Psychiatrists' attitudes
towards medical audit

Psychiatrists attitudes towards medical audit in its third year were sampled by questionnaire within the Oxford Regional Health Authority. Overall, positive responses towards audit were reported (p<0.05). However, there were reservations as to the time and resources available to undertake audit; and possible influences of the process upon management attitudes.

Introduction

Through the NHS reforms medical audit began initially as a confidential medical educational activity but soon the emphasis changed, highlighting the significance of its role in Quality Management and the necessity for it to be a multi-disciplinary activity along with the input from management and the views of the purchasers. To mark this shift in emphasis, the funding mechanism too have now changed and have become routed through the purchasers.

There is very little research available to indicate the attitudes and views of the clinicians in this rapidly changing climate. Bull and Firth-Curzons (1991) noted some of these attitudes from a workshop conducted with mixed groups of consultants in the early days of clinical audit. Perception of benefits included the possibility of improvements in patient care, professional education and research, multi-disciplinary working together, efficiency, management of resources and teamwork etc. Perception of disadvantages ranged from losses of valuable time, of clinical freedom, of confidentiality and of job satisfaction, together with an introduction of a `big brother/sister watching' climate and of unhealthy managerial controls. Similarly, Dwivedi (1992) has highlighted the fact that clinical audit is an important powerful tool which can be used in either a constructive or a destructive way depending upon the culture of the organisation where it is being used.

An attitude questionnaire designed by Firth-Cozens had been used in the Northern Region, North West Thames Region and the Wessex Region (Winyard, Personal communication). In the Oxford Region, too, the Regional Psychiatric Audit Committee became interested in surveying the attitudes of the psychiatrists within the Region. However, we decided to modify the Firth-Cozens questionnaire because the context for audit had moved on. A modified questionnaire was designed by the present authors and piloted within the then Oxford Region. The finalised questionnaire was sent to all Consultants and Senior Registrars and out of 110 questionnaires sent out, 75 were completed and returned.

Procedures

Psychiatrists' attitudes towards audit were investigated via the use of a likert-style questionnaire. The questionnaire was constructed using a standard procedure (Coolican, 1994). Firstly, a pool of twenty five potential questions was compiled in the form of equal numbers of positive and negative statements about audit. Then a pilot study was undertaken with psychiatrists working within the Oxford Regional Health Authority. On the basis of the returned responses, a correlational analysis was undertaken, following the guidelines in de Vaus (1990), whereby those questions with an item-total correlation of 0.3 or above were retained and those below this figure were rejected. This left eighteen questions to be used in the main survey, one half in favour and one half against audit.

This refined version of the questionnaire was sent out to all Consultant and Senior Registrar psychiatrists working in all of the eight districts within the then Oxford Regional Health Authority. Seventy five responses were received, the results from which are summarised in Appendix 1.

Analysis of Results

Given that the composition and presentation of the questionnaire was balanced in order to obviate against any possible acquiescent response set, it was therefore necessary to take this into account when analysing individual and aggregate responses.

Response	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
Average Score	5.39	11.39	19.78	28.67	9.00
Standard Deviation	6.52	8.68	6.63	11.65	5.96

This above summary table shows mean responses in each of the five categories from strongly disagree to strongly agree. It can be noted that overall, the averaged responses in support of audit were higher than those against.

For the inferential statistical analysis it was decided to use the Sign Test. The form of data yielded from the survey was deemed suitable for analysis by the Sign Test following the criteria and procedures set out in Cohen and Holliday (1984). By collapsing the Strongly Disagree/Disagree and Agree/Strongly Agree columns the data was summarised in the form of "-" and "+" responses to the questionnaire. This analysis would meet the requirements of the survey.

Reference to Appendix 1 shows that for the 18 questions used in the survey, there are 14 which are "+" and 4 which are "-", with no tied or equivocal responses. Following the procedure for the Sign Test, reference to a table of probabilities associated with the Binomial Test (Appendix 13a, Cohen and Holliday, 1984) shows that the probability of this distribution of responses being associated with the null hypothesis is 0.015. This probability is for a one-tailed test. Given that for the present survey a two-tailed test is appropriate then this probability will necessarily be doubled to 0.03. Therefore, at the 5% level of significance, it may be concluded that there was an overall response from the survey which was positive towards medical audit.

Discussion

Overall, this brief survey of psychiatrists attitudes towards audit reveals a broad movement which is supportive of the changes which have been introduced. This tendency has been shown to be statistically significant at the 5% level.

The only areas where there seemed to be some reservations about audit were the responses to questions 4, 14, 15 and 17 (see appendix 1). This suggests that psychiatrists are concerned about the lack of time and resources to undertake the audit, together with the apprehension that audit practices will result in managerial control. They also do not consider that audit has improved teamwork.

References

Bull, A. and Firth-Cozens, J. (1991) Medical Audit in Yorkshire. Yorkshire RHA document.
Cohen, A. and Holliday, M. (1984) Statistics for Social Scientists. London: Harper and Row.
Coolican, H. (1994) Research Methods and Statistics in Psychology (2nd Ed). London: Hodder and Stoughton.
de Vaus, D.A. (1990) Surveys in Social Research (second edition). London: Unwin Hyman.
Dwivedi, K.N. (1992) Role of Regional Audit Facilitators in Psychiatry. Psychiatric Bulletin. 16: 762-763.

Acknowledgement

We are grateful to the then Oxford Regional Health Authority Medical Audit Committee in Psychiatry and Community Services for the invaluable support, all the Psychiatrists in the Region who completed the questionnaires, and Mr. Lester Gill, Clinical Epidemiology Department of the Oxford Regional Health Authority for the statistical analysis at the pilot stage.

Appendix

Summary of Psychiatrists' Responses
Questions	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Summary: Positive or Negative
1. From your experience, to what extent would your own definition of medical audit agree with the DoH definition given in the covering letter?	1	4	17	35	17	+
2. Audit helps disseminate examples of good practice.	1	4	27	34	9	+
3. Audit will generate a `witch hunting' type of culture.	14	41	17	2	1	+
4. `Practitioner deskilling' is one of the likely consequences of audit.	19	40	11	4	0	+
5. Audit will take a disproportionate amount of clinicians time	2	14	20	28	11	-
6. The process of audit will interfere with clinical freedom.	7	33	22	12	1	+
7. Audit will facilitate the effective distribution of limited resources	8	13	19	30	5	+
8. Teamwork will improve as a result of audit.	4	12	27	27	5	+
9. Audit is likely to jeopardise clinical confidentiality.	12	35	16	11	0	+
10. Audit is a rather secretive activity.	17	39	12	5	2	+
11. Audit will help clinicians to use their expertise more effectively.	1	8	14	42	10	+
12. Audit will improve the quality of patient care.	0	7	20	37	11	+
13. Audit does not appear to be a value for money exercise.	8	22	26	10	9	+
14. Clinicians feel that they do not have adequate resources to undertake audit	0	2	13	32	26	-
15. Teamwork appears to have improved following the introduction of audit	9	16	38	10	0	-
16. Doctors are now more interested in patients' perception of care than they were prior to the introduction of audit.	10	10	19	26	7	+
17. Audit is likely to become an instrument for managerial control	3	15	22	24	9	-
18. Introduction of audit has led doctors to think more about the quality of clinical practices	4	3	16	34	16	+
TOTAL	97	205	356	516	162
AVERAGE SCORE	5.39	11.39	19.78	28.67	9

Dr Kedar Nath Dwivedi MBBS, MD, DPM ,FRCPsych, Consultant Child and Adolescent Psychiatrist, Northampton.Dr. M. Walley C.Psychol. PhD, Dip Counselling, Senior Lecturer in Psychology, Northampton. Rachel James Total Fundholding Project Manager, Oxford.