Clinicians' decisions - full abstract

Health professional’s supportive screening behaviours: a literature review and behavioural analysis

Andria Hanbury(1), Anna Sallis(2), Tim Chadborn(2)
(1)York Health Economics Consortium, (2)Public Health England

Background: Coverage rates for cervical, breast and bowel cancer screening in 2017-2018 were 69.4%, 70.5% and 56.6% respectively, indicating scope for improvement. This is an important area of health promotion, with screening uptake associated with earlier detection of cancer and better outcomes. It is also an important area to focus upon to reduce health inequalities, with uptake lower for people of lower socioeconomic status. Uptake of cancer screening within the general population can be targeted indirectly through supporting health professionals in their use of ‘screening behaviours’. Examples include health professionals maintaining their screening knowledge and skills to provide all patients with a high standard of screening, and providing good access to screening.  This study adopted a behavioural science approach, identifying health professional reported barriers to performing screening behaviours, and reviewing the design of real-world interventions targeting health professionals’ screening behaviours, both using leading behavioural science frameworks. The aim was to develop behavioural-science informed recommendations to optimise the design of real-world interventions that support promote health professionals’ screening behaviours through identifying missed opportunities in intervention design.

Methods: A literature search was used to identify the barriers to health professionals’ screening behaviours, which were subsequently coded to fourteen domains or groupings of barriers using a behavioural science framework; the theoretical domains framework. Real-world interventions were identified via stakeholder consultation, and the design of them - the function of the intervention (e.g., to educate, to persuade) and how it was delivered (via e.g., communication and marketing strategies, training) - were coded using the behaviour change wheel. The individual techniques used within the interventions were coded using a taxonomy of behaviour change techniques (BCTs). The codes from the literature and real-world intervention reviews were mapped using matrices which link theoretical domains framework coded barriers to expert recommendations regarding intervention design. This was to identify incongruence between reported barriers and what real-world interventions target and how. Areas of low congruence represent missed opportunities in the design of real-world interventions. These instances were highlighted and formed the basis of the recommendations for optimising the design of real-world interventions.

Results: The literature search shortlisted sixty papers for review. The reported barriers were coded to thirteen TDF domains, indicating the range of issues influencing screening behaviours. The most commonly reported barriers related to the environmental context and the resources for screening, and health professionals’ knowledge of and beliefs about the consequences of screening. Stakeholders identified 31 real-world interventions. High consensus was found between the literature identified barriers, expert recommended intervention functions and the functions underpinning the real-world interventions. Similarly, the BCTs used in real-world interventions largely aligned with those recommended to target the identified barriers. However, missed opportunities in intervention design comprised the over reliance on interventions to educate, train, or enable rather than to persuade health professionals and to model the desired screening behaviours. Further, interventions most commonly used behaviour change techniques designed to shape knowledge or to highlight the consequences of screening, missing opportunities to use ‘active’ techniques, such as encouraging health professionals to set their own goals. For training focused interventions, the BCTs focused on passive information provision, rather than recommended BCTs such as using ‘graded tasks’.  

Implications: Interventions relied on information and resource provision, missing opportunities to use a broader range of functions and BCTs to target the barriers identified as important from the literature. Recommendations include using a broader range of intervention functions and BCTs to address these shortcomings.

Judgement analysis approach to determine factors that influence prescribing decisions for patients with known penicillin allergy 

Yogini Jani
UCLH NHS Foundation Trust

Background: In the UK, nearly ten percent of the population report an allergy to penicillin of which only ten percent are truly allergic.  Treatment decisions are often based on recorded allergy status and description, and a judgment of risk versus benefit by the clinicians involved.  The aim of this was to evaluate doctor, nurses and pharmacists’ decisions to treat patients with a known penicillin allergy using a penicillin based medicine and to assess the variability between professions and grades depending on the perceived risks or benefits.  

Method: Doctors, nurses and pharmacists of various grades including medical and pharmacy students were invited to complete an online survey that presented hypothetical cases with differing factors.  The factors were identified from the literature and included allergy status, source and documentation of allergy status, knowledge about the antibiotics, including use of brand names and any potential cross reactivity, current infection severity, microbiology culture results, prescribing system (paper or electronic) and prescribing autonomy (senior or specialist recommendation or guidelines). The cases were based on reported patient safety incidents.  Within and between groups comparisons were made on decisions to treat with a penicillin prescription for a patient with a reported penicillin allergy.  Textual responses were analysed qualitatively.  The study was approved by the UCL research ethics committee. 

Results: 174 healthcare professionals of varying seniority and 64 students across four years of study completed the survey: 42 doctors, 77 nurses, 55 pharmacists, 12 medical students and 52 pharmacy students.  Overall, doctors were more likely to proceed with penicillin-based treatment in the presence of severe infection and on microbiology recommendations despite a documented or reported penicillin allergy.  All professional groups were less likely to proceed if there was an alert in an electronic prescribing system, even if it had been overridden by a previous clinician. All groups were more likely to continue with treatment if the patient had already been given doses prior to their review.  Themes from the qualitative analysis of textual responses showed a more ‘risky’ approach by doctors to treat, (yes, but would…) with qualifiers of additional actions they would take, such as confirming using another source of information, exhausting alternative options or prescribing supportive treatment in case of a reaction.  In contrast, nurses and pharmacists were more cautious (no, but if…), with similar qualifiers.  Factors influencing decisions by medical and pharmacy students were comparable to qualified professions, with little variation between the two groups.  Both student groups tended towards cautious decision making.

Implications: Factors other than documentation of the allergy status influence treatment decisions. Some factors are more likely to lead to prescription to the allergenic medicine than others and there was a difference between professional groups post qualification.  Deeper understanding of these factors is required to develop interventions to optimise safe prescribing of antimicrobials in patients with documented or reported penicillin allergies.

The Life Rooms: a social prescribing approach for people with mental health needs living in disadvantaged communities

Shaima Hassan(1), Clare Rotheram(2), Alan Price(2), Clarissa Giebel(1)
(1)University of Liverpool, (2)Mersey Care NHS Foundation Trust, UK

Background: One in 6 adults in the UK experience a mental health problem in any given week. Despite the ubiquitous nature of mental health problems, they disproportionately affect those from a poorer socio-economic backgrounds. Socio-economic issues are linked to variations in healthcare utilisation and suggest the need to address issues such as public transport and access to primary care. Lack of access to community-based social care results in people seeking social support from health care services. The Life Rooms provides a collaborative community-based initiative to support access that is grounded in the choice of the individual, but typically takes the form of learning opportunities or social support. This study aimed to explore The Life Rooms as a social prescribing model addressing the social determinants of mental health and identifying the elements that make the model effective.

Method: Six qualitative semi-structured focus groups (18 participants) were conducted with mental health service users from two locations in the North West of the UK. The interview topic guide was co-developed and the focus groups were co-facilitated via public involvement. Postcode data were collected to generate an Index for Multiple Deprivation (IMD) score, to understand participants’ socio-economic background. Data were analysed using thematic analysis.

Result: The Life Rooms social prescribing approach in addressing mental health needs for people living in disadvantaged areas was found to be effective by all participants. Four main themes emerged from the data: 1) social belonging: being able to just ‘be’; 2) resourceful and accessible; 3) social inclusion and connectedness; and 4) moving forward: self-development and independence. Participants found that the Life Rooms’ focus on the social determinants of mental health was beneficial in addressing their needs and having a range of in-house services within a local remit supported engagement and access.

Implications: Findings from this study were used to enhance The Life Rooms approach and further establishment of community-based hubs. The strong integration of public involvement in this study and in The Life Rooms hubs has resulted in creating an ethos of co-production that benefit both the further development of The Life Rooms and public representation. Further research into the wider benefits of this model on service users’ public and health services usage is needed.

Improving person-centred outcomes in social prescribing through occupational science

Cormac Lawler, Sarah Bodell, Rachel Martin, Alan Mathew
University of Salford

Background: Currently, person-centred outcomes in social prescribing are largely related to how people feel about the activities that they have been referred to, and/or the impact they have had on them[1]. Tools such as WEMWBS are useful for capturing quantitative data about people’s perception of the impact of the interventions on their overall wellbeing, however they don’t offer an explanation of why these outcomes come about. In other words, they don’t explain why people’s feelings, health and wellbeing are affected (positively or negatively) by the activities in which they participate.

There is also a recognised need to understand and support the work of link workers, who play a pivotal role in social prescribing and the success of its outcomes[2]. Link workers have wellbeing conversations with the person to find out ‘what matters to them’; however little is defined on how this is done in practice, and training and resources for link workers remain patchy.

These are core issues for the Salford Social Prescribing Hub, an interdisciplinary team in University of Salford with a focus on improving both the theory and practice of social prescribing. One of our key disciplines is Occupational Science[3,4], the theory underpinning Occupational Therapy, and which is the study of human participation in meaningful and purpose-led activities.

Methods: As a practical contribution to the rapidly emerging field of social prescribing, the Salford Social Prescribing Hub has developed an assessment and planning tool, based on Occupational Science, that helps link workers co-design a plan with the person that fits with their specific needs and desires at that particular time. In conjunction with the tool, the Salford team runs training for link workers to achieve improved and more person-centred outcomes. Together, the tool and training constitute a support package for link workers, which has been evaluated through qualitative methods to understand how it benefits both link workers’ practice and the wellbeing of their clients.

Results: This presentation is based on both a critical review of occupational science literature, and an evaluation of link workers’ perceptions and use of the Salford Social Prescribing tool. Occupational science offers a theoretical conceptualisation of the relationship between doing, health and wellbeing, and an evidence base that may assist practitioners in maximising the therapeutic value of their work. Link workers have said that the tool has helped broaden and enrich their thinking about their role and practice and has helped “centre” them in the process.

Implications: Taking an occupation-focused approach to social prescribing can both explain the ‘why’ of outcomes, and lead to increased consistency in the effectiveness of social prescribing. It can also help understand why people don't take up referrals – an area in need of further research. With social prescribing as a key component of NHS England’s Universal Personalised Care strategy[5], the contribution of Occupational Science to inform theory and practice of social prescribing is a ripe opportunity.


[1] Polley M, Whiteside J, Pilkington K. (2018) What are the outcomes of social prescribing — a mixed methods approach? 1st International Social Prescribing Research Conference. University of Salford, 14th June 2018.

[2] Moffatt S., Steer M., Lawson S., Penn, L., O’Brien, N. (2017) Link Worker social prescribing to improve health and well-being for people with long-term conditions: qualitative study of service user perceptions. BMJ Open, 2017(7).

[3] Kielhofner, G. (2002) A Model of Human Occupation: Theory and Application (3rd ed.). Lippincott Williams & Wilkins.

[4] Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., Letts, L. (1996) The Person-Environment-Occupational Model: A transactive approach to occupational performance. CJOT, 63(1), 9-23.

[5] NHS England (2019) Universal Personalised Care: Implementing the comprehensive model.

A collective phronesis (practical wisdom) from the medical community to facilitate ethical decision making: a major empirical study of doctors’ decision narratives

Mervyn Conroy
Health Services Management Centre, University of Birmingham

Background: This presentation is a summary of the first major study into the practical wisdom of around 130 doctors in primary and secondary care. 

In recent years calls to provide alternatives to prescriptive based ethical medical decision making have increased as the sheer volume of guidelines that clinicians are expected to follow has become unmanageable. This constitutes something of a crisis for evidence based medicine. Therefore alternative approaches to ethical decision making required research that did not lead to producing more guidelines. In addition ethical decision making in healthcare is under increased scrutiny due to healthcare scandals/ enquiries and the complexity has grown with demographic changes, austerity and higher public expectations. The main aim of the three-year research project ‘Phronesis (practical wisdom) and the Medical Community’ was therefore to improve patient care and community well-being by providing an alternative approach to guideline based ethical decision making.

Methods: The research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? Data collection included narratives and observations with hospital doctors and GPs at all stages in career progression.  Analysis included using the theoretical frames of phronesis and practice based neo-Aristotelean virtue ethics. The analysis was supported by an arts based film production process to form an easily accessible resource for all healthcare disciplines to use.

Results: We found that individually doctors conveyed many different practice virtues in their stories and those were consolidated into fifteen virtue continua which convey the participants’ collective practical wisdom including the phronesis virtue. So for the first time a ‘collective’ practical wisdom theoretical contribution containing fifteen virtue continua now exists. Given doctors and other healthcare can feel professionally and personally vulnerable the context of ethical decision making we suggest that this contributes a debating resource to make the process easier.  

Implications: The findings are available as a video series with accompanying social media, character biographies and notes to guide discussion or self reflection. The seven part video series conveys the 15 virtue continua acted out by professional actors in real life clinical situations based on the stories of wise and unwise decision making from the participants. The notes help to facilitate their use as a resource to support moral debate at every stage of an ethical decision. So far they have been used successfully in undergraduate, trainee and CPD settings by GPs and senior hospital consultants. An app that helps to facilitate process using the collective phronesis is also available to support ethical decision making for individuals or practice based communities to use.

Values vary considerably from person to person or organisation to organisation. Whereas virtues (of which phronesis is one) are ways of doing things, in this case taking medical decisions, that bring well-being to all in society. The particular form of virtues described in these research findings are practice virtues rather than individual character virtues. They will of course vary from practice to practice but all practices in healthcare have inter as well as intra relationships and together as a group of practice based communities their virtues interact to bring well-being to all in society. Healthcare practices also have to interact with many other practices such as policing, social work, cleaning services, etc. We argue that the findings and film resources from this study support ethical decision making that considers wider social responsibilities, communities, societal well-being as well as the patient's interests.

A qualitative study of the influences on emergency medical services clinicians’ decisions to follow guidelines or not to perform a prehospital 12 lead ECG in patients with Acute Coronary Syndromes

Mary Halter, Tom Quinn
Kingston University and St George's, University of London

Background: Use of the pre-hospital 12-lead electrocardiogram is recommended in international guidance for the early assessment of patients presenting with suspected acute coronary syndrome to emergency medical services (EMS). The pre-hospital 12-lead electrocardiogram supports decision-making in three components of immediate care: targeted pre-hospital treatment, transport to the appropriate receiving hospital, and provision of information required to activate a receiving cardiac catheter laboratory should particular types of myocardial infarction be recognised. Association of prehospital ECG has been found with process improvements such as speed to the desired treatment outcome and short-term mortality benefit. 

However, the PHECG has been found to be underutilised, particularly in older patients, women, and people with co-morbidities. EMS staff gender and uncontrolled confounding of presenting symptoms have been put forward as potential explanations for the variation in practice and deviation from international guidelines. In view of the paucity of evidence, we conducted a qualitative study with EMS clinicians, in the theoretical framing of influences on decision making in the uncontrolled emergency setting of the emergency medical services.  We aimed to explore the factors EMS clinicians report as influencing their decision to perform a prehospital 12 lead ECG. 


Methods: We conducted a qualitative phenomenological study, in six focus groups with a semi structured topic guide, in three UK regions. We selected a purposive sample from within volunteers, stratifying by length of experience as an EMS clinician and by study site. Forty seven 47 EMS clinicians participated, with clinical experience ranging from nine months to 31 years. We recorded, transcribed and anonymised each focus group; familiarised ourselves with the data including notes and reflections; formed and iterated a coding framework; and constructed themes with the study team, including patient and public representatives.


Results: All participants expressed a desire to perform a prehospital 12 lead ECG with patients suspected with acute coronary syndromes but described a setting characterised by uncertainty and ‘messy’ context. Clinicians demonstrated that the decision to perform, or not to perform a 12 lead ECG is not straightforward. We drew out three themes of influence on the decision to perform an ECG: surface characteristics (age, sex, ethnicity, privacy, presenting condition of the patient); pattern recognition (training, experience of atypical presentations, equipment availability, confidence in interpretation); and tensions/external pressures (distance to PCI, guidelines, organisational pressures). These three areas – at patient, clinician and system level - appeared to be interwoven with the concept of autonomy of clinicians, either limiting them or enabling them to operate and sparking debate on the relationship of such autonomy with the enactment of system-led evidence-based guidelines for practice.


Implications: The factors described as influencing clinicians’ decision out a 12 lead ECG ranged from straightforward to complex and difficult to unpick. Whilst qualitatively clinicians reported performing 12 lead prehospital ECGs wherever possible, the reported multifaceted influences on the decision reinforce the need for the quantitative arm of this study to examine this nationally, alongside its association with patient outcomes. Implications for practice are two-fold: first a practical need to reinforce the content of guidelines in a standardised manner and to do so in ‘real-world’ scenarios in which individual interpretations of the situation might be explored, and second to give broader consideration to how clinical autonomy can be supported whilst maintaining core guideline-led practice with evidence for improved outcomes for patients.