Stage 01: Co-Definition/Understand the Behaviour Activity 1.1 Workshop 01: Shared Understanding

** During the development of the New UTI Pathway for the ED, the ED SpR doctor responsible for leading this process, interacted with a number of nurses, HCAs, and doctors working in the ED. Most of these interactions took place within the unit, via face-to-face conversations. Additionally, the ED SpR doctor also sought the assessment and input from other stakeholders, using both the WhatsApp group, and email exchange.

4.3.1 Stage 01: Co-Definition/Understand the Behaviour

The first activity involving the Core Group of stakeholders consisted of a workshop in which card-sorting (Kensing et al., 1996; Sanders et al., 2010), user-journeys (adapted as a ‘care journey’) (Martin & Hanington, 2012), and group discussion methods (Aldersey-Williams et al., 1999) were employed to make collective sense of a large volume of findings stemming from in-depth interviews previously conducted with ED staff (see section 4.1.2 above). The workshop core objective was to develop a shared understanding among the participants about the main behavioural issues concerning UTI diagnosis and treatment.

154 A total of one-hundred statements taken from the interview study (PQS) were

converted into prompt cards, to be assessed and analysed by the workshop participants (Figures 4.2 and 4.3). The seven attending participants were divided into two groups as follows:

GROUP 1 – one theme: Why test – influences on decision to test (totalling 46 prompt cards).

Participants: consultant geriatrician/professor, healthcare researcher, consultant urogynaecologist, specialist pharmacist

GROUP 2 – five themes: Why not test – reasons not to test; Interpretation of urine dip result; Outcome of urine dip test; Guidelines about urine testing and UTI;

Education and training about UTI (totalling 54 prompt cards).

Participants: consultant microbiologist, consultant geriatrician, junior doctor

Due to the large volume of data contained across the 6 original themes and their uneven distribution (46 cards, almost half of the total, was concentrated on one of the themes), the four participants of Group 1 worked on a single theme, Why Test.

Conversely, the three participants in Group 2 focused on the remaining five themes, accounting for the other 54 cards. The division of participants per group was organic and led by the participants themselves.

The facilitator suggested that, at this first process of data selection, participants made use of dialectic intuition, sifting through the cards without excessive reflective

consideration, trusting their tacit knowledge of the issues when deciding to keep or put aside the cards within the themes the groups were looking into. Both groups utilised intra-group dialogue in order to make decisions regarding which cards to keep and which to discard. The facilitator remained mostly silent, offering sporadic advice when needed.

155 Figure 4.2 Cards clustered within subthemes created by participants of Group 1

Figure 4.3 Cards organised by participants of Group 2 with additional comments and redefinition of themes

The selected cards were then used to plot issues into care journey maps – previously prepared by the researchers – in an attempt to connect the suboptimal behaviours of specific professional groups (i.e. doctors, nurses, health care assistants, laboratorians

156 etc.), to particular points in time (admission, symptoms, actions/resources, diagnostic, treatment, discharge).

Each group took a different approach to this activity. While Group 2 used the care journey map template as provided by the workshop facilitators (Fig. 4.4), Group 1 felt constrained by the format and chose to devise their own visualisation of how the issues selected were interconnected (Fig. 4.5).

Figure 4.4 Issues plotted by Group 2 into care journey (digital version from original)

157 Figure 4.5 Group 1’s visualisation of the issues involved in why staff decide to use urine dip

tests in the ED (digital version from original)

The workshop finished with a group discussion during which participants presented their work process and outcomes to each other, and talked about the activities, so that the groups could reflect on their different perspectives and results. The observed differences were mainly a consequence of variations in their expertise and understanding of urinary tract infection. Also, because, due to the overwhelming number of findings to make sense of, the two groups had to analyse different sets of statements. In terms of approach, the main distinction between the work process of each group was that Group 1’s approach seemed more organic and erratic; this group was also less considerate of the facilitator’s suggestion of not trying to classify the findings at the first stage of the activity when the main goal was to select cards. The approach of Group 2 was more systematic, progressing through each of the five themes in order, and being more rigorous in following the instructions, selecting and

discarding cards first, then categorising and seeking relationships between the issues described in each of the cards.

The reflective discussion worked primarily to establish a common knowledge base regarding the challenges of diagnosing and treating UTI in the ED department, also

158 helping to establish group cohesion for future activities, since many participants had never worked together before this workshop.

Subsequent to the activities of Workshop 1, the researcher prepared a comparative analysis of the main issues identified and raised by the two groups of participants (Fig.

4.6). This process helped to surface some overlapping and complementary issues concerning the various aspects involved in diagnosing and managing UTI in the emergency department of the LRI. This analysis was used in preparation of a visual map to be used in Workshop 2, when the stakeholders would continue to build on the findings stemming from the previous interview study (PQS) in order to elaborate upon a long list of behavioural challenges to be later prioritised and tackled.

Figure 4.6 Comparative analysis of the issues selected by both groups (made by the researcher from the materials produced by the participants in Workshop 01)

159 Table 4.5 Summary of Workshop 01