Defensive healthcare practice: Systematic review of qualitative studies and systems-based logic model

Theo Lorenc*, Katy Sutcliffe, Claire Louise Khouja, Melissa Harden, Rebecca Rees, Pauline Meskell, Juliette O'Connell, Quan Nha Hong, Amanda Jayne Sowden, James Thomas

*Corresponding author for this work

Research output: Book/ReportCommissioned report


‘Defensive practice’ refers to clinicians modifying their practice to reduce the risk of litigation or complaints because of negative patient outcomes. This could take the form, for example, of overusing treatments or diagnostics which are not
medically necessary, or avoiding certain treatments which are potentially beneficial but risky. Some have argued that the risk of litigation is a major driver
of increased healthcare costs, although the evidence is equivocal.
This review combined two approaches to investigate how defensive practice is understood, how it affects practice, and its potential broader impacts. First, we carried out a systematic review and synthesis of qualitative evidence, including studies of clinicians’ views and experiences of defensive practice. This review included 15 studies. Second, we constructed a systems-based logic model to understand the institutional and cultural drivers of defensive practice.
Qualitative evidence synthesis
The findings show that a range of clinical decisions and treatment practices may
be motivated by concern for litigation risk, including Caesarean delivery, induction of labour, foetal monitoring, diagnostic testing, and referrals. Many participants also describe over-documentation as a form of defensive practice. Many participants see the threat of litigation as pervasive and unavoidable, and feel threatened by it. However, other motivations also enter into defensive practice: the desire to avoid adverse events; pressure from patients or families; the loss of trust in the clinician-patient relationship; and a broader culture which is seen to be intolerant of risk and suspicious of clinicians in general.
Participants identify several negative impacts of defensive practice on clinicians and patients. It affects clinicians’ perceived autonomy and their job satisfaction and may have broader emotional impacts on clinicians. It can lead to overtreatment and overdiagnosis, and poorer-quality care resulting from the diversion of clinician time and effort into documentation. Several participants reported avoiding certain patients, settings or clinical specialisms – particularly those involving patients with complex needs – to reduce litigation risk, suggesting that defensive practice could exacerbate health inequalities for underserved populations. Defensive practice may impair trusting, empathetic relationships between clinicians and patients.
Systems-based logic model
The analysis for the systems-based logic model identifies that whilst defensive practice may have been initially driven by a rational fear of litigation, it appears that over time the fear of litigation has transcended the objective risk of litigation. The logic model also suggests that the widespread fear of litigation and common awareness of the phenomenon means that defensive practice has developed into a cultural norm. This normalisation has evolved to such an extent that key institutional practices and policies reflect, and thereby further entrench, defensive practice as a cultural norm.
Defensive practice no longer appears to be driven by either an objective or irrational fear of litigation at the micro-system level, but driven instead by an interwoven network of widely-held cultural ideas (macrosystem) and by the embodiment of these ideas in institutional policies and practices (exosystem).
The findings suggest that defensive practice should be seen not simply as a reaction to litigation risk, but as a focus for a broader range of concerns about clinical practice, including perceptions that clinical roles are being deskilled and that practice more generally is becoming bureaucratised and depersonalised. Reforms narrowly focused on the medico-legal context, without attention to the institutional and cultural processes by which defensive practice becomes entrenched, may have limited scope to reduce overtreatment and improve the quality of care.
Original languageEnglish
Place of PublicationLondon
PublisherEPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London.
Commissioning bodyNIHR Policy Research Programme
Number of pages116
ISBN (Electronic)978-1-911605-48-5
Publication statusPublished - 2023


  • Defensive
  • Medicine
  • Practice
  • Healthcare
  • Logic model
  • Systematic review
  • Qualitative

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