Factors leading to overutilisation of hospital pathology testing: the junior doctor's perspective.

Objective Pathology overutilisation is a significant issue affecting the quality and cost of health care. Because junior medical officers (JMOs) order most pathology tests in the hospital setting, the aim of the present study was to identify the main reasons for hospital pathology overutilisation from the perspective of the JMO. Methods A qualitative method, using focus group methodology, was undertaken. Sixteen JMOs from two hospitals participated in three focus groups. Data were analysed using thematic analysis. Results Three major themes contributed to overutilisation: the real and perceived expectations of senior colleagues, the level of JMO clinical experience and strategies to manage JMO workload around clinical systems. Within these themes, 12 subthemes were identified. Conclusions Overutilisation of hospital pathology testing occurs when there are high social costs to JMOs for underordering, with little cost for overordering. Interventions should restore this balance through reframing overutilisation as both a costly and potentially harmful activity, promoting a supportive culture with regular senior guidance, and addressing clinical systems in which missed tests create an excessive workload. What is known about the topic? Mean overutilisation rates of pathology testing are reported to be as high as 44%. Although numerous studies have reported successful efforts to decrease hospital pathology overutilisation, no primary research was identified that examined the JMO perspective on this subject. What does this paper add? Clinical need is not the primary factor guiding the pathology-ordering decisions of junior practitioners; rather, medical team culture, limited JMO experience and systems factors have a significant role. What are the implications for practitioners? The social and behavioural determinants of pathology ordering must be considered to achieve appropriate pathology test utilisation. These include senior medical officer engagement, the guidance of JMOs and clinical workflows.

Reflection on observation: A qualitative study using practice development methods to explore the experience of being a hand hygiene auditor in Australia.

BACKGROUND: Within the Australian public health care system, an observation model is used to assess hand hygiene practice in health care workers, culminating in a publicly available healthcare service performance indicator. The intent of this study was for the results to inform the development of a strategy to support individual auditors and local sustainability of the hand hygiene auditing program. METHOD: This qualitative study used a values clarification tool to gain an understanding of the experiences of hand hygiene auditors. The methodology involved qualitative interpretation of focus group discussions to identify the enablers and barriers to successful performance of the auditors' role. RESULTS: Twenty-five participants identified congruous themes of the need for peer and managerial support, improved communication and feedback, and consideration for succession planning. There was consistency in the participants' most frequently identified significant barriers in undertaking the role. CONCLUSION: Hand hygiene auditors take pride in their role and work toward the goal of reducing health care-associated infections by having a part to play in improving hand hygiene practices of all staff members. Important themes, barriers, and enablers were identified in this study. This research will be of interest nationally and globally, considering the dearth of published information on the experience of hand hygiene auditors. This study provides evidence of the need to support individual hand hygiene auditors.

Investigating the role of Clinical Nurse Consultants in one health district from multiple stakeholder perspectives: a cooperative inquiry.

BACKGROUND: The impetus for this research came from a group of 11 Clinical Nurse Consultants (CNCs) within a health service in NSW, Australia, who wanted to investigate the CNC role from multiple stakeholder perspectives. With support from academic researchers, the CNCs designed and implemented the study. OBJECTIVES: The aim of this research project was to investigate the role of the CNC from the multiple perspectives of CNCs and other stakeholders who work with CNCs in the Health District. DESIGN: This was a co-operative inquiry that utilised qualitative descriptive research approach. METHODS: Co-operative inquiry methods enabled 11 CNCs to work as co-researchers and to conduct the investigation. The co-researchers implemented a qualitative descriptive design for the research and used interviews (7) and focus groups (16) with CNC stakeholders (n = 103) to gather sufficient data to investigate the role of the CNC in the organisation. Thematic analysis was undertaken to obtain the results. FINDINGS: The CNC role is invaluable to all stakeholders and it was seen as the "glue" which holds teams together. Stakeholder expectations of the CNC role were multiple and generally agreed. Five themes derived from the data are reported as "clinical leadership as core", "making a direct difference to patient care", "service development as an outcome", "role breadth or narrowness and boundaries", and "career development". There was clear appreciation of the work that CNCs do in their roles, and the part that the CNC role plays in achieving quality health outcomes. CONCLUSION: The role of the CNC is complex and the CNCs themselves often negotiate these complexities to ensure beneficial outcomes for the patient and organisation. For the wider audience this study has given further insights into the role of these nurses and the perspectives of those with whom they work.

Nurses' discharge planning and risk assessment: behaviours, understanding and barriers.

AIMS AND OBJECTIVES: To examine nurses' discharge planning understanding, adherence and barriers. BACKGROUND: Discharge planning commenced at admission by nurses plays a key role in improving patient outcomes,but policies in place to maintain effective discharge planning are often not followed by nurses. DESIGN: This is a descriptive study. METHODS: Nurses (n = 64) working in acute wards undertook a self-report survey of discharge planning understanding, adherence and barriers. RESULTS: Adherence to discharge planning policy is low (23%), despite a general awareness of the reduced quality of patient outcomes that may result. The most common barriers to discharge planning identified were lack of time and patient factors. Further contradictions occurred in that nurses understood the importance of discharge planning, yet did not comply with discharge planning policies. CONCLUSIONS: Nurses require additional encouragement and support in complying with discharge planning policies, and discharge planning policies should be adapted to better handle unpredictable illness trajectories. RELEVANCE TO CLINICAL PRACTICE: Completion of discharge planning is important for the safe transition of patients from one care setting to the next. Before a systematic approach to discharge planning can be implemented, a greater understanding of nurses' discharge planning practice in acute care wards is required. Greater incorporation of discharge planning activities into nurses' daily practice may also occur if nurses are involved in the development and implementation of the discharge processes and then provided with education and regular feedback on monthly audit results.

Substance users' perspective of pain management in the acute care environment.

The aim of this exploratory study was to examine substance users' perspectives towards their acute pain management in the acute hospital setting. Barriers to optimal pain management in the substance user population include: altered physiologic responses to analgesia; cultural values; and health professionals' perceptions of drug-seeking behaviours.

Early completion of the discharge risk screen by nurses in acute care wards.

The aim of this study was to investigate nurses' compliance with discharge risk screening (DRS) policy, the accuracy of this screening, and factors associated with its completion. An audit of 99 acute care patients' medical records revealed that compliance with DRS completion was very low (24%), although accuracy was high, and the 2 factors associated with completion of the DRS were patient diagnosis and day of week admitted. Further research on nurses' attitudes, beliefs, and perceived barriers to DRS is needed as a foundation to increase the use of the tool.