Decision making in diagnostic imaging investigations : a case study of processes and interactions between patients and health care professionals

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.