Defensive healthcare practice: systematic review of qualitative evidence

TY - JOUR

T1 - Defensive healthcare practice

T2 - systematic review of qualitative evidence

AU - Lorenc, Theo

AU - Khouja, Claire

AU - Harden, Melissa

AU - Fulbright, Helen

AU - Thomas, James

N1 - © Author(s) (or their employer(s)) 2024.

PY - 2024/7/18

Y1 - 2024/7/18

N2 - OBJECTIVE: To synthesise qualitative evidence on clinicians' views and experiences of defensive practice.DESIGN: Systematic review of qualitative data.DATA SOURCES: MEDLINE, Embase, PsycINFO, AMED, Maternity and Infant Care, CINAHL, ASSIA, Sociological Abstracts, Proquest Dissertations & Theses and PROSPERO were searched from 2000 to October 2023.ELIGIBILITY CRITERIA: We included English-language studies of clinicians which reported qualitative data on the impact of litigation or complaints on clinical practice.DATA EXTRACTION AND SYNTHESIS: We coded findings data line by line using a grounded theory approach. We assessed quality using Hawker et al's tool and synthesised data thematically. RESULTS: 17 studies were included. Participants identify a range of clinical decisions which may be defensively motivated, relating to diagnosis and documentation as well as to treatment. Defensive practice often relates to a diffuse sense of risk rather than the direct threat of litigation and may overlap with other motivations, such as perceived pressure from patients or the desire to avoid harm. Defensive practice is seen to be harmful in many ways, but again, these perceptions may gain force from broader narratives of mistrust and disempowerment, as much as from the risk of litigation.CONCLUSIONS: The idea of defensive practice, as enacted, is more complex than some theoretical accounts suggest and may often function to express broader concerns about the work of clinical care. The qualitative evidence calls into question the view of defensive practice as a key mediator linking litigation risk to inappropriate treatment and excess costs.

AB - OBJECTIVE: To synthesise qualitative evidence on clinicians' views and experiences of defensive practice.DESIGN: Systematic review of qualitative data.DATA SOURCES: MEDLINE, Embase, PsycINFO, AMED, Maternity and Infant Care, CINAHL, ASSIA, Sociological Abstracts, Proquest Dissertations & Theses and PROSPERO were searched from 2000 to October 2023.ELIGIBILITY CRITERIA: We included English-language studies of clinicians which reported qualitative data on the impact of litigation or complaints on clinical practice.DATA EXTRACTION AND SYNTHESIS: We coded findings data line by line using a grounded theory approach. We assessed quality using Hawker et al's tool and synthesised data thematically. RESULTS: 17 studies were included. Participants identify a range of clinical decisions which may be defensively motivated, relating to diagnosis and documentation as well as to treatment. Defensive practice often relates to a diffuse sense of risk rather than the direct threat of litigation and may overlap with other motivations, such as perceived pressure from patients or the desire to avoid harm. Defensive practice is seen to be harmful in many ways, but again, these perceptions may gain force from broader narratives of mistrust and disempowerment, as much as from the risk of litigation.CONCLUSIONS: The idea of defensive practice, as enacted, is more complex than some theoretical accounts suggest and may often function to express broader concerns about the work of clinical care. The qualitative evidence calls into question the view of defensive practice as a key mediator linking litigation risk to inappropriate treatment and excess costs.

KW - Humans

KW - Qualitative Research

KW - Defensive Medicine

KW - Attitude of Health Personnel

U2 - 10.1136/bmjopen-2024-085673

DO - 10.1136/bmjopen-2024-085673

M3 - Article

C2 - 39025824

SN - 2044-6055

VL - 14

JO - BMJ Open

JF - BMJ Open

IS - 7

M1 - e085673

ER -