Rural general practice staff experiences of patient safety incidents and low quality of care in Norway: an interview study.

BACKGROUND AND OBJECTIVES: General practitioners (GPs), nurses and medical secretaries (practice staff) are responsible for the continuous provision of safe care in rural general practice. Little is known about their role in situations where patients were or could have been harmed in a rural setting. Therefore, we sought to investigate rural general practice staff experiences of patient safety incidents and low quality of care. METHODS: Descriptive qualitative interviews using the critical incident technique. Systematic text condensation analysis involving GPs and practice staff in eight rural municipalities in Norway. RESULTS: Sixteen participants (eight GPs, one nurse and seven medical secretaries) with mean work experience of 11.8 years were interviewed for a total of 11.5 hours. We identified three main factors that make rural GP clinics vulnerable to patient safety incidents and low quality of care: use of locums, work overload and rough weather and distance to hospital. There was a wide range of patient safety incidents. The healthcare personnel explained how they used local knowledge about people and context and greater awareness of risk of error in order to prevent these incidents from happening. CONCLUSION: Rural GP clinics that suffer from frequent use of GP locums and work overload are vulnerable to patient safety incidents. Practice staff use various forms of continuity of care to prevent safety incidents from happening; this highlights the strengths but also some major safety concerns in these GP clinics. Staff at these clinics proved to be a resource for patient safety research. PODCAST: An accompanying podcast on patient safety is available as Supplementary Data, in which Martin Bruusgaardf Harbitz and Per Stensland provide insights into the context of this study.

When we go to see the doctor, we all want our diagnosis and treatment to be safe and free from mistakes. Unfortunately, patient harm and low quality of care happen every day in medical practice. This article looks at staff experiences of these mistakes; the staff were general practitioners, nurses and medical secretaries. We show how the use of locum doctors, work overload and long distance to hospital are linked to examples of patient harm. Our findings also show how nurses and medical secretaries may help to prevent harm to patients.

Medical malpractice in Norway: frequency and distribution of disciplinary actions for medical doctors 2011-2018.

BACKGROUND: Physicians who perform unsafe practices and harm patients may be disciplined. In Norway, there are five types of disciplinary action, ranging from a warning for the least serious examples of malpractice to loss of licence for the most serious ones. Disciplinary actions always involve medical malpractice. The aims of this study were to investigate the frequency and distribution of disciplinary actions by the Norwegian Board of Health Supervision for doctors in Norway and to uncover nation-wide patient safety issues. METHODS: We retrospectively investigated all 953 disciplinary actions for doctors given by the Board between 2011 and 2018. We categorized these according to type of action, recipient's profession, organizational factors and geographical location of the recipient. Frequencies, cross tables, rates and linear regression were used for statistical analysis. RESULTS: Rural general practitioners received the most disciplinary actions of all doctors and had their licence revoked or restricted 2.1 times more frequently than urban general practitioners. General practitioners and private specialists received respectively 98.7 and 91.0 disciplinary actions per 1000 doctors. Senior consultants and junior doctors working in hospitals received respectively 17.0 and 6.4 disciplinary actions per 1000 doctors. Eight times more actions were received by primary care doctors than secondary care doctors. Doctors working in primary care were given a warning 10.6 times more often and had their licence revoked or restricted 4.6 times more often than those in secondary care. CONCLUSION: The distribution and frequency of disciplinary actions by the Norwegian Board of Health Supervision clearly varied according to type of health care facility. Private specialists and general practitioners, especially those working in rural clinics, received the most disciplinary actions. These results deserve attention from health policy-makers and warrant further studies to determine the factors that influence medical malpractice. Moreover, the supervisory authorities should assess whether their procedures for reacting to malpractice are efficient and adequate for all types of physicians working in Norway.

Mediators of change in healthcare organisations subject to external assessment: a systematic review with narrative synthesis.

OBJECTIVES: External inspections are widely used to improve the quality of care. The effects of inspections remain unclear and little is known about how they may work. We conducted a narrative synthesis of research literature to identify mediators of change in healthcare organisations subject to external inspections. METHODS: We performed a literature search (1980-January 2020) to identify empirical studies addressing change in healthcare organisations subject to external inspection. Guided by the Consolidated Framework for Implementation Research, we performed a narrative synthesis to identify mediators of change. RESULTS: We included 95 studies. Accreditation was the most frequent type of inspection (n=68), followed by statutory inspections (n=19), and external peer review (n=9). Our findings suggest that the regulatory context in which the inspections take place affect how they are acted on by those being inspected. The way inspections are conducted seem to be critical for how the inspection findings are perceived and followed up. Inspections can engage and involve staff, facilitate leader engagement, improve communication and enable the creation of new networks for reflection on clinical practice. Inspections can contribute to creating an awareness of the inspected organisation's current practice and performance gaps, and a commitment to change. Moreover, they can contribute to facilitating the planning and implementation of change, as well as self-evaluation and the use of data to evaluate performance. CONCLUSIONS: External inspections can affect different mediators of organisational change. The way and to what extent they do depend on a range of factors related to the outer setting, the way inspections are conducted and how they are perceived and acted on by the inspected organisation. To improve the quality of care, the organisational change processes need to involve and impact the way care is delivered to the patients.

Case stories in general practice: a focus group study.

OBJECTIVES: To explore the interactive process of sharing case stories in small-group activity in general practice. DESIGN: Qualitative focus group study. SETTING: Peer-group meetings of doctors attending specialist training or continuous medical education in general practice. PARTICIPANTS: Twenty female and 30 male doctors working in general practice in Norway. RESULTS: The storyline of case presentations included detailed stories with emotional engagement, co-authored by other group members. The stories initiated discussions and reflections concerning patients' and doctors' perspectives, medical ethics as well as clinical problems. The safe atmosphere allowed testing out boundaries of socially shared knowledge. CONCLUSIONS: Sharing case stories in small groups in general practice initiated interaction that facilitated meaning-making, reflection and peer support.

Power and powerlessness: GPs' narratives about lifestyle counselling.

BACKGROUND: Power in doctor-patient relationships is asymmetrically distributed. The doctor holds resources the patient needs and has a mandate to promote healthy living. Power may benefit or harm the patients' health, and the doctor-patient relationship. AIM: To identify aspects of power and powerlessness in GPs' narratives about lifestyle counselling. DESIGN AND SETTING: A qualitative study using focus groups from peer-group meetings of Norwegian GPs attending continuing medical education. METHOD: GPs discussed case stories about lifestyle counselling in focus groups. The discussions were transcribed and the text analysed using systematic text condensation. RESULTS: Aspects of power concerning the framework of the consultation and the GPs' professional role were found. Also identified were: power expressed by opportunistic approaches to change patients' lifestyle; rhetoric communication; paternalism; and disclosure. GPs reported powerlessness in complex communication, when there were difficulties reaching goals, and when patients resisted or ignored their proposals. CONCLUSION: Case-study discussions in peer groups disclose several aspects of power and powerlessness that occur in consultations. Consciousness about aspects of power may facilitate counselling that benefits the patient and the doctor-patient relationship.

A qualitative study of physicians' and nurses' experiences of multidisciplinary collaboration with pharmacists participating at case conferences.

OBJECTIVES Previous studies have revealed a range of drug-related problems for nursing home and hospital patients. Different attempts to reduce drug-related problems have been tested. Medication reviews performed by pharmacists and subsequent presentation of findings at case conferences is one of these methods. Physicians' and nurses' experiences from multidisciplinary collaboration with pharmacists have to a lesser degree been investigated. This study aims to describe how Norwegian physicians and nurses experience collaborating with pharmacists at case conferences to reduce drug-related problems in elderly patients. METHODS This was a qualitative interview study using systematic text condensation. The setting was nursing homes (long-term care) and hospital wards (gerontology and rheumatology). Four physicians and eight nurses participated and the main outcome was physicians' and nurses' experiences of multidisciplinary collaboration with pharmacists. KEY FINDINGS Organizational problems were experienced including, among others, what professional contribution team members could expect from pharmacists and what professional role the pharmacist should have in the multidisciplinary team. Both professions reported that ambiguities as to when and if the pharmacist was supposed to attend their regular meetings resulted in some aggravation. On the other hand, the participants valued contributions from pharmacists with regard to pharmaceutical skills, and felt that this raised awareness on prescribing quality. CONCLUSIONS Physicians and nurses valued the pharmacists' services and reported that this collaboration improved patients' drug therapy. However, before implementing this service in nursing homes there is a need to make an organizational framework for this collaboration to support the professional role of the pharmacist.

Lifestyle consultation in general practice--the doctor's toolbox: a qualitative focus group study.

BACKGROUND: GPs consider individual lifestyle counselling as part of their obligation. There is a lack of knowledge about how such counselling is done. OBJECTIVE: To investigate what tools GPs utilize in individual consultations concerning lifestyle change. METHODS: Qualitative analysis of six focus groups with 50 GPs sharing and commenting each other's case stories. RESULTS: To enhance change of lifestyle, GPs adjusted the organization of their practice and utilized visualization tools. They established doctor-patient relationships based on shared decision making and trust, and gave their patients advice and tips to accomplish change, but also used paternalistic approaches and rhetoric manipulation. CONCLUSIONS: GPs use a variety of tools in consultations about lifestyle change. A patient-centred approach is shown, but GPs also deliberately use distressing communication tools.

[General practioners and patients' general life problems]. / Korleis møter allmennlegane pasientanes livsproblem?

BACKGROUND: Many contact general practitioners (GPs) about non-medical problems in their lives; a situation which may be frustrating for GPs. MATERIAL AND METHODS: Semi-structured in-depth interviews with six Norwegian GPs by e-mail. The interviews were analysed according to a discourse analysis of which role the GPs considered they had, whether they saw themselves as therapists and how they perceived the personal strain related to working in general medicine. RESULTS: The majority of GPs did not distinguish clearly between somatic and more general life-related problems. Nevertheless, they defined medical problems as quite strictly somatic and saw themselves mainly as experts in somatic medicine. They described themselves more as spiritual advisers (pastor-like) than as psychotherapists. Some meant that their work had given them more self- confidence and made them more tolerant, but many said they felt helpless in their role as doctors. INTERPRETATION: GPs are doctors for all people. They have to relate to healthy and sick individuals with various medical and general life problems, and often experience a discrepancy between their medical competence and the challenges they meet.

[Approaching the locked dialogues of the body]. / Tilnaerming til fastlåste samtaler om kroppen.

BACKGROUND: The objective of this project was to develop a clinical communication tool to change locked dialogues between doctor and patient in general practice consultations. The target group was patients suffering from long-standing symptoms without clinical findings. Patients were encouraged to keep an illness diary or to write personal notes on their illness as a tool for cooperating with the doctor. MATERIAL AND METHODS: The material was collected from 36 consultations with 16 patients. The qualitative evaluation aimed at giving a description and analysis of how the illness diary affected the doctor-patient dialogue in the consultation. The analysis was modified from phenomenology-based methodology. A part of the project dealt with the methodological problems of doing research on an interaction in which the general practitioner is both participant (doctor) and observer (researcher). RESULTS AND INTERPRETATION: The diary enhanced the doctor's basis for clinical decision making by giving medically relevant information from the patient and by producing more concrete information. The diary gave the doctor access to patients' insight in their own problems. The clinical dialogue modified the patient's negative internal monologues in order to search for alternate dialogues as a basis for personal coping strategies. The project demonstrated that written notes might give patient and doctor a new understanding of a previously spoken message. The writing procedure gave patients an opportunity to reflect upon their illness presentation.

Action research on own practice. Methodological challenges.

OBJECTIVE: Using experiences from a study on clinical communication, the objective was to clarify the methodological challenges that general practitioners are faced with when researching their own practice. DESIGN: A case study of the methodological challenges of an action research project in which the researcher is both participating observer and observing participator. The material comprised notes and transcripts from audiotapes, and was investigated with a view to highlighting experiences that might facilitate the research process. SETTING: The practice of the author. SUBJECTS: 36 consultations with 16 patients during which the illness diary method was applied. RESULTS: The challenges of the project are presented as turning-point stories, i.e. stories demonstrating relations, perspective shifts and metapositions. Perspective shifts were established by introspection through dialogues with oneself, and by relation to helpers through dialogues with patients and supervisors. Reflexivity was promoted by combining pictures from different perspectives. CONCLUSION: It is possible and sensible to study oneself in interaction. The information gained from carefully designed research in one's own practice could be an underestimated source of valuable knowledge about the personal and existential aspects of clinical medicine.