed with the chi-square test, numerical and percentage calculations. RESULTS According to the emergency department employees, more than half of emergency department visits were inappropriate with most visits occurring between the hours of 19:01 and 01:00. In order of occurrence, employees also indicated that most inappropriate use concerned requests for prescription renewals, treatment for pain, and upper respiratory tract infections (URTI). According to the employees, patients made inappropriate use of emergency departments in the belief that these provide services for every kind of health problem. Unfortunately, according to the health care workers this misperception of emergency services results in less effective patient care and a decrease in employee motivation. CONCLUSION Health team members thought that inappropriate use of emergency services led to negative outcomes in the quality of care and motivation of the workers. Solutions to minimize inappropriate use of emergency departments need to be developed and put into place.
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Secondary traumatic stress among emergency nurses: a cross-sectional study. Int Emerg Nurs 2015; 23:53-8. [DOI: 10.1016/j.ienj.2014.05.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/15/2014] [Accepted: 05/18/2014] [Indexed: 12/21/2022]
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