This is the first of the clinical influence themes. They have an under-pinning role in the clinical reasoning process. Safety and accountability is defined as elements within the assessment that link the clinician to aspects of safe practice, vigilance, medico- legality, and litigation. There are three main elements seen within this code.
1. Clinician professional safety. This aspect of the theme is composed of the
clinicians’ awareness of their own professional liability. It encompasses the components of the reasoning process that is influenced by the clinicians’ awareness of how a decision could be affected by potential litigation.
2. Patient safety. This component of the theme emphasises the reasoning
processes relationship to what the clinician perceives as the clinical safety of the patient. This differs to professional safety as some clinical questions may extend to what is safe for the patient such as identification of risk of serious pathology.
3. Accountability. This part of the theme relates to how safety elements lead to
levels of accountability. It relates to the perceived clinician accountability and its development is in contrast to the non-ESP clinicians.
The ESPs provided initial codes that were in contrast to the non-ESP group and possibly shows some preliminary differences that support this type of reasoning. Safety played a greater role in ESP work than in non-ESP practice, and exemplified how these clinicians perceived their role. In all three focus groups and within the interviews, there was emphasis on this aspect, with examples alluding to specific incidents.
The quotes below highlight two examples of safety: One relates to the patient, the other relates to themselves as a clinician. Cauda equina syndrome is a medical
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emergency and could be life changing for the patient if not correctly managed
(Markham 2004). The clinician is aware of this and therefore it suggests an important role in their thought process. The second quote demonstrates that safety also relates to protecting themselves as clinicians, and their professional status.
“In the ESP role it is always cauda equina questions rather, I always cover them, completely all of them.”Focus group 2 ESP 222
“…if we get something wrong or miss something then we’ve got no one else to sort of hide behind.” Focus group 1 ESP 698-699
The ESPs also realise that as ESP practitioners there is a role to play in taking
responsibility in a medical environment where in the past, the medical profession has taken the responsibility for the diagnosis of serious pathology. However,
physiotherapy has been an autonomous profession since 1977 (CSP 2006), but perhaps the extra perceived responsibility of ESPs is more overt and emphasises physiotherapeutic autonomous practice to a degree that has not been accepted fully since 1977. Therefore, this theme has the two elements of safety and also links closely with levels of accountability. The data below gives examples of each of these
processes with more depth. The ESP clinicians speak of the link that accountability has with stress and pressure. The ESPs perceive that they work in a pressured environment and used non-physical formal testing to reduce anxiety.
“I mean personally I think I feel less anxious having access to this. I think I would be more anxious if I didn’t have access. So I think I can more effectively help people by having access.” SSI 2 172-175
The clinician above is discussing access to MRI scans. The practice of these clinicians has changed, within the comparative focus groups there was no mention of using scans by the non-ESPs as they do not have access. Therefore, these clinicians base clinical judgements on patients without these investigations, and still deal potentially with patients that have serious pathology. However, as soon as they have changed roles the anxiety changes;
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“I mean I think if your first job as an ESP was in a community clinic, you know I think you would just melt. You know you would be so stressed so I think adequate support, adequate infrastructure/ technology so you want to see the images, you want to see the results.” SSI 2 298-302
The clinician in this example highlights the potential/perceived stress level differences between the ESP and non-ESP, and how using non-physical formal testing can reduce this stress. One clinician did relate to this but used their medical colleague to deal with a clinical investigative scenario to help reduce anxiety.
“Anxiety in that I think the pressure is to get it right and things like interpreting bloods I think is a really complex thing that gives me anxiety; well I would be hugely anxious if I didn’t have Dr C down the corridor on a Wednesday morning”. SSI 3229-232
This is in contrast again to how a non-ESP will deal with the pressure of a diagnosis, they may not have access to medical colleagues, or have the support of a scan, and therefore the reasoning process is different in this scenario. The elements of caution play a greater part in the ESP assessment.
“I am more cautious than I would be in a normal physiotherapy.” FG 1 ESP 501
The non-ESP has more time, perhaps a greater chance to explore their hypotheses and has the time to explore patient feedback. They are trying to develop a treatment protocol as against the ESP who in the quote below is doing two things; Firstly checking their safety elements;
“In the first instance you’re thinking, “Is this anything serious?” SSI 4 11 Secondly, moving the patient through a clinical pathway;
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“In terms of clinical diagnosis and if they have got, you know radiculopathy with imaging then an Orthopaedic option maybe appropriate for them.” Pilot FG ESP 260-263
This decision-making links to clinical/patient safety, pathway management and also medical/professional safety. Ensuring not only do they do right by the patient, that they also protect themselves. This was very evident in the ESP data and dominated some of the focus groups discussions.
“So that legally it does and our responsibility to the patient and not to just dump it on the physio department” FG 1 676-677
The word legal is used here, suggesting that pressure is not just linked to diagnostic differentials, and actioning scan reports, but also the professional accountability and perception of the role. An earlier quote spoke of “melting” when moving into the first ESP role. This is an example of the pressure that they feel, and the possible change in role that they experience. Considering the levels of concern, responsibility, time restrictions and the perceived change in role, these clinical posts may need high levels of support and governance to ensure these components do not dominate the reasoning processes of the clinicians. If the clinicians are driven by these thoughts, worries and concerns, then it could be argued that this could affect the reasoning process by adversely being the prevalent factor rather than the retrieved clinical data, potentially biasing the impression in an un-helpful manner.
“So there is a time pressure and I suppose there is a pressure of getting it right
as well, so I think it is more of a pressured situation than physiotherapy.” SSI 6 113-115
The quote above suggests ESPs work in a more pressured situation, whilst
accountability and worry have also led these posts to be perceived differently from
non-ESPs.The profession has been drawn into these roles for a number of reasons.
Government plans (DOH 2000) have wished to see greater options for patients, and different ways to deliver services supported by shorter waiting times, therefore delivering cost-effective care. The research base supports physiotherapists in these
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roles in terms of their diagnostic capabilities (Hourigan and Weatherley 1994; Weatherly and Hourigan 1998), yet there is a gap regarding what a supported ESP practitioner requires, and what pressure the practitioner deals with. Competency ESP manuals and definitions of ESPs are available (Symes 2009), yet evaluating these highlights that the clinical decisions and the work that they do is not heavily driven by these perceived and identified pressures. The direct effect of these safety pressures on the behaviour of the clinician which could impact on the patient and the local health economy (i.e. requesting scans due to worry rather than clinical need) has yet to be evaluated, and would be a useful adjunct to the support structure that these clinicians potentially require.
Therefore, returning to the data highlights some of the personal elements that influence clinical reasoning; it demonstrates that the ESPs internally feel that they need to be able to demonstrate certain characteristics well, to allow them to perform the role.
“Have to have someone who fairly confident in themselves, they have to
approach consultants, they have to be able to negotiate with radiologists about a MRI scan, it takes confident people.” SSI 9 112-115
“What I say is, “Worry about the things you can change and that you need to worry about, but the stuff you don’t need to worry about, just try and forget it,” and I’m very good at it I can do that.“ SSI 8 197-200
“I think it is letting go and not worrying. I think we’ve all been there.” SSI 7 322
These pieces of data suggest two supportive components of how the clinicians deal with the decisions they are met with. They have to be confident; they have to use that confidence not to support themselves, so lessening worry. These comments outline a supportive structure of the clinical reasoning model. The model is developed with a further theme which was identified as external/internal.
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