Following a description of the GPs who contributed to this study, this section presents findings from the theoretically-informed analyses of the interview transcripts. For clarity, the section presents findings that were informed by the use of the agency, institutional, and situated change theories, respectively – furthermore, each of these three subsections commences with a brief overview of the theory and includes signposts to denote: findings associated with the thematic analysis; findings associated with the lexical analysis; as well as a summary of key findings.
Participants
Twenty-one GPs participated in the study, including four registrars, or GPs-in-training (female: 14; mean age: 45 years; age range: 27–69 years) – however, for reasons unknown, one GP was not available to participate in the second stage of data collection. On average, the 21 GPs had been in practice for over 16 years. Although all but two had graduated in English-speaking countries (the exceptions being Egypt and India, where English is not the most common language), approximately half conducted a portion of their consultations in a language other than English (52.4%). The GPs practiced in diverse settings – while one practiced part-time in a solo-setting, another practiced in a group-setting comprised of 15 fulltime GPs. Although five practiced in an independent practice, on average, there were 4.5 fulltime equivalent GPs at the practices represented in this study. Most of the practices also employed a Practice Nurse (61.9%), and all but two of the practices were accredited. Approximately half of the practices bulk-billed all patients, accepting government benefits as full payment for a service (52.4%). Most of the remaining practices bulk-billed recipients of government-benefits and/or children under 16 years of age. All but four practices were also teaching sites, offering training opportunities chiefly to GP registrars and/or undergraduate students. All GPs used computers as part of their practice, primarily for prescribing, placing orders, and maintaining medical records.
Agency theory
Agency theory suggests the primary driver of organisational change is the continued process of negotiation between the principal – in this case, the organisations and patients to who the GPs were accountable – and the agent – that is, the GPs. The theory emphasises the role of incentives and self-interest and draws attention to the strong professional identity within medicine.
Thematic analysis
A thematic analysis of the research material suggests that sexual healthcare occupied a trivial place, relative to general practice (sensu lato). Sexual healthcare was considered a comparatively small part of the GP platter of responsibilities; these consultations were infrequent and this in turn could hinder the recall of evidence-based sexual healthcare. Although this makes a compelling case for resources like the STI Testing Tool, securing GP attention – given competing priorities – might be difficult:
I can pretty much put my hand on… information about lipids, cholesterol, diabetes, and hypertension, and probably asthma any day of the week. But other things, I don’t know where they are, tossed out, or thrown away or something like that, because you’re not dealing with them in that same repetitive way.
Integrating information into general practice appeared to be a challenge. This was partly due to limited time. GPs spoke of having limited opportunity to develop a trusting relationship with patients and provide appropriate care. They had to manage their limited time frugally:
compared to diabetes, cardiovascular, strokes… those hardcore medical things, STIs, even though it’s very prevalent… I don’t want to spend lots… of time on that because I might see… one case a month, one case every fortnight… not… ten cases a week.
Another determining factor was the perceived value of a resource. Some GPs suggested they worked within a paradigm that did not correspond well with resources that compartmentalised healthcare:
nurses are trained to follow protocols and go by guidelines and they don’t sway outside of that, whereas a doctor is… taught to think more laterally… that’s why doctors are not good at following flowcharts and guidelines… they explore the issue and make a decision about what they think should be done, not according to whether this is a yes or no.
This was affirmed by others who spoke of the sensitive nature of sexual healthcare. Sexual health consultations could reveal instances of infidelity and abuse. As such, these consultations were not always determined by clinical guidelines, but rather, by a GP’s personal interest in the area:
there was one girl recently who was very shy about it and so I just backed off and… I made some reason to call her back because I just felt there was something else going on and there was. She’d been abused as a child, which was why she wasn’t comfortable talking about it… we… got some counselling and then [I] called her back to see how she was going a week later and then said… ‘I appreciate this is really tough, but would you like the peace of mind of knowing?’
Lexical analysis
A lexical analysis was conducted by developing two concept maps. Within the first, the 21 GPs were categorised according to whether they would increase STI testing if an incentive payment was offered (see Fig. 2); within the second, the GPs were categorised according to whether or not they would increase STI testing if subsidised by the government (see Fig. 3). Both figures suggest that the concept, ‘clinical practices’, and to a lesser extent, ‘clinical knowledge’, are closer to the category of GPs whose use of sexual health tests would increase in response to an incentive payment and/or a government subsidy. This suggests that those whose clinical practices could be incentivised were more inclined to speak of screening, testing, treating, and/or the resources required to support these practices. For instance, these GPs spoke of the ways they ‘generally’ broached the sensitive topic of sexual health and their delicate use of sexual health ‘talk’ to engage a patient in a sexual health consultation:
You tend to fire warning shots that you’re going to ask a question that might be a personal one, and if they back off at that point, then you can address it differently.
These concept maps and the aforesaid excerpt indicate that GPs who spoke of an incentive were inclined to speak of the complex and processual nature of sexual healthcare, which required time, and relatedly, due recompense in recognition of this time. However, this is not to suggest a uniform preference for incentivised sexual healthcare. Some GPs recognised that this was likely to be associated with protocolled care, which may not bode well with its processual nature:
You’re not doing everything by flowcharts and guidelines. You’re making an assessment about that person as an individual and their risks for things… doctors make decisions all the time that aren’t according to guidelines.
Furthermore, incentive payments for sexual healthcare were associated with discourse around, ‘access’. For instance, some GPs commented on the need for information that was obtainable and user-friendly; while others considered how an increase in sexual health testing might increase consultation times and affect patient throughput:
that’s actually quite extensive. If you really do the HIV [human immunodeficiency virus] pre-test counselling properly, or as it’s done in the books, that alone could be a whole consultation.
Key findings
Collectively, the findings from both the thematic and lexical analyses connect with agency theory in three ways. First, identity as a general practitioner might reduce the attention awarded to health issues that are considered infrequent. General practice might be dominated by perceived priorities; as such, GPs might require additional guidance on the conditions they have limited exposure to. Second, the findings allude to the influential role of self-interest – for instance, the need to manage time – as well as personal interests – like, the need to be primarily familiar with evidence-based practices deemed to have direct relevance to current patients. Irrespective of the desires of the principal – that is, the organisation in which the GPs worked or their patients – the agents – namely, the GPs – largely self-organised around particular interests. Third, the findings draw attention to the difficulty principals can face when attempting to influence the behaviour of agents who are accustomed to particular practices. The challenge for the principal is to enable those who ‘think [they]… sort of know what to do’ to reappraise well-trodden cognitive paths:
you get set in the ways of patterns… Unless you graduated last year… you’re set in your ways of investigating and treating and it takes a little bit more… to change things.
Institutional theory
Institutional theory encourages us to consider the, ‘processes used by organizations to adapt to the political, cultural, and social demands of their environment and gain legitimacy in the eyes of stakeholders’ ([87], p. 84). This study considers these processes from the perspective of the GP, thereby foregrounding institutional work, rather than institutional logics [88]. Although these organisational processes can constrain change, they can also help individuals to understand how the organisation functions and identify viable ways to introduce and sustain change.
Thematic analysis
A thematic analysis of the research material suggests that, for the most part, the GPs were unable to describe the ways their work-context functioned. Notwithstanding cursory references to patient-booking systems, bulk-billing, and the use of information technology, they seldom detailed the ways their practices were organised, administered, and/or governed:
If you’ve got good software, they’ll actually put those templates in for you, so that when you’re doing investigations or tests… you’ve already got that in place.
Although a few GPs described occasional opportunities to shape organisational practices, there was little active involvement in organisational life:
We have a larger practice meeting with everyone including the receptionists… maybe twice a year… There, we could also sort out issues of how the practice runs… how results are dealt with, how the receptionists communicate with us and vice-versa, and how appointments are run and whether there are things that can be changed.
Notwithstanding the aforesaid excerpt, the GPs seldom recognised an association between their work-context and their professional role. With few exceptions, general practice was typically described as occurring behind closed doors, somewhat dissociated from factors beyond the clinic. For instance, when asked whether organisational factors influenced their capacity to provide evidence-based practice, a GP stated:
The practice doesn’t do much at all – it’s the GP.
According to the GPs, management fundamentally occurred at a micro level as they attended to patients’ clinical needs. They spoke of filtering the information that patients presented; eliciting further information when required (or at least, attempting to); negotiating patient relationships; diagnosing and treating conditions; and helping patients to manage these conditions:
The actual style of management will all vary… Some colleagues of mine are fantastic; they’ll spend half-an-hour just really counselling the patient, whereas some colleagues might say, ‘Well this is the result, this is the treatment, see you later’… or, ‘I can refer you to a further clinic’.
Given the GPs’ key role as clinicians (even among the five sole clinicians who managed their own practices), the paucity of detailed references to institutional life might be attributed to a range of reasons. For instance, the GPs might have been unfamiliar with, overwhelmed by, and/or uninterested in the organisation in which they worked, which was obliged to adhere to national standards. Similarly, they might not have considered the operation of the practice within their role, preferring to distance themselves from managerial responsibilities:
Every year I say this is the last year I’ll go through accreditation.
Although it is not the purpose of this article to hypothesise reasons, these findings do not portray the GPs as inextricably connected to their practices. But rather, they seem somewhat disconnected from institutional work, particularly those practices that maintain the heavily-regulated institution of medicine.
An exception however pertains to one GP who used her institutional savoir faire to promote sexual health. She was the only female GP in a practice of male GPs who were largely uncomfortable with sexual healthcare. Her expressed interest in sexual healthcare offered some relief to her colleagues who were content (if not relieved) to refer most, if not all sexual health cases to her. In addition to allowing her opportunity to develop her expertise in this area, it also helped to ensure that evidence-based sexual healthcare was delivered by the practice. This suggests the benefit of institutional savviness, whereby familiarity with the practice and its modus operandi can be used to introduce and sustain health services that might not be offered otherwise:
The blokes have all been very supportive because they’ve said, ‘Fantastic, you can do all that’… they’ve put an advertising campaign out so that people are aware that I’ve got sexual health and reproductive health interests.
Lexical analysis
Complementing this thematic analysis, a lexical analysis was conducted by developing three concept maps. Within the first, the 21 GPs were categorised according to their years of experience (see Fig. 4); within the second, they were categorised according to their year of graduation (see Fig. 5); and within the third, the GPs were categorised according to whether or not they were a Fellow of the RACGP (see Fig. 6). Each map is interpreted in turn.
Within Fig. 4, the concept, ‘clinical knowledge’, is closer to the category of GPs with less than ten years of experience, while the concept, ‘clinical practices’ is closer to the category of those with more than ten years of experience, and thus, more likely to have established practice or routines. This suggests those with less clinical experience primarily referred to clinical guidelines, resources, and other repositories of knowledge, while those with greater experience spoke of screening, testing, and treating. Furthermore, these experienced GPs often noted the value of ‘meetings’ in which they would confer with, and learn from clinical peers, rather than the aforesaid knowledge repositories:
I go to [Division] meetings and sometimes the… issues [discussed]… are probably very compact. I think that’s probably been the most useful.
we could do a lot better at having regular clinical meetings… we’ve got about six doctors [here]… and there isn’t a day goes by when we’re all here at once.
Figure 4 also situates the concept, ‘practice’, closer to the category of GPs with less than ten years of experience. This suggests that those with relatively less time within the profession spoke of ways in which they performed and enacted their role. Sometimes, their ‘practice’ abraded against organisational requirements, thus revealing connections between the individual clinician and the institution they represented:
[The] quality cycle involves a clinical audit… It involves an audit at the beginning, and then an audit to see if the changes everybody agreed on have… been implemented… We do it, but we could do it better…We haven’t incorporated it that well enough into the culture of the practice, so a few people do that, but it’s not generalised.
Figure 5 locates the concept, ‘tend’, close to the category of GPs that graduated after 1982. These younger GPs largely referred to the ways they readily sourced information, independently, to guide their practice. These individual efforts reveal a disconnect from the practice they were affiliated with, and the clinical colleagues therein. Rather than refer to organisational resources, including the colleagues therein, they were more inclined to use familiar resources beyond the organisation, including teaching aides and mentors:
my supervisor’s got a lot of information… I can just call him … he’s my main resource… he’s got quite an evidence-based mind, so I feel comfortable asking him what he thinks about something because often it’s not just his opinion; he would have read a lot and done a lot of research on the particular topic… if you notice over… time that [a doctor]… always prescribe[s] an antibiotic for upper respiratory tract infections, or they always give a steroid for itchy skin… you kind of go, ‘Well, obviously you’re just doing that because you don’t want to think about it’. So, I’ve just stopped asking those kinds of people.
The aforesaid excerpt helps to clarify this penchant for familiar resources that lie beyond the immediate organisational domain – not only why particular resources were used, but how their value came to be recognised. As the excerpt suggests, some GPs thoughtfully observed whether their colleagues dutifully complied with what their profession or their organisation expected, and how they deviated from these expectations to deliver what they understood to be evidence-based care.
Figure 5 places ‘clinical practices’ and ‘clinical knowledge’ thematically closer to the category of GPs who graduated after 1982, as these concepts are located within the largest theme. This suggests these relatively inexperienced GPs made greater reference to varied clinical resources, discerning appraisal processes to determine their value, the use of preferred sources of knowledge, and the delivery of sexual healthcare:
I don’t use guidelines as a backup tool; I use research as a backup tool… guidelines come from somewhere, and unless you know exactly where they come from – it’s a summary… When someone asks you for proof, I don’t want to use a tool as proof.
Conversely, those who graduated before 1982 are connected with discourse on being ‘aware’. Cognisant of the potential fragility of the patient relationship, they were conversant with how to broach, discuss, and deliver sexual healthcare. Embedded within their profession, some were unable to precisely articulate how they developed these skills – yet they recognised the ways in which context, including the patients they consulted, shaped what they did and how they did it:
I don’t pretend… that I’m an expert… but I certainly am aware of, especially in young people, the potential problems.
here, it’s pretty much suburbia; it’s not like in Kings Cross [a city suburb]… we are aware of the STDs [sexually transmitted diseases] among certain age groups… So we just raise the index of suspicion and screen them if it’s possible.
Together, Figs. 4 and 5 suggest a form of cognitive inertia is associated with discourse on sexual healthcare, when considering the GPs according to their years of experience and year of graduation. Those with over ten years of experiences and (related to this) those who graduated before 1982 seemed to own the language on ‘clinical practices’, relative to their inexperienced counterparts. This might indicate a greater preference for institutional ‘rules of thumb’ ([22], p. 489) than different forms of ‘clinical knowledge’. What these findings reveal is that experience is a powerful predictor in terms of engagement with clinical guidelines and resources. Although inexperienced GPs might frequently draw on external resources to supplement their knowledge-base, this tendency perhaps for some, fades over time.
Within Fig. 6, although the concepts, ‘clinical knowledge’ and ‘clinical practices’, are equidistant between the categories of GPs who are, and are not Fellows of the RACGP, it is only the former group that has a direct relationship to discourse on both concepts. This suggests that Fellows of the RACGP made greater direct references to both clinical resources and their use. This is supported by the position of, ‘access’, which is closer to the category of RACGP Fellows:
it’s very important that we have access to clear and up-to-date information on things like chlamydia, gonorrhoea, hepatitis, because it’s all so daunting for the patient and they’ve just got a horrible sinking feeling.
to have things online can be very helpful in that sense, because at least you can do ongoing education.
Key findings
The thematic and lexical analyses reveal the relevance of institutional theory by highlighting the ways in which embeddedness within an organisation and a profession can shape clinical practices. Although the thematic analysis largely suggests the GPs were somewhat disconnected from institutional life, it also revealed the value of institutional savviness. Extending this finding, the lexical analysis illustrated how experience can be both an asset and a limitation when attempting to engage with, and keep abreast of evidence-based practices.
Situated change theory
The situated change theory suggests that change is emergent and evolves over time. Furthermore, subtle change is no less significant than large-scale, deliberate, orchestrated change [9].
Thematic analysis
Following the thematic analysis, this was demonstrated by several GPs, particularly those who had a personal interest in sexual healthcare. While some spoke of adapting clinical guidelines to their clientele, others participated in self-initiated study groups to review and debate sexual healthcare resources:
me and a couple other of my colleagues from a different practice… are in a study group and we look up guidelines for each sexual health problem… and then we’d go through that and then I’d base my practice largely on that.
Similarly, a young female GP spoke of availing herself to information from an array of sources. In addition to clinical guidelines and professional development workshops, she consulted ‘as many people as possible’. Furthermore, she reflected on these discussions and identified feasible strategies to improve her own practices. For instance, inspired by a ‘long and… open’ discussion with colleagues, she recognised some of the awkwardness she experienced when consulting mature-age male patients about sexual health; this was the impetus for personal change. She endeavoured to better understand her practices, harness opportunities to deliver sexual healthcare to this cohort, and gauge improvement:
I used to photograph myself after each consultation to see how red I’d gone to… sort of mark how red I was, because I just felt very uncomfortable… now I don’t blush at all… I’m still not fully, completely comfortable, but I’m much better than I was.
Although multiple sources of information helped this GP to transform her practice, others spoke of information-overload. Some grew indifferent towards the resources they received from the government, not-for-profit, or corporate sectors; this was because the resources needed time and concentration – assets that were largely limited. Such indifference might suggest a retreat to well-trodden cognitive paths:
I did have a look at [the STI Testing Tool]… and probably I was a little bit more aware for the first little while, but I think I’ve slipped back into my old habits, to be honest.
This reliance on familiar practices is supported by GP responses to the clinical vignettes they were presented with on sexual healthcare. Although most appropriately indicated they would screen the patient for chlamydia (90%) and the Hepatitis B virus (65%), many also inappropriately noted they would screen for gonorrhoea (65%) and HIV (70%). The suggested use of these unnecessary tests was largely consistent across both stages of data collection. An interpretation here is that change does not occur instantly, but rather is characterised by a series of forwards and backwards mini-steps that require time to fully emerge, if at all.
A thematic analysis of the research material suggests that limited responsiveness might be curbed using novel channels to communicate information, like public health campaigns and sexual health training. Some GPs indicated greater interest in sexual healthcare due to broad initiatives to promote sexual health:
It’s just become a lot more in journalism and the pathology department newsletters.
These initiatives helped to ensure that sexual healthcare remained on the GP-radar. Similarly, sexual health training enabled the GPs to delve deeper into relatively unfamiliar territory. They had opportunity to practice skills that might have remained out-of-form:
we had a… series of clinics that you could self-place in sexual health clinics, just sitting in and sometimes they’d let us consult… sitting in with the sexual health registrars and… specialists and… learning from them.
Lexical analysis
To examine change over time, a lexical analysis was conducted by developing a concept map, in which the research material was categorised according to the stage of data collection (see Fig. 7). The map locates the concept, ‘clinical knowledge’, closer to the category denoting the first stage of data collection, while, ‘clinical practices’, is closer to the category denoting the second. This suggests the GPs’ utterances had a greater focus on artefacts of knowledge, like guidelines, during the initial interview, at which they were presented with the STI Testing Tool, while there was greater focus on the delivery of healthcare, during the subsequent interview. Curiously, the concept, ‘practice’, is located at the tag associated with the first stage – it is worth noting that this concept, unlike ‘clinical practices’, was not created by merging conceptually similar concepts; but rather, it represents unaltered ‘collections of words that generally travel together throughout the text’ ([48], p. 9). An examination of this concept indicates that, during the initial interview, the GPs largely described intuitive, routinised practices, whereby the delivery of sexual healthcare followed well-worn cognitive paths:
you’ve seen this before and you know how to deal with it, so… unless… the treatment’s not working, then… I think it’s easy… the more time you spend in general practice.
Some GPs indicated that over time, they awarded greater primacy to their internal repositories of knowledge, except when uncertainty prompted a search for external knowledge. Knowledge thus became embodied in practice:
you read about the [guidelines]… and then they just become part of my embedded practice
I certainly use the sexual health clinics… just ringing them and asking them for advice.
The concept, ‘Clinical practices’, which denotes screening, testing, and treating, is relatively more associated with the second round of interviews, which occurred three to four months after the GPs were provided with the STI Testing Tool. This is not to suggest their practices changed; but rather, that their language changed, whereby there was greater focus on how they performed their role and enacted their knowledge:
I had a patient who was a man who had sex with men. I was at a loss to know what to test for – here it is [picks up the STI Testing Tool]… I remember thinking, ‘Oh my God, where am I going to find out what’s the appropriate test?’
They described how the initial interview, and the anticipation of the second, prompted different observations of the self and different conversations with others. This is reaffirmed by the concept, ‘meeting’, which refers to meeting with the researcher, rather than ‘meetings’ with clinical colleagues:
immediately after our meeting last time, it was more in the forefront in terms of actually approaching patients and actually making it part of the consultation, if that’s not what they came in for, and… I thought [about whether] it was appropriate to at least bring up the topic, even if we didn’t do anything at that consultation.
I put the effort more in taking more sexual history, just asking people about the relationships and their partners and if they’ve changed partners or had more than one partner. I certainly aim to do it more, I’m aware of it more.
Yet the improvisations that were triggered, in part, by the novelty of the STI Testing Tool and interviews with the researcher, sometimes paled against other contributors to their knowledge, including familiar resources that could be readily sourced within the organisation they worked, and trusted teaching aides. Consider for instance, the concept, ‘aware’, which is positioned close to the category denoting stage two of the study. Within this concept are excerpts in which the GPs spoke of myriad resources they were cognisant of, including ‘Therapeutic Guidelines… [and the] Red Book guidelines’, among others:
I’m still aware of the same resources.
it’s what we have been taught more than anything else. There isn’t a lot in the way of resources that I’ve been drawn attention to.
Reflecting situated change theory, this concept map illustrates the dynamic, gradual, vacillating, and faltering nature of change. The mere exposure to, and comprehension of knowledge artefacts is unlikely to simply align individual behaviours with evidence, as defined by accredited organisations. But rather, knowledge artefacts might help to ignite (even if temporarily): reflectivity and reflexivity [89] around whether and how change might happen, as well as marginal improvisations, with their associated slippages. This reveals the situatedness of knowledge translation – a process of mini defeats and victories, shaped by contextual nuances. The GPs, as registered professionals who largely worked behind closed doors, performed knowledge work within a context that simultaneously structured and freed their thinking and their practices to determine, ‘what things get done and how they are done’ ([90], p. x). This in turn can open additional opportunities for change – as Weick indicated:
The advantages of emergent change include its capability to increase readiness for and receptiveness to… change and to institutionalize whatever sticks… sensitivity to local contingencies… experimentation, learning, and sensemaking; comprehensibility and manageability; likelihood of satisfying needs for autonomy, control, and expression; proneness to swift implementation; resistance to unraveling; ability to exploit existing tacit knowledge; and tightened and shortened feedback loops from results to action ([91], p. 227).
As such, seemingly trivial change in patient consultations, the consideration of resources, or recognition of awkwardness around sexual healthcare might prime the GP towards evidence-based care – not necessarily as defined by accredited organisations, but rather, as a practice that reflects the situated blend of clinician expertise; patient (and potentially carer) preferences; available resources; and the context of care. This is supported by the relative infrequency of those exceptional strategies used by a small number of GPs to explicitly change their sexual healthcare practices. The challenges that GPs face in familiarising with, synthesising, and adhering to ‘evidence’, while managing their workload and accommodating patient expectations, might suggest that these exceptional strategies are precisely that; the exception. Most of their counterparts appeared to inhabit a space that either: primed them to varying degrees of (less exceptional) change; or pushed them back towards the familiar.
Key findings
Although the thematic analysis elucidated the factors that influenced change among the GPs, the lexical analysis clarified the dynamic nature of change. This confirms the complementary value of the two approaches.