Abstract:
The aim of this study was to get an understanding of the various decision-making processes
involved in referral for and the choice of the most appropriate diagnostic imaging investigation
and how they had a bearing on the interactions between patients and health care professionals.
A social constructivist conceptual framework informed the inductive, emerging
qualitative research design adopted for this study.
An instrumental case study of one district hospital and its referral links was selected as
methodological point of departure. The study consisted of two main phases, the one following
on the other. In the first phase, real-life, individual mini-case studies were conducted by
“shadowing” 24 patients, from the point of reporting to the hospital up to their discharge from
hospital or admission for in-hospital treatment. Data collection methods in this phase not
only included entry and exit interviews with patients but also observations at various points
of care, and interviews with different health care providers involved with the care of each
patient (medical practitioners and specialists, radiologists and radiographers, and nurses). In
the second phase, focus group interviews were conducted with the same and other health
professionals to triangulate the findings emerging from the shadowing process. The data
was analysed inductively around three main units of analysis: the district hospital; patients;
and health professionals.
The findings are presented in six chapters, starting with an overview of the health-facility
complex in which the district hospital was situated and the various referral pathways for
diagnostic imaging investigation that could be followed. This exposition is followed by an
exploration of structural and organisational interactions between health care providers from
referral for diagnostic imaging, to investigation, interpretation and integration. Interprofessional
interactions with regard to diagnostic imaging investigation are discussed, with a
special focus on the role of the radiographer as trainer, mediator, gate keeper and gap filler
and the differences in interactions inside a radiology department and outside of it. Hierarii
chies, boundaries and task-shifting are also highlighted. Radiographers were found to
occupy a tenuous space in decision-making processes and interactions, with their services
needed but their profession not appreciated by all cadres of health professionals. Providerpatient
interactions are explored in terms of patterns of interaction during the consultation
and the diagnostic imaging investigation, as well as in terms of issues of communication,
continuity and fragmentation. Patient expectations and experiences are explored from the
viewpoint of health providers and of the patients themselves.
The thesis ends with a higher-level reconstruction of the “bigger” picture in which interactions
and decision-making processes with regard to diagnostic imaging investigations take place,
drawing eclectically on a number of theoretical models and themes from the literature. In
order to accommodate the complexities of and all role players involved in diagnostic imaging
investigations, it is proposed that the notions of patient-centre care and shared decision
making be replaced with a patient-provider-centred approach to care and collective decision
making. Collective decision making includes a sequence of discreet decision-making moments
and events in which elements of distributed, shared, negotiated and collaborative
decision making are found.
