In total 17 health services participated in focus groups (ranging from 1-2 hours), according to their allocated wave. Discussion among participant across the serial focus groups provided insights into resource allocation and decision-making, including the interplay between barriers and facilitators concerning implementation of recommendations outlined in evidence-based policy recommendation document. Five key themes emerged:
- Local data trumps, or is more influential
- How good is the evidence and does it apply to us
- It is difficult to change things
- Historically that’s how we have done things
- What if we get complaints?
Local data trumps, or is more influential
There were similarities across each wave of focus groups towards participant understanding of reading and interpreting research evidence. The nature of participant’s questions, the silence of participants or hesitation towards interpreting the systematic review appeared to reflect a lack of understanding, and confidence in understanding research data. For example, participants’ asked questions about the outcome measures reported in the included studies, and felt more should be included. They also expressed concern about why studies were included and questioned the timing of included studies.
Your research was before 12 months ago. How does that apply to the orthopaedic ward that is in practice today? (Wave (W) 2, Session (S) 1)
Specifically there appeared limited understanding about statistic interpretation. Most participants reported to be more confident in results if there were a larger number of studies supporting an outcome, in contrast to the sample size, effect size, and confidence interval reported within a given study. As a result, participants reported there was, “Insufficient data” (W6, S2) of research findings. This was closely linked with a reluctance to consider changing the status quo.
What we are saying is there is not a great number of studies. Yes, there is pooled results, but this is based on still a very limited number of studies. (W5, S2)
I guess we do not feel that there is enough evidence out there to make a change. (W2, S2)
Most participants cited a preference for making decisions according to studies they had previously relied referred to develop their current weekend clinical protocols. All of these studies advocated for weekend allied health, such as early mobilisation post-surgery. However, these studies were not included in the systematic review (criteria cited elsewhere(31)).
Surgery is an interesting one, because there is evidence for it outside of the weekend service. There is actually evidence out there with regard to early mobilisation, for a fractured knee, the knee replacement….I am inclined to say we should stick with the protocols we have got with that regards. I would not be changing anything there. (W1, S2)
After reviewing the results of the systematic review, participants reported an overwhelming response for the need to revisit internal, local health service data. Subsequent participant reports suggested that internal data was the primary source of information for consideration when making resource allocation decisions.
The lack of evidence [in the systematic reviews] does not mean that we should not be providing that service; we just do not have enough evidence ….so we deal with our own evidence. We know what works in our site or have information. (W1, S2)
Other participants indicated they preferred to verify the results for themselves before making decisions. This reportedly involved revisiting the papers in the systematic review, as well reflecting on internal data.
I think for me, I need to go back, re-read the document. I need to also go back and look at some of the data [internal] that I actually have around…. look at some of the files to see exactly what has happened. (W7, S1)
Alternatively, participants reported hearing studies in progress promoting weekend-allied health services and preferred to wait for findings to be published. As such, participants appeared to place value in incomplete research over and above completed work.
From my understanding, there is a very positive trial happening. I do not remember what they are looking at, but they think they have actually increased orthopaedic services [on the weekend], in response. (W3, S1)
Closely linked with a reliance on descriptive local knowledge when making resources decisions, was a reliance on collective data, such as benchmarking.
What about what other sites are doing?…is there benchmarking data?.(W4, S1)
An additional factor potentially driving respondents to prioritise local data and other forms of evidence, not included in the systematic review, was that the findings and recommendations were often not congruent with participants’ reported beliefs, values and wishes for their practice. Where the evidence conformed to their beliefs, the evidence was more enthusiastically accepted.
In regards to the research around the subacute setting, we would absolutely love to provide some sort of weekend service. (W1, S3)
Participants reportedly valued anecdotal evidence such as feedback or satisfaction from people receiving their health care services. At times, this appeared to be valued over and above published evidence. For example, participants stated that patient comfort, satisfaction and desire for regular contact with a therapist were integral to decision making about what services were needed.
Anecdotal data on patient comfort, you know things like that….that is what we rely on. (W2, S1)
Participants working in private settings most commonly cited the importance of patient feedback and decision-making.
You might say that, you know, I have been in private heath now, our clients are, our customers are fairly demanding. I would argue more so than when I was in public health.
(W2, S2)
Participants also strongly relied upon anecdotal staff reports, which cited that weekend allied health services facilitated flow of people through the health care service, discharge, and workload pressures, while ensuring care.
To actually churn things through [move patients] is, I suspect, why we have the weekend staff at the end of the day. (W5, S2)
- How good is the evidence and does it apply to us?
Participants readily stated that local context was a key factor informing decision-making and these were based on internal reviews of their weekend service.
We have moved services around and have a number of proposals [for weekend allied health services] ready to go. These are based on evidence so to speak of the actual work that we have been doing. (W1, S3)
Some participants reported confusion about the perceived variances in models of care across the Australian states and this impacted decision-making. For example, there was a perceived lack of sub-acute services in NSW providing the impetus for more acute services, including weekend-allied health. As a result, important local contextual differences influenced allied health manager decision making.
We do not have a very good understanding of models of care across Australia and how they are similar or different. Yet we are being asked to make decisions on evidence from some studies, not looking at the whole picture. (W5, S1)
Other frequently cited local contextual issues were the expectations of medical and nursing staff. Many participants reported that surgeon expectations influenced allied health service delivery and as such, they felt curtailed in what they could change. Despite the availability of skilled nurses, many sites reported there was an expectation of allied health providing key interventions, such as mobilising or assisting with activities of daily living. In many health services, this to informed nursing roles and staff rosters, thus, to make changes reportedly required a cultural shift underpinned by extensive consultation and education.
Now, I hear what you are saying, that things do not necessarily have to be done by a physiotherapist. But, often there are barriers that come up if [a service] it is not instigated by allied health - depending on their local culture strength. (W3, S2)
Participants reported that components of their weekend services were often funded by different divisions whereby there was the expectation to provide weekend-allied health. While making a change was not considered insurmountable, it was perceived to be difficult. As such, there was a preference among participants to continue meeting the expectations of their funders.
We could move the staff… but the difficulty comes when you have been allocated specific funding by a specific part of the organisation. I am not saying that it cannot be done, but certain parts of the service do allocate the funds (W1, S2)
We provide professional supervision for them; so we can still influence [service provision] but we cannot actually make the decisions to change weekend staffing. (W2, S3)
Overall, upper level managers cited data was only one of many components that informed decision making, such as staff availability, managing resources and system processes.
I think the complexity for managers is that published evidence is one source of data, but it is not the only source of data in which we make decisions. We draw on a systems-based approach to thinking about how services are delivered, whom they are delivered to, how we have to manipulate and be flexible with resources. Both parts of the puzzle are not necessarily things that you will go to a formal piece of evidence to look at, because it is a dynamic decision-making process. Does that make sense? (W1, S3)
- It is difficult to change things
Participant reports highlighted their hesitancy in responding to recommendations and making a decision. A key reported barrier towards implementing evidence was that participants anticipated that additional, future conflicting evidence would emerge in support of weekend allied health service delivery.
Because I don’t need to find out later that someone comes out with a really fantastic control trial in two years’ … proving equivocally that occupational therapists and physiotherapists get people out much quicker if they see them on a weekend. (W2, S1)
Another challenge expressed by participants was balancing the research evidence with what they believed to be high quality, individualised care, even if data was not available to support these beliefs.
Out of all of those, I think most clinicians probably say function and quality of life is what they are hoping to change. I do not think people go into health so they can reduce length of stay. (W2, S3)
In the absence of sufficient evidence, participants placed significant value in their clinical reasoning and the perceived effectiveness of services provided by their profession.
Yeah, just without the evidence, we are going to rely on our own reasoning, I guess, and that is what we have done. (W3, S1)
Given the majority of studies in the systematic review pertained to occupational therapy and physiotherapy services on the weekend, participants from other allied health disciplines expressed an interest in undertaking research or publishing existing, local research in order to advocate for their profession.
It is not public, but I tell you what, you really encouraged me to publish. This has really lit a fire in my belly to do some research and publish [local data] on this stuff. (W1, S1)
Overall, where there was more evidence, there was more willingness to take action.
I think our sense is probably we will be looking at the physiotherapy and occupational therapy recommendations where there are sort of more evidence taken. (W4, S1)
Interestingly for rural and regional services, the lack of allied health on the weekend was routine practice. However, metropolitan sites appeared reluctant to reflect on this variance, despite consistency with study recommendations. Instead, metropolitan participants remained silent at this point in the focus group.
- Historically, that is how we have done things
Participants who were reluctant to change weekend allied health service delivery, cited a belief in the perceived benefit of historical weekend allied practice, particularly when considering the need for allied health to respond to the timing of orthopaedic surgery.
I mean it [the recommendations] goes against the physiotherapist. And obviously we have a long tradition of providing quite extensive services to acute medical and surgical wards. (W1, S1)
We have acute care cover for the elective surgical patients on the weekend so that we can meet their requirements with most surgeries done on Thursday and Friday. (W2, S3)
When considering relocating staff in response to the recommendations, many participants reportedly feared that any weekend allied funding would be lost and re-distributed to services other than allied health.
It will take us more than 10 years to try and find that funding again - you know what I mean? We are going to shoot ourselves in the foot. (W1, S1)
Participants also reflected on the past time and effort required to successfully advocate for a weekend allied service delivery on the weekend. As a result, considering making changes was difficult and participants feared that a change in service would reflect poorly on the allied health service reputation.
We worked so hard across disciplines to actually get allied health as a recognised part of
care over the weekend (W3, S2)
- What if we get complaints
The majority of participants reported the fear of receiving complaints was a major barrier to modifying their weekend allied health service model. The most commonly cited reason was the long-standing expectation in providing a weekend service.
I think we have a lot of pushbacks from our facility if we even stop to talk about stopping weekend services that we currently provide. (W2, S2)
Enormous amount of noise [complaints]. You will also potentially get complaints from patient and patient’s family. (W1, S2)
Participant reports also suggested that some recommendations placed patients at risk of complication if they were not seen on the weekend. This had the potential to create additional costs to the organisation.
As a dietitian, it is just appalling that someone would be left [nil by mouth] for 72 hours [over the weekend]. What you are going to have to do is put in a drip, and all the cost associated with that. So, even though there may not be evidence, I think that’s a pretty big common-sense element that comes in to have an assessment from a speech pathologist, rather than having to wait… (W1, SA1)
A lot of our joint replacement patients are going home day two and if day two falls on a weekend - we are going to miss them. We need to see and review them and make sure everything is in place for when they go home. (W3, S2)
Dealing with complaints was perceived to be a time-consuming process and therefore efforts were made to pre-empt and avoid complaints wherever possible. As such, when participants anticipated complaints in response to toward making staff change to a well-established service delivery model, then they cited they need to, “Do our homework” (W6, S2)to be certain before making a change.
Perceived changes in society towards seven-day workweek was another commonly cited variance towards the need to maintain weekend allied health service delivery. Indeed, having seven day allied health was viewed as favourable in light of society expectations, such as those observed in the retail industry.
It is becoming almost archaic now: the notion of a weekend and will definitely be so in 10 years’ time. (W3, S1)