Theme 1: In the grey zone

Certain presentations and constitutional symptoms were clinically ambiguous and considered potentially consistent with UTI even in the absence of urinary features, so would trigger clinicians to order UC perceiving this would reduce uncertainty.

Inability to get an accurate history was cited as a complicating factor, particularly with delirium in older people and conditions which made communication challenging. Some participants defined confusion as a key symptom, “All the confused ones have UTIs.” (P21), while others indicated it required clinical judgment.

Catheterized patients could also present diagnostic challenges and potential for premature closure or confirmation bias.

Some patient presentations perceived to be in the grey zone were more relevant to specific settings. For example, abdominal pain in General Surgery patients or ambiguous blood test results such as impaired kidney function. UC were ordered with the perception they would exclude a UTI.

Theme 2: The pressure to act

Clinicians’ experience of internal and external pressure toward action could impact UC ordering. Fear of uncertainty, the expectations of others, and the demands of the healthcare system encouraged “just in case” testing.

Junior doctors and senior doctors, recollecting their junior days spoke about uncertainty leading them to order tests to mitigate their lack of experience and confidence. However, junior doctors and nurses also described doing what they believed were unnecessary tests simply because they were told to by their seniors. This expectation was then reinforced through peer pressure and contributed to “for completeness” being a common rationale for UC.

Participants also reported that sometimes they might order UC at patient or family request. Ordering a test could fulfill a clinician’s own desire to feel like they were doing something to help.

Furthermore, these pressures to test were framed as a defensive practice against potential complaints or investigations by regulatory bodies.

Theme 3: It depends on who you talk to

Knowledge and communication gaps between clinicians influenced testing behaviors in a range of ways. Differences in participant knowledge across professions, settings, and levels of seniority were evident. This extended to what participants believed about others knowledge and contribution to low-value UC.

ED participants estimated that most tests were unnecessary, while medical and surgical participants often did not perceive many unnecessary UC. In discussions about whether UC were needed before admission onto a ward, inconsistency was an underlying issue:

Interprofessional miscommunication contributed to some unnecessary UC. Doctors perceived nurses as trying to be helpful but lacking clinical knowledge to determine or question test appropriateness, while nurses described doctors’ poor communication of testing rationale. Nurses collected the UC sample in almost all cases, but doctors seemed to expect the nurse to do the request form without knowing the indication.

In another example, a non-culture test on urine could be intended, but a UC was sent instead.

Varied perceptions about the consequences of unnecessary UC also influenced testing practices. Although some participants were concerned about misdiagnosis, diagnostic delay, and downstream antibiotic use and resistance, most participants perceived financial costs to the organization as the main drawback. This led some to favor a less expensive, but also potentially unnecessary test.

Alternatively, participants noted that in comparison to other diagnostics, urine tests were inexpensive, non-invasive, and easy to collect, inferring these characteristics limited motivation to reduce testing. Others believed testing was ultimately beneficial to patient care.

Theme 4: It’s just how we do things here

Hospital cultural norms and processes further encouraged low-value UC. Descriptions of how things were done revealed both dogma and inertia behind status quo practices.

ED participants identified a major reason for unnecessary UC was ED staff preemptively sending samples to the laboratory because they believed a specialty would not accept a patient without it. Fatalistic attitudes towards challenging other specialities were apparent.

Similar passivity was expressed about UC undertaken for septic symptoms, with phrases such as “the septic screen reflex,” “scattergun approach,” “knee jerk reaction,” and “a bit pointless.”

Several relatively new staff reflected on differences in practice from those at their former hospitals, indicative of cultural embeddedness.

Inertia around testing was linked to perceived efficiency and patient flow. Examples included nurses batching samples and dipstick testing while patients were waiting in ED, opportunistically getting a sample when a patient wanted the bathroom or even sending off samples found randomly on the wards. Nurses and Health Care Assistants often sent samples in advance of the doctor seeing the patient.

The relationship between efficiency concerns and apparent complacency over low-value UC extended to why doctors didn’t cancel incorrect orders:

Theme 5: Solutions to change the culture

Strategies that empowered clinicians not to test were viewed as critical to reducing unnecessary UC. Education was a favored strategy, but opinions varied on content, delivery, timing, and who needed it.

Given the hierarchical dynamics of medicine, participants felt it was important for key leaders to endorse guidelines or process changes. This was particularly noted in relation to overcoming interdepartmental differences in testing expectations.

Having grassroots clinical champions drive quality improvement initiatives was also seen as pivotal for enabling cultural change. A nurse recalled this approach working for other low-value practices.

The emphasis on culture change was further reflected in wariness toward mandatory solutions such as limiting access to UC through the laboratory or requiring clinical indications on forms. Doctor participants generally believed doctors would game the system if their clinical autonomy was restricted or workflows impeded.

Nurses, however, were optimistic that mandatory clinical indications would be more efficient.