Background
Methods
Design
Quantitative methods
Survey recruitment
Survey content
Theoretical Domain | Item |
---|---|
Knowledge(1) | I am aware of the objectives of patient triage. |
Knowledge(2) | I am familiar with how to triage patients in general practice. |
Skills | I have the skills required to triage patients in general practice. |
Social/Professional role and Identity | I feel it is my responsibility as a general practitioner to triage patients effectively. |
Beliefs about capabilities(1) | I am confident that, if I wanted, I could triage patients effectively within general practice. |
Beliefs about capabilities(2) | For me, triaging patients effectively in general practice is very easy. |
Optimism | I feel that patient triage is the best way to match the patient’s problem with the right person, for the right amount of time. |
Beliefs about consequences(1) | For me, triaging patients effectively in general practice is very useful. |
Beliefs about consequences(2) | If I triage my patients in general practice, it will have disadvantages for my relationship with my patients.* |
Reinforcement | If I triage my patients in general practice, I feel I am making a difference. |
Intentions | How strong is your intention to triage your patients in primary care over the next year? |
Goals | Generally, how often do you feel something else takes priority over setting up patient triage systems?* |
Memory, attention, and decision processes | When I need to concentrate on triaging my patients in general practice, I have no trouble focusing my attention. |
Environmental context and resources | Patient triage systems provide the possibility to adapt services to the patient’s needs. |
Social influences | I can rely on my colleagues when things get tough in regard to patient triage in general practice. |
Emotion | Thinking about yourself and how you normally feel as a professional that delivers patient care, to what extent do you feel nervous with regard to patient triage within general practice?* |
Behavioral regulation | I have a clear plan under what circumstances I will triage my patients in general practice. |
Analyses
Qualitative methods
Interview recruitment
Interview materials
Type | Question |
---|---|
Principle | Tell me how you use triage in your current day-to-day work and any past experience you may have had? |
What are your thoughts on patient triage? Specifically, what are the advantages or disadvantages? | |
How do patients feel about triage, i.e. “patient satisfaction”? | |
How do you feel triage impacts on your stress, workload, time management or job satisfaction? | |
Do you have any thoughts or opinions regarding triage or digital triage that we haven’t covered and you would like me to capture today? | |
Probe | What is your experience of referring on to other [non-face-to-face] services within triage? |
Do any patient groups have particular difficulties with triage models? | |
What do you think could make triage better? | |
Do you have any specific thoughts on total digital triage? | |
Do you think that your practice will carry on using total triage after COVID-19? |
Interview analyses
Results
Quantitative findings
Participants
Triage systems
Behavioral factors
Theoretical Domain | Number | Median (Interquartile Range) | Mann-Whitney Test | |||||
---|---|---|---|---|---|---|---|---|
Overall | Partner | Non-partner | Partner mean rank | Non-partner mean rank | Z-value | p-value | ||
Knowledge(1) | 204 | 6 (1.75) | 6 (1) | 6 (2) | 106.5 | 93.25 | 1.62 | 0.11 |
Knowledge(2) | 203 | 6 (1) | 6 (1) | 6 (2) | 105.53 | 93.55 | 1.47 | 0.14 |
Skills | 204 | 6 (1.75) | 6 (1) | 6 (2) | 110.7 | 85.11 | 3.12 | 0.00* |
Social/Professional role and Identity | 204 | 6 (2) | 6 (2) | 6 (2) | 103.82 | 98.46 | 0.65 | 0.52 |
Beliefs about capabilities(1) | 204 | 6 (1) | 6 (1) | 6 (2) | 110.39 | 85.71 | 3.04 | 0.00* |
Intentions | 204 | 6 (2) | 6 (2) | 5 (2) | 113.66 | 79.36 | 4.06 | 0.00* |
Beliefs about capabilities(2) | 204 | 5 (2) | 5 (2) | 4 (2) | 110.48 | 85.54 | 2.92 | 0.00* |
Optimism | 204 | 5 (2) | 6 (1) | 5 (2) | 112.44 | 81.73 | 3.61 | 0.00* |
Beliefs about consequences(1) | 203 | 5 (1) | 6 (2) | 5 (1) | 108.8 | 87.43 | 2.54 | 0.01* |
Reinforcement | 204 | 5 (2) | 5 (2) | 4 (1) | 109.03 | 88.34 | 2.44 | 0.01* |
Memory, attention, and decision processes | 203 | 5 (3) | 5 (2) | 4 (2) | 108.72 | 87.59 | 2.48 | 0.01* |
Environmental context and resources | 204 | 5 (1.75) | 5 (1) | 5 (2) | 107.44 | 91.43 | −1.9 | 0.06 |
Social influences | 204 | 5 (2) | 5 (2) | 5 (3) | 109.6 | 87.24 | −2.62 | 0.01* |
Behavioral regulation | 203 | 5 (2) | 6 (3) | 4 (3) | 111.73 | 81.78 | −3.52 | 0.00* |
Beliefs about consequences(2) | 204 | 4 (3) | 4 (3) | 4 (1) | 103.22 | 99.64 | 0.42 | 0.68 |
Goals | 204 | 4 (1) | 4 (2) | 3 (1) | 107.85 | 90.63 | 2.03 | 0.04* |
Emotion | 204 | 4 (2) | 4 (3) | 4 (1.5) | 93.15 | 119.19 | −3.05 | 0.00* |
Qualitative findings
Participants
Theme 1: patient accessibility
New ways of accessing the practice also created new challenges for vulnerable patients who did not have supportive carers, e.g., patients with difficulties hearing. Participants raised concerns about a lack of dedicated methods to reach some vulnerable populations, e.g., people who are homeless. One participant noted that:“There are no barriers at all, and we are a free service that is highly valued. In the end, we end up rationing by our waiting times and queuing … and I’m just worried about where this is going.”
“I think it [our triage] excludes most vulnerable people that need the access— if you’re not online or haven’t got a phone, you’ve got a hearing problem, or you’ve got dementia, mental health issues, or learning disabilities, or you’re socially awkward. I just think it’s putting lots of barriers in those patients’ way, and some of them are actually really needy, and nobody seems to be interested in that. Nobody is talking about that … some of the most needy people they can’t deal with the triage process, so they get lost in the system.”
Theme 2: confusions around what triage is
If a practice is not clear about what triage model they adopt, then different practitioners may operate under different mental models, potentially increasing confusion and decreasing efficiency. One participant commented that change was particularly difficult during the COVID-19 pandemic because they were unable to have a group meeting. This participant said that:“quite hard to manage the expectations of the patient and say, ‘ok that’s your problem then we’re going to book you into an appointment in a week to discuss this properly.’ It is quite hard because the patients’ expectation of what the triage contact is about maybe is not the same as what triage really is [about].”
“I guess change is the hardest thing to do in GP [general practice], for us all, and we’re not all at the same page at the same time in terms of making a change to the system, and its quite hard. It’s an effort to bring everyone to that point. Even harder when we can’t all sit in the same meeting room as a mass group to talk about things.”
Theme 3: risk and uncertainty
Participants did not mention alternative non-visual signals they might use during non-face-to-face consultations to explore potential problems, e.g., changes in vocal tones or unexpected background noise. Participants were also concerned about the brief duration of calls. They believed that a longer appointment was often needed to build sufficient trust with patients, as this trust enables patients to express deeper problems. For example, one participant recollected that:“Video doesn’t work near us. The internet is not reliable on either our side or their side, which pixelates and freezes all the time and that is worse than having a phone call.”
“Patients present with minor ailments because they really have something else going on. We see it all the time, don’t we? They come and they sit there. They test you with something really boring and you think, ‘Why did they come with a cough?’, … and then they tell you, ‘Actually, doctor, I just want to let you know, that my husband’s been beating me up,’ or ‘Actually, doctor, I just want to let you know, I’m really low and I’ve had these horrible suicidal thoughts,’ and it [these sorts of comments] always comes at the end. Or, you know, a male patient often is quite embarrassed about a male [problem], you know, impotency for example. They always tell you at the end, don’t they, of a long consultation? They have to gain your trust.”
Theme 4: relationships between service providers
As the pandemic lifts and other services resume, these difficulties may naturally resolve where good relationships previously existed, but there was a sense that problems due to poor relationships pre-date the pandemic. Participants highlighted a longstanding issue with the general practice being used as a backstop expected to pick up the tab when other services ran out of capacity or were unresponsive to patient needs. One participant reflected that their practice was trying to overcome this problem by bringing in a partner physiotherapist. However, when that physiotherapist was unavailable, patients still expected the practice to offer treatment.“Mental health services are down. We don’t have access to all the investigations that we need [e.g., from hospital services], and we can’t examine patients. So, I think the stress is building up from the fact that we can’t actually do what we’d like to do for our patients, and we can’t signpost them appropriately—there are no other services.”
Theme 5: job satisfaction
Thus, the negative views discovered in this theme are strongly connected to the confusions discussed in Theme 2.“I know that a lot of job satisfaction comes from good interactions with patients. So, if our aim is always not to see people, that might reduce [job satisfaction]. I certainly don’t want to feel like I’m working in a call center. That’s what I’d be worried about.”