Table Of ContentPerforming under pressure:
A framework for understanding healthcare
performance in complex, dynamic and
unpredictable situations in Ecuador
Alicia Marifernanda Zavala Calahorrano
MD. MSc
School of Medicine
Griffith University, QLD, Australia
A thesis submitted in fulfilment of the requirements
for the degree of Doctor of Philosophy
December 2016
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Abstract
Aim: This study examines the performance of healthcare professionals in a variety of high-
pressure scenarios.
Methodology: In order to gain a broad, detailed, practical understanding of ‘pressure’ and its
impact on performance, a wide range of clinical scenarios were analysed using a Grounded
Theory approach. A total of forty-five interviews were undertaken with key health
professionals (medical doctors, nurses, paramedics) in a variety of locations including the
Galapagos Islands, the Amazon Region, the Andean Highlands, and the Pacific Coast. Using
participants as field observers, diverse scenarios were captured: emergency field work,
natural disasters, emergency departments, large and small medical facilities, intensive care
units and operating theatres.
Results: The research took an ‘emic’ approach to understanding ‘pressure’, whereby
participants identified scenarios that were important to them and how they experienced
‘pressure’ personally. Three broad interacting categories of factors contribute to ‘pressure’:
personnel, clinical complexity, and the context in which teams operate. These factors are not
static, and using dramaturgical analysis, I developed a ‘performative matrix’ that helped
deepen understanding of performance under pressure as a dynamic, collectively-determined
social phenomenon shaped by facilities and systems (staging); teams and personal qualities
(roles and actors), and case complexity (plots and storylines).
Conclusion: The study contributes to the body of knowledge regarding the understanding of
performance under pressure and, rather than capturing a static view of individuals and
outcomes, this study models performance as a complex unfolding of collective drama. Using
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this model provided the ability to conceptualise and analyse performance under pressure and
to propose pathways for optimising performance in uncertain and dynamic scenarios.
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Statement of Originality
This work has not previously been submitted for a degree or diploma in any university. To the
best of my knowledge and belief, the thesis contains no material previously published or
written by another person except where due reference is made in the thesis itself.
(Signed)________________________________
Alicia Zavala Calahorrano
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Table of Contents
Abstract
ii
Statement of Originality............................................................................................................iv
Table of Contents.......................................................................................................................v
List of Figures...........................................................................................................................xi
List of Tables ...........................................................................................................................xii
Acknowledgments.................................................................................................................. xiii
Chapter 1
Introduction......................................................................................................14
1.1 Introduction..................................................................................................................14
1.2 Introducing the researcher............................................................................................16
1.3 Ecuador’s demographic profile....................................................................................17
1.4 The healthcare system in Ecuador................................................................................21
1.5 Statement of the problem .............................................................................................22
1.6 Significance of the study..............................................................................................23
1.7 Expected study outcomes.............................................................................................24
1.8 Methodological approach.............................................................................................24
1.9 Importance of the study................................................................................................26
Chapter 2
Decision-making under pressure....................................................................27
2.1 Clinical decision-making processes under normal conditions.....................................27
2.2 Decision-making frameworks......................................................................................28
2.3 Decision-making processes in diagnosis and treatment under normal conditions.......32
2.3.1
Sense making....................................................................................................35
2.4 Shared decision-making model in a standard consultation..........................................35
2.5 Clinical decision-making in dynamic and unpredictable situations.............................47
2.5.1
Sense making in unpredictable situations ........................................................47
2.6 Factors affecting clinical decision-making and performance ......................................49
2.6.1
Scenarios and their impact on performance .....................................................52
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2.6.2
Police and security personnel...........................................................................53
2.6.3
Aviation............................................................................................................54
2.6.4
Emergency areas ..............................................................................................54
2.6.5
Emergency medicine........................................................................................57
2.6.6
Patient outcomes and safety.............................................................................63
2.6.7
Human factors ..................................................................................................64
2.6.8
Teamwork.........................................................................................................68
2.7 Conclusions..................................................................................................................70
Chapter 3
Methodology......................................................................................................72
3.1 Introduction..................................................................................................................72
3.2 Grounded Theory: concepts and application................................................................73
3.3 Epistemology ...............................................................................................................75
3.4 Research design............................................................................................................75
3.5 Research questions.......................................................................................................77
3.6 Research aims...............................................................................................................78
3.7 Objectives.....................................................................................................................78
3.8 Methodological background.........................................................................................79
3.9 Confidentiality .............................................................................................................79
3.10 Theoretical sampling....................................................................................................80
3.11 Sample size...................................................................................................................81
3.12 Data collection .............................................................................................................82
3.13 Data analysis ................................................................................................................89
3.14 Credibility and rigour...................................................................................................90
3.15 Conceptualisation.........................................................................................................93
3.16 Building categories.......................................................................................................94
3.17 Dramaturgy ..................................................................................................................96
3.18 Theories about performing...........................................................................................99
3.19 Goffman: The presentation of self in everyday life ...................................................102
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3.20 The process of staging................................................................................................103
3.21 Critiques of Goffman’s work .....................................................................................105
3.22 Impression management.............................................................................................106
3.23 Summary ....................................................................................................................107
Chapter 4
Scenarios..........................................................................................................109
4.1 The eruption of Tungurahua volcano.........................................................................109
4.2 From Nepal to Ecuador and disaster preparation.......................................................110
4.3 Hospital evacuation after an earthquake ....................................................................111
4.4 A day in the life of a paramedic.................................................................................112
4.5 Rescue in the Amazon region ....................................................................................112
4.6 Double identity: fire-fighter and paramedic...............................................................114
4.7 Under water rescue.....................................................................................................115
4.8 An oil refinery: inferno ..............................................................................................117
4.9 Refinery worker dies from an electric shock .............................................................117
4.10 Civil arrest..................................................................................................................118
4.11 Disaster preparation ...................................................................................................120
4.12 Delivering twins in the jungle....................................................................................121
4.13 A patient from the Amazon region in a critical condition .........................................122
4.14 A busy cardiac department.........................................................................................123
4.15 The 1991 cholera epidemic........................................................................................126
4.16 Multiple simultaneous cardiac arrests in the ED........................................................127
4.17 Emergencies at the Galapagos Islands Hospital ........................................................129
4.18 An operating theatre...................................................................................................130
4.19 High-complexity cardiac surgery...............................................................................132
4.20 Problems in the operating theatre...............................................................................134
4.21 A post-surgical ward ..................................................................................................135
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4.22 Emergency surgery following a car accident.............................................................137
4.23 A neonatal intensive care unit....................................................................................138
4.24 Summary ....................................................................................................................139
Chapter 5
Pressure............................................................................................................140
5.1 Classes of pressure.....................................................................................................141
5.2 Pressure in relation to individuals actors ...................................................................141
5.2.1
My patients first .............................................................................................141
5.2.2
Family issues and domestic problems............................................................142
5.2.3
Personal financial issues.................................................................................144
5.2.4
Personal beliefs as a source of pressure .........................................................145
5.2.5
Emotional factors ...........................................................................................156
5.2.6
Fatigue............................................................................................................162
5.2.7
The impact of “failure” ..................................................................................163
5.2.8
Expertise.........................................................................................................164
5.3 Pressure in relation to teams ......................................................................................168
5.3.1
Inter-professional factors................................................................................170
5.3.2
Inter-professional training..............................................................................171
5.3.3
Size of the team..............................................................................................173
5.3.4
Roles and lines of authority............................................................................174
5.3.5
Cohesion, compatibility and camaraderie ......................................................175
5.3.6
Situational awareness .....................................................................................176
5.3.7
Characteristics of team members ...................................................................177
5.4 Pressure in relation to patients and case complexity..................................................184
5.4.1
Patient as pressure ..........................................................................................184
5.4.2
Patient culture and the internet.......................................................................187
5.4.3
Patient clinical outcomes................................................................................188
5.4.4
Case complexity and procedures....................................................................188
5.5 Pressure of institutions and systems...........................................................................189
5.5.1
Layout & facilities..........................................................................................190
5.6 Summary ....................................................................................................................196
Chapter 6
Performance .....................................................................................................198
6.1 The elements of performance.....................................................................................198
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6.1.1
The scenario: the stage and the plot ...............................................................198
6.1.2
Healthcare professionals and patients: cast, actors and roles.........................200
6.1.3
The patients’ illness: storyline, plots and scripts............................................207
6.1.4
Production and rehearsals...............................................................................208
6.2 Conditions that improve performance........................................................................210
6.3 Conditions that compromise performance .................................................................214
6.4 Complexity in healthcare ...........................................................................................218
6.5 Adaptation during crisis: when pressure is the status quo .........................................221
6.6 Satisfaction of accomplishment and performance .....................................................223
6.7 Summary ....................................................................................................................224
Chapter 7
Discussion: The art of performing under pressure...........................................226
7.1 Towards a model for performing under pressure.......................................................229
7.2 Bringing the elements together: the underlying metaphors .......................................230
7.2.1
Drama.............................................................................................................230
7.2.2
Orchestral models...........................................................................................233
7.2.3
Health professionals and emergency situations .............................................238
7.2.4
Performance as a process ...............................................................................243
7.3 Teamwork ..................................................................................................................243
7.4 The complexity of the healthcare system...................................................................246
7.5 Performative matrix ...................................................................................................248
7.6 The elements of the matrix.........................................................................................249
7.7 Characteristics of the matrix ......................................................................................251
7.8 Applying performative matrix....................................................................................252
7.9 Summary ....................................................................................................................254
7.10 Strengths and limitations............................................................................................255
7.10.1 Study strengths ...............................................................................................255
7.10.2 Study limitations ............................................................................................256
7.11 Recommendations......................................................................................................256
7.12 Future directions.........................................................................................................257
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7.13 Summary ....................................................................................................................259
Appendices 261
Appendix 1 How to build a matrix.....................................................................................261
Appendix 2 Scripts for matrix building .............................................................................267
Appendix 3 Participants code Highland.............................................................................277
Appendix 4 Participants for the Coast and Galapagos Islands...........................................278
Appendix 5 Participants Amazon region ...........................................................................279
Appendix 6 Interview guide...............................................................................................280
Appendix 7 Information sheet in English ..........................................................................281
Appendix 8 Information sheet in Spanish..........................................................................284
Appendix 9 Informed consent form in English..................................................................287
Appendix 10 Informed consent form in Spanish ...............................................................288
Appendix 11 Letter of Agreement .....................................................................................289
References
290
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List of Figures
Figure 1.1 Map of Ecuador, distribution of health facilities and research respondents
20
Figure 2.1 Decision-making cycle
29
Figure 2.2 Decision-making model
30
Figure 2.3 The cycle for assessing the patient
31
Figure 3.1 Data analysis Grounded Theory.
92
Figure 5.1 Sources of Pressure
197
Figure 6.1 The elements of performance
225
Figure 7.1 Musical script of L’Boheme
242
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List of Tables
Table 2.1 Doctor-patient relationship
50
Table 3.1 Distribution of participants according to regions and professions
84
Table 3.2 Distribution of participants according to gender and profession
85
Table 3.3 Distribution of participants according age and profession
85
Table 3.4 Distribution of participants according regions
86
Table 3.5 Distribution of participants according range of age
86
Table 3.6 Number of years of work experience and gender distribution
87
Table 3.7 Number of years of work experience and distribution amount professions
88
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Acknowledgments
Firstly, I would like to thank God for giving me the opportunity to embark on this journey
and for his guidance throughout these past years. To my dear mother, who was an inspiration
and to whom I owe so much gratitude for her steadfast belief in me and providing the support
needed to come to Australia. I will always love you and dedicate this work to you.
I would also like to thank my children, Maria Camila, Andres and Julio for their love and
encouragement to complete this piece of work. Camila's presence and constant support during
the ups and downs have given me strength to face this challenge. Andres with his brave heart
provided the endless strength needed in my darkest hours. Julio, your patience and wisdom
have been invaluable. To Merryl, Sharon and John who are part of my family, thank you for
your company, your helping hand and your faith.
I would like to thank all the health professionals and support staff who have contributed to
this research by sharing their in-depth stories and making this dream a reality.
I would like to give credit and thanks to my supervisors Professor Gary Day, Professor David
Plummer and Professor Anita Bamford-Wade for their constant support, guidance and
encouragement during these years. Thank you to Professor Day for opening the door to
commence this journey and for the privilege of working with Professor Plummer for his
unmitigated belief and support which constituted the bedrock upon which this work has been
built. And to the many baristas who ably supported the in-depth briefings and debriefings
under the tutelage of Professor Plummer.
Finally, I want to acknowledge The National Secretary of Technology and Science of
Ecuador for the opportunity to contribute from the beginning to the conclusion of this
journey. Griffith University for opening the door and facilitating the development this thesis;
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to the HDR Department with Professor David Shum and the HDR Convenor in Public Health
Professor Neil Harris. To the Disability Department (Griffith University) that provided the
opportunity to learn and complete this journey using assisted technology, to the outstanding
staff of the English Help Department (Griffith University) for the uncountable hours helping
me to express my ideas in another language.
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Chapter 1
Introduction
1.1
Introduction
Clinical decision-making is front and centre to every medical practitioner’s practice. Factors
influencing the decision and treatment for any patient are multifaceted. Undertaking this
research has provided an opportunity to reflect and examine ways clinicians make, implement
clinical decision-making and perform through the different stages of the consultation process.
Moreover, I will examine performance and decision-making processes in both pressured and
non-pressured situations. This research aims to create a better understanding of how
clinicians make and implement clinical decision-making and perform through the different
stages of the consultation process. The world has never faced such an enormous scale of
humanitarian need (Blaikie, Cannon, Davis, & Wisner, 2014). Those working in the health
system have a responsibility to ensure collective actions result in better health outcomes,
guaranteeing populations have access to timely and efficient health services in times of
emergency. In practice, this involves ensuring the system at all levels has in place accurate or
judicious responses to managing emergencies (based on incident management). This entails
adequate and coordinated mechanisms that include all relevant stakeholders, undertaking
joint assessments and planning with peers, by sharing health information and providing
logistical and operational support during an emergency response. This thesis addresses a
challenging landscape for healthcare professionals and endeavours to analyse performance of
health professionals at a national level and how it has adapted to the many challenges of both
internal and external conditions. This research showcases scenarios that identify the factors
that influence the responses of health professionals in diverse and changing scenarios and
examines their performance under pressure in extreme crisis situations. The aim is to
develop a model to understand clinical performance, identify the factors and critical points to
