Análisis de las perturbaciones producidas en las señales de corriente

dimension, which concerns the impact on Practice; followed by the Macro dimension, the System level; and finally, the Micro dimension, regarding impacts on Patients;

B. Yet, the Meso and Macro dimensions behave more similarly as a pair than any other pair. Hence, if further rationalisation is to be pursued, the Macro

dimension can be 'disregarded', thus favouring a deeper look into the Meso and Micro dimensions only;

C. In a cluster analysis, 3 groups of behavioural challenges were identified according to their importance. This means in practical terms that, there is one top cluster with only one challenge (ranked #1), a middle-cluster with 5 challenges, and a third cluster with 4 challenges that are the 'least priority';

The vertical reading of the results was prioritised when doing the cluster analysis because its results are more reliable (i.e. they look more at RANK/POSITION, than at QUANTITIES/NUMBER VALUES). Since the voting system is subjective and the number values are not absolute (Likert-scales do not have actual correspondence with

objective, measurable quantities or values), a horizontal reading is less precise because it basically looks at the sum of the quantities, whereas a vertical reading looks at the resulting ranking of preferences. Therefore, when defining the final rank of challenges, a decision was made to follow the leading dimension Meso/Practice as reference for ordering of all challenges.

Following this method, the final order of the ten priorities, according to the scores of all respondents from the Core Group is shown in Table 4.14:

Table 4.14 Order of behavioural challenges: impact on practice scores, all Core Group participants

Rank Order Behavioural Challenge Total Points

1 Poor understanding of diagnostic testing. Are we putting tests ahead of clinical judgement and individual patient care?

45

2 Rush to use a test to get a diagnosis (time pressures - patient flow). Pressures to make a decision or do adequate

assessment

43

3 Over-reliance on dipstick test. Are we ignoring / missing the

bigger clinical picture? [Tests are] done automatically 41 4 Not undertaking the test in the correct way - doing press

pads, collection from catheter bag not tubes, etc. 41 5 Poor understanding of diagnostics / symptoms of UTI do

over-reliance on urine dip to see what is going on 40

178 6 Making assumptions about patient groups + their risk of

UTI; i.e. older people (esp. women) + women of childbearing age are routinely tested

39

7 [Tests are] seen as ‘something that we do’. No authorisation needed to do the test. Need to address behaviour in the department

38

8 Protocols: over reliance on diagnostic protocols and there are too many (medical staff) - too many protocols. Do the nursing staff or HCAs follow these when deciding to do a urine dip?

37

9 Complex patients - are our patients getting more complex?

Problems/symptoms in complex patients can be hard to interpret. Is urine dip seen as something that can help build a picture? (multimorbidity/living older + longer/mental health)

36

10 Defensive mentality? [Staff] need to be seen to be doing adequate tests - risks of missing a diagnosis due to not doing a test, especially non-invasive/simple tests like urine dip

34

Interestingly, this ordering is quite similar to the ordering resulting from the sum of scores per dimension for each individual challenge. The top priority is the same in both ranks, while priorities two and three are swapped.

All respondents ranked the behaviours from the list of ten challenges identified in Workshop 2. However, since respondents were invited to include new challenges that they felt were not represented in the list, two additional behaviours were included (each proposed by a different respondent): 11. Urine is dipped because a patient has passed urine in the department, seen as opportunity to get simple test, not done on clinical basis, but due to convenience; and 12. Patients who are symptomatic of a UTI but are also incontinent or are unable to vocalise the need to pass urine are less likely to have a dip stick test. When a dip stick is required to rule out UTI, e.g. Sepsis, some patients are treated for a UTI without being tested.

These two additional challenges were not considered in the overall analysis presented above because they were not ranked by all respondents. Nonetheless, they were included in the list of challenges used in the subsequent prioritising exercise with ED staff, as explained next.

179 With the ED Group (Second Meeting with ED Consultants)

The second prioritisation exercise involved the ED group and was done on-site, using a fifteen-minute voting activity, during a senior staff weekly meeting. Considering the reduced time, a simplified voting system using coloured stickers to signal preferences was adopted. Participants were asked to individually select their first and second priorities, from the same list of ten challenges previously used in the prioritisation exercise with the Core Group of stakeholders (plus the two additional challenges, included by two Core Group participants). Participants in this exercise were invited to consider their priorities for ‘short-term action’, an instruction not given to the Core Group of participants in the previous prioritisation exercise, to whom no time constraint was posed.

This second prioritising exercise (Fig. 4.12) was conducted with twelve staff working in ED, including three managers, six doctors, and three nurses. Each participant was given three coloured stickers (colour-coded according to expertise – blue for managers, orange for nurses, and green for doctors) and were asked to vote with two stickers placed on the issue they judged to be most pressing with regards to UTI practice in the ED, and to vote with one sticker for their second choice. Each participant was given a sheet of paper with the list of challenges to cast their vote. The list was ordered hierarchically according to the results of the first prioritising exercise conducted with the Core Group (though this information was not shared with the ED group to avoid influencing their choices).

Figure 4.11 shows the collated results of the votes of ED staff.

180 Figure 4.11 Collated results of the prioritisation exercise with ED staff (digital version from

original)

Seven out of the twelve challenges received votes. An analysis of the voting results reveals that, for the ED group, the top priority is the behavioural challenge: Poor understanding of diagnostics/symptoms of UTI due to over-reliance on urine dip to see what is going on.

This is because:

A. It received more overall votes than any other challenge (11 stickers);

B. It received a total of 3 first-priority votes (two doctors and one nurse gave it a 2-sticker vote); and

C. It received votes from all professional groups (managers, doctors, and nurses), whereas some challenges only got votes from one or two professional groups.

Considering the number of first-priority votes, the total sum of votes, and the results from the Core Group voting (used as tie breaker) the resulting order for the seven behavioural challenges, according to the ED respondents is shown in Table 4.15: