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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Social and professional influences on antimicrobial prescribing for doctors-in-training: A realist review
Background: Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods: The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results: By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-intraining often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions: This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.
Interventions to improve antimicrobial prescribing of doctors in training: The IMPACT (IMProving Antimicrobial presCribing of doctors in Training) realist review
Introduction: Antimicrobial resistance has been described as a global crisis-more prudent prescribing is part of the solution. Behaviour change interventions are needed to improve prescribing practice. Presently, the literature documents that context impacts on prescribing decisions, yet insufficient evidence exists to enable researchers and policymakers to determine how local tailoring should take place. Doctors in training are an important group to study, being numerically the largest group of prescribers in UK hospitals. Unfortunately very few interventions specifically targeted this group. Methods and analysis: Our project aims to understand how interventions to change antimicrobial prescribing behaviours of doctors in training produce their effects. We will recruit a project stakeholder group to advise us throughout. We will synthesise the literature using the realist review approach-a form of theory-driven interpretive systematic review approach often used to make sense of complex interventions. Interventions to improve antimicrobial prescribing behaviours are complex-they are context dependent, have long implementation chains, multiple non-linear interactions, emergence and depend on human agency. Our review will iteratively progress through 5 steps: step 1-Locate existing theories; step 2-Search for evidence; step 3-Article selection; step 4-Extracting and organising data; and step 5-Synthesising the evidence and drawing conclusions. Data analysis will use a realist logic of analysis to describe and explain what works, for whom, in what circumstances, in what respects, how and why to improve antimicrobial prescribing behaviour of doctors in training. Ethics and dissemination: Ethical approval was not required for our review. Our dissemination strategy will be participatory and involve input from our stakeholder group. Tailored project outputs will be targeted at 3 audiences: (1) doctors in training; (2) clinical supervisors/trainers and medical educators; and (3) policy, decision makers, regulators and royal societies.
Optimising feedback for early career professionals: a scoping review and new framework
Context: Meta-analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. Methods: We undertook a scoping literature review, using search terms such as ‘feedback’ and ‘effectiveness’ in MEDLINE, MEDLINE-In-Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. Results: A total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. Conclusions: We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences.
Improving patient safety for older people in acute admissions: Implementation of the Frailsafe checklist in 12 hospitals across the UK
Background: checklists are increasingly proposed as a means to enhance safety and quality of care. However, their use has been met with variable levels of success. The Frailsafe project focused on introducing a checklist with the aim to increase completion of key clinical assessments and to facilitate communication for the care of older patients in acute admissions. Objectives: to examine the use of the Frailsafe checklist, including potential to contribute to improved safety, quality and reliability of care. Methods: 110 qualitative interviews and group discussions with healthcare professionals and other specialties, 172 h of ethnographic observation in 12 UK hospitals and reporting of high-level process data (completion of checklist and relevant frailty assessments). Qualitative analysis followed a thematic and theory-driven approach. Results: through use of the checklist, hospital teams identified limitations in their existing assessments (e.g. absence of delirium protocols) and practices (e.g. unnecessary catheter use). This contributed to hospitals reporting just 24.0% of sampled patients as having received all clinical assessments across key domains for this population for the duration of the project (1,687/7,021 checklists as fully completed). Staffperceptions and experiences of using the checklist varied significantly, primarily driven by the extent to which the aims of this quality improvement project aligned with local service priorities and pre-existing team communications styles. Conclusions: the Frailsafe checklist highlighted limitations with frailty assessment in acute care and motivated teams to review routine practices. Further work is needed to understand whether and how checklists can be embedded in complex, multidisciplinary care.
Challenges, solutions and future directions in the evaluation of service innovations in health care and public health
Evaluating service innovations in health care and public health requires flexibility, collaboration and pragmatism; this collection identifies robust, innovative and mixed methods to inform such evaluations.
Privacy as articulation work in HIV health services
Normative accounts on health information privacy often highlight the importance of regulating data sharing. Yet, little attention has been paid to how health professionals perform and negotiate privacy practices in highly multidisciplinary, technologically-mediated medical work. This paper examines information privacy practices in two HIV outpatient clinics based in two NHS hospitals in London (UK). Methods include 46 semi-structured interviews, primarily with health professionals and technology developers, ethnographic observation and document analysis. Drawing on an empirically informed understanding of privacy as 'articulation work', we focus on the indeterminate nature of information privacy practices and examine the work required to translate privacy, from a normative professional duty to an enacted medical practice. This analysis also highlights the invisibility of privacy practices and their coordinating role in delivering technologically-supported medical care. The paper ends with a discussion of implications for practice and technology design.
A reflexive analysis of 'context' in privacy research: Two case studies in HIV care
Privacy is a much discussed and politically charged topic in contemporary healthcare. Yet, studying the actual privacy practices of healthcare professionals and patients remains extremely challenging. In this paper we reflect on our experiences using qualitative methods in two projects on HIV care, the first researching internet use by a particular group of patients, and the second looking at issues of information technology integration in hospitals. Our aim in doing so is to highlight some of the opportunities and challenges involved in including an explicit focus on 'context' in qualitative privacy research in healthcare. We suggest that adopting a more reflexive approach to the way methods are used in relation to 'context' in privacy-related HCI research provides opportunities for understanding how different 'privacy contexts' are enacted in and through our research practices in different environments. © 2013 Elsevier Ltd. All rights reserved.
A reflexive analysis of 'context' in privacy research: Two case studies in HIV care
Privacy is a much discussed and politically charged topic in contemporary healthcare. Yet, studying the actual privacy practices of healthcare professionals and patients remains extremely challenging. In this paper we reflect on our experiences using qualitative methods in two projects on HIV care, the first researching internet use by a particular group of patients, and the second looking at issues of information technology integration in hospitals. Our aim in doing so is to highlight some of the opportunities and challenges involved in including an explicit focus on 'context' in qualitative privacy research in healthcare. We suggest that adopting a more ref exive approach to the way methods are used in relation to 'context' in privacy-related HCI research provides opportunities for understanding how different 'privacy contexts' are enacted in and through our research practices in different environments. © 2013 Elsevier Ltd. All rights reserved.
Privacy dictionary: A new resource for the automated content analysis of privacy
This article presents the privacy dictionary, a new linguistic resource for automated content analysis on privacy-related texts. To overcome the definitional challenges inherent in privacy research, the dictionary was informed by an inclusive set of relevant theoretical perspectives. Using methods from corpus linguistics, we constructed and validated eight dictionary categories on empirical material from a wide range of privacy-sensitive contexts. It was shown that the dictionary categories are able to measure unique linguistic patterns within privacy discussions. At a time when privacy considerations are increasing and online resources provide ever-growing quantities of textual data, the privacy dictionary can play a significant role not only for research in the social sciences but also in technology design and policymaking. © 2011 ASIS&T.