Andrée le May

Practice-based evidence for healthcare : clinical mindlines

1. Introduction: evidence in practice 2. From formal knowledge guided complexity 3.Clinical thinking and knowledge in practice 4. Growing mindlines: laying the foundations 5. Growing mindlines: cultivating contextual adroitness 6. The place of storytelling in knowledge sharing 7. A community of clinical practice? 8. Co-constructing collective mindlines 9. Co-constructing clinical reality 10 Conclusions and implications

A Case Study of Knowledge Management in Multiagency Consumer-Informed `Communities of Practice': Implications for Evidence-Based Policy Development in Health and Social Services

We report a study that facilitated and evaluated two multiagency Communities of Practice (CoPs) working on improving specific aspects of health and social services for older people, and analysed how they processed and applied knowledge in formulating their views. Data collection included observing and tape-recording the CoPs, interviewing participants and reviewing documents they generated and used. All these sources were analysed to identify knowledge-related behaviours. Four themes emerged from these data: (1) the way that certain kinds of knowledge became privileged and accepted; (2) the ways in which the CoP members transformed and internalized new knowledge; (3) how the haphazard processing of the available knowledge was contingent upon the organizational features of the groups; and (4) the ways in which the changing agendas, roles and power-relations had differential effects on collective sense making. We conclude by recommending ways in which the process of evidence-based policy development in such groups may be enhanced.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

The meaning and importance of dignified care: findings from a survey of health and social care professionals

BackgroundThere are well established national and local policies championing the need to provide dignity in care for older people. We have evidence as to what older people and their relatives understand by the term ‘dignified care’ but less insight into the perspectives of staff regarding their understanding of this key policy objective.MethodsA survey of health and social care professionals across four NHS Trusts in England to investigate how dignified care for older people is understood and delivered. We received 192 questionnaires of the 650 distributed.ResultsHealth and social care professionals described the meaning of dignified care in terms of their relationships with patients: ‘respect’ (47%), ‘being treated as an individual’ (40%), ‘being involved in decision making’ (26%) and ‘privacy’ (24%). ‘Being treated as an individual’ and ‘maintaining privacy’ were ranked as the most important components of dignified care. Physical caring tasks such as ‘helping with washing, dressing and feeding’ were rarely described as being part of dignified care and attributed much less importance than the relational components.ConclusionDignity in care is a concept with multiple meanings. Older people and their relatives focus upon the importance of providing physical care when describing what this means to them. Our participants focussed upon the relational aspects of care delivery rather than care itself. Proactive measures are therefore required to ensure that the physical aspects of care are met for all older people receiving care in NHS trusts.

Action research: A design with potential

This paper discusses the main challenges posed by action research. These include issues related to definition, researcher role, collaboration, ethics and resources. We argue that action research has the potential simultaneously to contribute to the development of knowledge as well as to facilitate and evaluate change. The central tenets of action research are described and we use our research on the development of communities of practice as a means of illustrating these elements. We conclude that while the lack of precise definition may have led to suspicion about the robustness and scientific merit of action research, different and imaginative ways of employing it as an approach are proving that it is both a legitimate and highly contemporary research design for the exploration of health and social care issues and the development of practice.

Mindlines: making sense of evidence in practice

Coffee-room chat may impact on evidence-based practice at least as much as all those guidelines that deluge GPs. If so, we need to understand better how and why that is, so that our informal conversations help rather than impede the spread of best practice. The pressure to comply with guidelines and evidence-based patient pathways has been rising inexorably, but so too has the feeling that the evidence-based medicine movement often misses the point.1 Its champions, who include many policymakers and managers as well as researchers, lament clinicians’ apparent slowness in implementing research evidence, while clinicians grumble that their hard-learned clinical judgement is undervalued by an overemphasis on conforming to guidelines. The struggle is not just about practice, but also professional autonomy and identity. Yet both sides of the argument recognise that best practice must be grounded in best evidence and that guidelines have their place. So what exactly is that place and how do we get from the linear rationalism of guidelines to the complex wisdom of good practice? Fifteen years ago we decided to examine such questions afresh by observing what actually happens when practitioners develop and use their clinical knowledge. We used the ethnographic methods of anthropologists, who while retaining some analytical distance immerse themselves among their chosen subjects to try to get an inside understanding of their beliefs and actions. Our subjects were deliberately selected as highly respected primary care teams, and our aim was to comprehend the complexities of their everyday practice, observing and analysing exactly how they put their knowledge into practice. We published our preliminary findings in 2004,2 but continued to gather data from our principal study site over the next 5 years3 while supplementing and exploring our …

Organisational innovation in health services : lessons from the NHS treatment centres

© The Policy Press 2011. All rights reserved. Amid a welter of simultaneous policy initiatives, treatment centres were a top-down NHS innovation that became subverted into a multiplicity of solutions to different local problems. This highly readable account of how and why they evolved with completely unforeseen results reveals clear, practical lessons based on case study research involving over 200 interviews. Policy makers, managers and clinicians undertaking any organisational innovation cannot afford to ignore these findings.

Crafting intermediate care: one team’s journey towards integration and innovation

Aim This paper describes one multi-disciplinary, multi-agency team’s development of Person-Centred Intermediate Care (PCIC) for older people. This development involved integrating three separate enterprises – a not-for-profit charitable organisation, a local primary health care trust and referring hospitals and their local social care providers. Methods We used a mixed-methods case study, underpinned by the notion of an innovation journey, to explore how PCIC was developed by the team and how effective it was. Data were collected through semi-structured interviews, documentary analysis, closed-end questionnaires/scales and routinely collected activity data. Thematic and statistical analyses were used. Results were triangulated. Twelve staff, four key informants and 94 service users participated. Results The development followed the trajectory of innovation journeys. Our mixed-methods approach enabled us to expose staff’s negative experiences during this time whilst patients were largely satisfied with their care and made appropriate recovery. The triangulation of data in this mixed-methods study allowed us to seek explanations for this mismatch. We conjecture that the staff used emotional labour to lessen the effects of their negative experiences for the benefit of the patients. Conclusions This paper extends our knowledge of how, in a policy environment that encourages collaborative practice between public, private and voluntary alliances, and across sectors, such innovations work. In addition, the results suggest that emotional labour is used during change and care practices: preparing nurses better in order to use this ‘technique’ is a recommendation from this research.Aim: This paper describes one multi-disciplinary, multi-agency team’s development of PersonCentred Intermediate Care (PCIC) for older people. This development involved integrating three separate enterprises – a not-for-profit charitable organisation, a local primary health care trust and referring hospitals and their local social care providers. Methods: We used a mixed-methods case study, underpinned by the notion of an innovation journey, to explore how PCIC was developed by the team and how effective it was. Data were collected through semi-structured interviews, documentary analysis, closed-end questionnaires/scales and routinely collected activity data. Thematic and statistical analyses were used. Results were triangulated. Twelve staff, four key informants and 94 service users participated. Results: The development followed the trajectory of innovation journeys. Our mixed-methods approach enabled us to expose staff’s negative experiences during this time whilst patients were largely satisfied with their care and made appropriate recovery. The triangulation of data in this mixed-methods study allowed us to seek explanations for this mismatch. We conjecture that the staff used emotional labour to lessen the effects of their negative experiences for the benefit of the patients. Conclusions: This paper extends our knowledge of how, in a policy environment that encourages collaborative practice between public, private and voluntary alliances, and across sectors, such innovations work. In addition, the results suggest that emotional labour is used during change and care practices: preparing nurses better in order to use this ‘technique’ is a recommendation from this research.

Pre-registration nurse education: building the foundations of a nursing career and profession?

All nursing careers are built on the foundation of one’s pre registration nurse education: it is from these foundations that student nurses (and later Registered Nurses) develop their understanding of what it is to be a nurse and to be part of the nursing profession. These foundations lead to aspirations about where careers in nursing may lead (e.g. Barton and le May, 2012) and these, in turn, influence the development of the profession of nursing. As a result of the introduction of the latest Standards for Pre-registration Nurse Education by the Nursing and Midwifery Council (NMC) (2010), all pre-registration nurse education programmes in the United Kingdom, like many others across the world, will have to be at degree level from 2013. There have been many differing views expressed in reaction to this requirement, at one end of the continuum is the view that this is nothing new as degree level courses in nursing have existed in the United Kingdom and internationally for over 30 years, indeed some post-graduate courses exist within pre registration nurse education – a point of view explored by Kathryn Jones in her editorial on this topic. At the other end of the continuum, is the somewhat spurious notion that a move to degree level preparation for nurses will distract them, during their studies and once qualified, from their core role of competently nursing people. Much media attention, public debate and professional re-focussing activities – e.g. the Willis commission on nurse education (Education Commission, 2012) and no doubt the Nursing and Care Quality Forum (Department of Health, 2012) – has become entwined with this change, so much so that one could be forgiven for thinking that obtaining graduate status for nurses is the only important change introduced within the new standards. This, of course, is not the case – the NMC standards show all of us involved in educating nurses, be that in the lecture room, the simulation suite or at the patient’s side, the key components of this endeavour required to build a 21st century workforce. The standards show prospective nurses what contemporary nursing involves, they show practising nurses areas for updating

Chasing Chameleons, Chimeras and Caterpillars: Evaluating an Organizational Innovation in the National Health Service

Although some might argue that too little attention is paid to the evaluation of health service innovations, evaluation research has burgeoned alongside the ubiquitous healthcare reform of the UK NHS which escalated under the Conservative government of the 1980s and has continued under the Labour government since the late 1990s. In terms of funding and activity health service evaluation is something of an industry: to give just one example the NHS Service Delivery and Organization (SDO) RD indeed we argue that the chameleons, chimeras and caterpillars we encountered may well be persistent features of evaluative research.