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Diffusion of innovations in service organizations: Systematic review and recommendations
This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.
Tensions and paradoxes in electronic patient record research: A systematic literature review using the meta-narrative method
Context: The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Methods: Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used "conflicting" findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation. Findings: Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ("container" or "itinerary"); (2) the EPR user ("information-processer" or "member of socio-technical network"); (3) organizational context ("the setting within which the EPR is implemented" or "the EPR-in-use"); (4) clinical work ("decision making" or "situated practice"); (5) the process of change ("the logic of determinism" or "the logic of opposition"); (6) implementation success ("objectively defined" or "socially negotiated"); and (7) complexity and scale ("the bigger the better" or "small is beautiful"). Conclusions: The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research. © 2009 Milbank Memorial Fund.
Narrative methods in quality improvement research
This paper reviews and critiques the different approaches to the use of narrative in quality improvement research. The defining characteristics of narrative are chronology (unfolding over time); emplotment (the literary juxtaposing of actions and events in an implicitly causal sequence); trouble (that is, harm or the risk of harm); and embeddedness (the personal story nests within a particular social, historical and organisational context). Stories are about purposeful action unfolding in the face of trouble and, as such, have much to offer quality improvement researchers. But the quality improvement report (a story about efforts to implement change), which is common, must be distinguished carefully from narrative based quality improvement research (focused systematic enquiry that uses narrative methods to generate new knowledge), which is currently none. We distinguish four approaches to the use of narrative in quality improvement research - narrative interview; naturalistic story gathering; organisational case study; and collective sense-making-and offer a rationale, describe how data can be collected and analysed, and discuss the strengths and limitations of each using examples from the quality improvement literature. Narrative research raises epistemological questions about the nature of narrative truth (characterised by sense-making and emotional impact rather than scientific objectivity), which has implications for how rigour should be defined (and how it might be achieved) in this type of research. We offer some provisional guidance for distinguishing high quality narrative research in a quality improvement setting from other forms of narrative account such as report, anecdote, and journalism.
Story-based scales: Development and validation of questionnaires to measure subjective health status and cultural adherence in British Bangladeshis with diabetes
Questionnaires that measure subjective health status are increasingly used in clinical trials. But scales based on the quantification of subjective traits ("rate your feelings on a scale of 1 to 5") and initially developed in western population samples may not be valid for use in minority ethnic groups, even if accurately translated. The measurement of cultural adaptation and assimilation in immigrant groups is important for health research but has well documented methodological challenges. The aim of this study was to develop valid and reliable questionnaires to measure subjective health status and cultural adherence in a minority ethnic group, using the story as the unit of inquiry. The design was a multi-phase study involving (a) narrative interview, (b) vignette construction, (c) questionnaire development, and (d) questionnaire validation in relation to two scales (well-being and cultural adherence) in British Bangladeshis with diabetes. Using data from in-depth narrative interviews (i.e., a non-directive research technique in which the participant is invited to "tell me the story about your diabetes, starting with when you first noticed anything wrong", and the only prompts used are "tell me more about that" or "what happened next?"; Greenhalgh, Helman, & Chowdhury, 1998; Muller, 1999), we constructed culturally congruent vignettes to depict different subjective health states and behaviours. We refined these items in focus group interviews and validated the instruments on 98 Bangladeshi participants, randomly sampled from GP diabetes registers in inner London and interviewed by a Bangladeshi anthropologist. We used factor analysis to explore the underlying structure in the responses to questionnaire items, plus Cronbach alpha tests to measure internal consistency of scales. The questionnaires were acceptable and credible to Bangladeshi participants with diabetes. Ninety of 98 participants were able and willing to complete them with interviewer assistance. Following factor analysis, we produced two definitive instruments. The well-being scale was a single-factor model with four story-based items (measuring depression, anxiety, physical energy, and social activities), with a Cronbach's alpha of .92. The cultural adherence scale was a single-factor model with five items (measuring religious restrictions, ethnic practices, and social ties), with a Cronbach's alpha of .83. In conclusion, this study has produced two important outputs: (a) easy-to-administer, story-based questionnaires that measure well-being and cultural adherence, which are specific to British Bangladeshis with diabetes; (b) a general method for developing story-based instruments to quantify the subjective experience of illness and adherence to cultural norms, which potentially has applications beyond the study population. © 2006 Taylor & Francis.
Research governance: Where did it come from, what does it mean?
For a variety of historical and social reasons, research has become increasingly formalized and regulated. This change has potential benefits (reduction in fraud and misconduct, protection of vulnerable groups, financial probity) but also disadvantages (increased paperwork, time delays, constraints on research freedom). The terms 'research' and 'governance' mean different things in different contexts. Even with explicit guidance, ambiguities must be resolved by human judgement. Variation in the nature and outcome of approval decisions is therefore a fact of life. The type of approval needed for a research study depends on the official remit of the approval body, the question to be addressed; the methods to be used; the context in which the work will take place; the level of analysis and interpretation; and the plans for how the findings will be presented and used.
Putting your course on the web: Lessons from a case study and systematic literature review
Background: Education via the Internet offers enormous potential, but many online courses are pedagogically or technically weak and many good projects are never mainstreamed. Method: In drawing up our recommendations to address the issues around putting a course on the web, we drew on 3 main sources of data: an extensive in-depth course evaluation; a systematic review of the literature, and questions raised by participants on our training-the-trainers courses. Recommendations: For any web-based course to succeed, 10 overlapping and iterative areas of activity must be addressed. These are: the market for the course; course aims and intended learning outcomes; choice of software platform; staff training needs; writing high quality study materials; design features for active learning; technical and administrative challenges; evaluation and quality improvement; mainstreaming the course within the institution, and financial viability.
Peer observation of teaching in the online environment: An action research approach
This paper describes a collaborative action research approach used to explore peer observation of teaching (POT) within the online environment. Although POT has become familiar in face-to-face teaching contexts, little is understood of its potential role in online settings. We conducted 'virtual' focus groups to explore the experience and views of 28 teachers and subjected our data to a thematic analysis. This informed the implementation of an innovative programme of POT, 'Peer-to-peer Reflection on Pedagogical Practice' (PROPP) among tutors of a Web-based MSc in International Primary Health Care at University College London. Modeled on an action learning set, the programme encourages collaborative reflection on teaching practices, based on participants' specific examples of online teaching. The PROPP model is consistent with Quality Enhancement, which we distinguish from Quality Assurance. Here, we describe the implementation of the PROPP programme within an action research framework and identify the factors that we consider critical to the success of peer observation within online courses. We highlight examples of aspects of teaching that have been discussed within the PROPP programme and offer suggestions of the kinds of evidence that could be incorporated into a portfolio to demonstrate the effectiveness of such an initiative. © 2008 Blackwell Publishing Ltd.
First aid kits for recreational dive boats, what should they contain?
Background: Well-equipped first-aid kits are necessary but not always provided on recreational dive boats. We aimed to review the types of illness and injury likely to be encountered on such boats and inform a content list for such kits. Method: We conducted a 3-round Delphi study by email using a volunteer panel of 18 experts drawn from diving, dive medicine and nursing. In round 1, panellists shared examples of illnesses and injuries they had come across personally. These scenarios were circulated along with findings from a literature review, including existing recommendations. In rounds 2 and 3, the list of kit for dive boats in different settings was iteratively refined through online discussion and feedback. Main findings: Passengers and crew on recreational dive boats may encounter a range of medical problems from minor injuries to serious accidents and non-dive-related illnesses. Recommended kit varied depending on context and setting (e.g. distance from land, qualifications and experience of crew). Consensus was quickly reached on key first-aid items but experts' views on emergency medicines differed. Conclusions: The study highlights the diversity of medical problems encountered on recreational dive boats. We offer preliminary guidance on the content of suitable first-aid kits and suggest areas for further research. © 2010 Published by Elsevier Ltd.
Interpreted consultations as 'business as usual'? An analysis of organisational routines in general practices
UK general practices operate in an environment of high linguistic diversity, because of recent large-scale immigration and of the NHS's commitment to provide a professional interpreter to any patient if needed. Much activity in general practice is co-ordinated and patterned into organisational routines (defined as repeated patterns of interdependent actions, involving multiple actors, bound by rules and customs) that tend to be stable and to persist. If we want to understand how general practices are responding to pressures to develop new routines, such as interpreted consultations, we need to understand how existing organisational routines change. This will then help us to address a second question, which is how the interpreted consultation itself is being enacted and changing as it becomes routinised (or not) in everyday general practice. In seeking answers to these two questions, we undertook a qualitative study of narratives of interpreted primary care consultations in three London boroughs with large minority ethnic populations. In 69 individual interviews and two focus groups, we sought accounts of interpreted consultations from service users, professional interpreters, family member interpreters, general practitioners, practice nurses, receptionists, and practice managers. We asked participants to tell us both positive and negative stories of their experiences. We analysed these data by searching for instances of concepts relating to the organisational routine, the meaning of the interpreted consultation to the practice, and the sociology of medical work. Our findings identified a number of general properties of the interpreted consultation as an organisational routine, including the wide variation in the form of adoption, the stability of the routine, the adaptability of the routine, and the strength of the routine. Our second key finding was that this variation could be partly explained by characteristics of the practice as an organisation, especially whether it was traditional (small, family-run, 'personal' identity, typically multilingual, loose division of labour, relatively insular) or contemporary (large, bureaucratic, 'efficient' identity, typically monolingual, clear division of labour, richly networked). We conclude that there is a fruitful research agenda to be explored that links the organisational dimension of interpreting services with studies of clinical care and outcomes. © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.
Communicative and strategic action in interpreted consultations in primary health care: A Habermasian perspective
We report a qualitative study of accounts of interpreted consultations in UK primary care. The study sought to explore how three Habermasian tensions between (a) system and lifeworld, (b) communicative and strategic action, and (c) interpersonal and macropolitical spheres played out in the triadic consultation between clinician, interpreter and patient. In a total of 69 individual interviews and two focus groups, we collected narratives from service users (through interpreters or bilingual researchers), interpreters and doctors and other staff in general practice. We recorded, transcribed and analysed these, taking the story as the main unit of analysis. Our data suggest that the preconditions for communicative action are rarely met in the interpreted consultation. The interpreter's presence makes a dyadic interaction into a triad, adding considerable complexity to the social situation and generating operational and technical challenges. Lack of trust, intense pressure of time, mismatch of agendas (biomedical versus lifeworld), firm expectations of a specific outcome (e.g. referral, prescription) and profound power imbalances all promote strategic action (i.e. speech that seeks consciously or unconsciously to manipulate an outcome) rather than communicative action (i.e. sincere efforts to achieve understanding, and reach consensus) by all parties. In consultations interpreted by family members (an option traditionally seen as 'second best' by policy makers), the social situation is very different. Family members are generally trusted, share the lifeworld agenda, and shift the power balance in the patient's favour. The interpreter occupies multiple social roles, including translator, interpersonal mediator, system mediator, educator, advocate, and link worker. The essence of professionalism in interpreting is shifting judiciously between these potentially conflicting roles. We discuss the implications of our findings for communication with limited English speakers in healthcare consultations and for realizing contemporary policy goals such as concordance, shared decision-making, empowerment, and choice. © 2006 Elsevier Ltd. All rights reserved.
Integrating qualitative research into evidence based practice.
This article attempts to provide an overview of qualitative tools and methods using mainly examples from diabetes research. The other articles in this issue of the Endocrinology and Metabolism Clinics of North America have demonstrated the enormous contribution made in the past 15 years or so by rigorous quantitative studies of prevalence, diagnosis, prognosis, and therapy to clinical decision-making in endocrinology. In the early 21st century, the state of qualitative research into such topics as the illness experience of diabetes; the barriers to effective self care and positive health choices; the design of complex educational interventions; the design of appropriate, acceptable and responsive health services; and the decision-making behavior of health professionals, is such that there remain many more questions than answers. But qualitative research is increasingly recognized as an important, legitimate and expanding dimension of evidence-based health care (18;19). It is highly likely that the major landmark studies in diabetes care over the next decade will build on an exploratory qualitative study or incorporate an explanatory or evaluative dimension based on qualitative methods.
Looking for a better future: Identity construction in socio-economically deprived 16-year olds considering a career in medicine
The medical profession has traditionally been dominated by middle-class white males in the UK, but it is a political priority to widen access to all socio-economic and ethnic groups. This paper describes an empirical study based on biographical life narrative interviews with 45 16-year olds from inner London who were considering applying to medical school, drawn mainly from the most socio-economically deprived 25% of the population. Most of them were immigrants or the children of immigrants, and all had been selected by their teachers as highly able and motivated. Students were asked to "tell the story of your life so far". Interviews were tape recorded, transcribed and analysed thematically. Five influences on the development of academic identity and medical ambition were identified: (1) the private sphere (Bourdieu's 'family habitus'), especially a family meta-narrative of immigration to secure a better future and of education as the vehicle to regaining a high social position previously held in the family of origin; (2) the school (Bourdieu's 'institutional habitus'), and especially the input of particular teachers who inspired and supported the student; (3) friends and peers, many of whom the student had chosen strategically because of shared aspirations to academic success; (4) psychological resources such as maturity, determination and resilience; and (5) past experiences (especially meeting the challenge of immigration, changing school, or dealing with illness or death in a relative), which had proved formative and strengthening to the individual's developing ego. Despite their talents and ambitions, many students had important gaps in their knowledge of the application process and lacked sophistication in the 'admissions game'. The findings are discussed in relation to contemporary educational and social theories. © 2007 Elsevier Ltd. All rights reserved.
Realist review - A new method of systematic review designed for complex policy interventions
Evidence-based policy is a dominant theme in contemporary public services but the practical realities and challenges involved in using evidence in policy-making are formidable. Part of the problem is one of complexity. In health services and other public services, we are dealing with complex social interventions which act on complex social systems - things like league tables, performance measures, regulation and inspection, or funding reforms. These are not 'magic bullets' which will always hit their target, but programmes whose effects are crucially dependent on context and implementation. Traditional methods of review focus on measuring and reporting on programme effectiveness, often find that the evidence is mixed or conflicting, and provide little or no clue as to why the intervention worked or did not work when applied in different contexts or circumstances, deployed by different stakeholders, or used for different purposes. This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging 'realist' approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how. The first step is to make explicit the programme theory (or theories) - the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then look for empirical evidence to populate this theoretical framework, supporting, contradicting or modifying the programme theories as it goes. The results of the review combine theoretical understanding and empirical evidence, and focus on explaining the relationship between the context in which the intervention is applied, the mechanisms by which it works and the outcomes which are produced. The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively. Realist review does not provide simple answers to complex questions. It will not tell policy-makers or managers whether something works or not, but will provide the policy and practice community with the kind of rich, detailed and highly practical understanding of complex social interventions which is likely to be of much more use to them when planning and implementing programmes at a national, regional or local level. © The Royal Society of Medicine Press Ltd 2005.