Perceptions of general practitioners towards the use of a new system for treating back pain: a qualitative interview study

BackgroundChanging clinicians' behaviour is recognised as a major challenge. It is clear that behaviour change not only depends on demonstrating the proven effectiveness of clinical interventions; contextual and occupational factors, such as 'change readiness', may be central to their implementation. This paper highlights the context of behaviour change in relation to a healthcare innovation introduced within primary care, highlighting the importance of organisational and interpersonal factors that may help explain the dynamics of implementation.MethodsQualitative interviews were conducted with general practitioners (GPs) before (n = 32) and after (n = 9) the introduction of a subgrouping for targeted treatment system. GPs were offered an electronic six-item subgrouping tool, to identify patients according to their risk of poor outcome ('high', 'low') in order to help inform their decision making about treatment approaches. Recruitment was based on a 'maximum diversification sample', to obtain a wide representation of views across all five practices. A coding scheme was developed based on the emergent findings, and the data were analysed using 'constant comparison', drawing upon insights and developing connections between themes. We adopted the normalisation process theory (NPT) to explain the uptake of the new system and to examine the relevance of coherence for the implementation of innovations in organisations.ResultsGPs perceived back pain as a low clinical priority, and highlighted the importance of 'practical' and 'relational' coherence in decisions to adopt and engage with the new subgrouping for targeted treatment system. Health professionals often engage in 'sense making' about new innovations to 'road test' their applicability or relevance to daily clinical routines. Low back pain was generally perceived as an 'uninteresting' and clinically unchallenging health problem by GPs, which may partly explain their lack of engagement with the new subgrouping for targeted treatment system. The adoption of this new way of working by GPs was determined by the meaning that they ascribed to it in the context of their daily clinical routines.ConclusionsWe conclude that the key obstacle to implementation of the new subgrouping for targeted treatment system for low back pain in primary care was an initial failure to achieve 'coherence' of the desired practice change with GPs. Despite this, GPs used the tool to different degrees, though this signified a general commitment to participating in the study rather than a deeper attitude change towards the new system.

[1]  A. Rashidian,et al.  Practice nurses' intentions to use clinical guidelines. , 2004, Journal of advanced nursing.

[2]  A. Kilbourne,et al.  Organizational factors and depression management in community-based primary care settings , 2009, Implementation science : IS.

[3]  E. Freidson.  Profession of Medicine: A Study of the Sociology of Applied Knowledge , 1970 .

[4]  T. Marteau,et al.  General practitioners' perceptions of the effectiveness of medical interventions: an exploration of underlying constructs , 2010, Implementation science : IS.

[5]  S. Harrison,et al.  Autonomy and bureaucratic accountability in primary care: what English general practitioners say , 2002 .

[6]  M. Elston.  The politics of professional power: medicine in a changing health service , 2002 .

[7]  David Jewell,et al.  How to change clinical behaviour: no answers yet. , 2003, The British journal of general practice : the journal of the Royal College of General Practitioners.

[8]  Michael Bury,et al.  The Sociology of the Health Service , 1991 .

[9]  Elizabeth Murray,et al.  Understanding the implementation of complex interventions in health care: the normalization process model , 2007, BMC Health Services Research.

[10]  D. Armstrong.  Embodiment and ethics: constructing medicine's two bodies. , 2006, Sociology of health & illness.

[11]  P. Croft,et al.  Classification of Low Back Pain in Primary Care: Using “Bothersomeness” to Identify the Most Severe Cases , 2005, Spine.

[12]  H. Kraus,et al.  Diagnosis and treatment of low back pain. , 1952, GP.

[13]  Marc Berg,et al.  Guidelines, professionals and the production of objectivity : standardisation and the professionalism of insurance medicine , 2000 .

[14]  B. Guthrie,et al.  Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract. , 2008, Sociology of health & illness.

[15]  M. Charns,et al.  Institutionalizing evidence-based practice: an organizational case study using a model of strategic change , 2009, Implementation science : IS.

[16]  A. Abbott.  The System of Professions: An Essay on the Division of Expert Labor , 1988 .

[17]  C. Dowrick,et al.  Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. , 2004, The British journal of general practice : the journal of the Royal College of General Practitioners.

[18]  K. Dunn,et al.  A randomised clinical trial of subgrouping and targeted treatment for low back pain compared with best current care. The STarT Back Trial Study Protocol , 2008, BMC musculoskeletal disorders.

[19]  J. Ogden,et al.  The role of etiquette and experimentation in explaining how doctors change behaviour: a qualitative study. , 2006, Sociology of health & illness.

[20]  C. Silagy,et al.  Factors affecting the level of interest and activity in primary care research among general practitioners. , 1989, Family practice.

[21]  Catherine Pope,et al.  Contingency in everyday surgical work , 2002 .

[22]  J. Braithwaite,et al.  Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals , 2009, Health.

[23]  D. Armstrong,et al.  Clinical autonomy, individual and collective: the problem of changing doctors' behaviour. , 2002, Social science & medicine.

[24]  C. Dowrick,et al.  Complex interventions , 2022, International Review of Sport and Exercise Psychology.

[25]  C. May,et al.  Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory , 2009 .

[26]  Ricky Mullis,et al.  A primary care back pain screening tool: identifying patient subgroups for initial treatment. , 2008, Arthritis and rheumatism.

[27]  J. van Engelen,et al.  Disseminating educational innovations in health care practice: training versus social networks. , 2010, Social science & medicine.

[28]  J. Sandars,et al.  Knowledge transfer for the management of dementia: a cluster-randomised trial of blended learning in general practice , 2010, Implementation science : IS.

[29]  N. Foster,et al.  GP attitudes and self-reported behaviour in primary care consultations for low back pain , 2009, Family practice.

[30]  C. Chew‐Graham,et al.  Framing the doctor-patient relationship in chronic illness: a comparative study of general practitioners' accounts. , 2004, Sociology of health & illness.

[31]  S. Harrison.  New Labour, Modernisation and the Medical Labour Process , 2002, Journal of Social Policy.

[32]  E. Freidson.  The Changing Nature of Professional Control , 1984 .

[33]  K. Jones.  Evidence Based Medicine—How to Practice and Teach EBM , 1996 .

[34]  Catherine Pope,et al.  Resisting Evidence: The Study of Evidence-Based Medicine as a Contemporary Social Movement , 2003 .

[35]  J. Grimshaw,et al.  From best evidence to best practice: effective implementation of change in patients' care , 2003, The Lancet.

[36]  K. Charmaz,et al.  Constructing Grounded Theory: A practical guide through qualitative analysis Kathy Charmaz Constructing Grounded Theory: A practical guide through qualitative analysis Sage 224 £19.99 0761973532 0761973532 [Formula: see text]. , 2006, Nurse researcher.