Elizabeth Hart

System induced setbacks in stroke recovery

This study reports research on the experiences of stroke survivors and their informal carers who are receiving stroke services in the community. As part of a qualitative evaluation of a Pilot Community Stroke Service in Nottingham, England, interviews were conducted with stroke survivors, their families and friends, alongside interviews with the managers and professionals providing the service. The findings from the interview data were compared across cases and with findings from analyses of documentary data such as clients’ individual plans, and participant observational data, such as those of team meetings. Data analysis revealed that of the 57 survivors, 13 had suffered setbacks that were a direct consequence of their interactions with health and social care services and were system induced. This paper introduces and discusses the concept of the system induced setback by exploring the experiences of these 13 survivors. Implications for understanding the interplay of service provision and disease process are highlighted.

Early development of immune reconstitution inflammatory syndrome related to Pneumocystis pneumonia after antiretroviral therapy

Immune reconstitution inflammatory syndrome is a recognized complication after the initiation of combination antiretroviral therapy (cART). We report a patient who developed life-threatening pulmonary immune reconstitution inflammatory syndrome (IRIS) three days after initiation of cART. We reviewed published cases of IRIS after Pneumocystis pneumonia (PCP), in particular the time from initiation of cART to IRIS event. The median duration from the initiation of cART to the onset of IRIS was 15 days in the 33 patients reviewed. This report alerts clinicians to the rapidity of the development of pulmonary IRIS following PCP after the initiation of cART.

Addressing the complexity of health care: the practical potential of ethnography

Ethnography’s promise Health care is becoming increasingly complex! As a result, health services research has to adapt to current realities and engage with non-linear research methods if it is to contribute to service improvement. Promising developments include conducting ‘formative evaluations’ within implementation research and ‘process evaluations’ within randomized controlled trials of complex interventions. These may entail a mix of methods, using both quantitative and qualitative data. The ethnographic tradition has much to contribute here. However, the current tendency to define ethnography as merely one of many qualitative methods masks its full potential. The distinguishing feature of ethnography is longterm multi-method participant observation. Participant observation allows researchers to collect data informally as well as formally (crucial with sensitive topics), compare reported with actual behaviour and explain the socioculturally situated nature of knowledge and action. Insights are produced through iterative collection and analysis of different data-sets. The simultaneous use of immersion in the setting on the one hand and structured data collection on the other entails a tension between the ‘insider’ or ‘emic’ view of social life and the ‘outsider’ or ‘etic’ view. This forces the ethnographer to consider different perspectives on a topic, both from ‘within’ and ‘outwith’ the setting under study, and to compare a number of different perspectives on the same reform, intervention or service. The everyday can be seen in a new light, allowing us to ‘reconfigure the boundary of [the] problem’ and suggest new ways to address old woes. The ethnographic approach allows researchers to understand complexity by systematically exploring important relationships (for example, between a health care intervention and a particular social group), and by examining how these relationships generate different and often unexpected results in different circumstances. The ethnographic approach thus helps identify system dynamics and their key outcomes, which may not be apparent at the outset. It also helps bridge the research–practice ‘gap’, as it involves exchange of knowledge with key stakeholders at all stages of the research. This lays the ground for rigorous application of the principles of ‘linkage and exchange’ when integrating evidence in practice and policy.

Methodological understandings and misunderstandings in interprofessional research: Experiences of researching transitional rehabilitation for older people

Drawing on our shared experience of a mixed-methods evaluation of a rehabilitation scheme for older people in six residential care homes in Nottingham, this paper examines the challenges and rewards of interprofessional research. A social anthropologist, social work academic and medical academic respectively, we explore understandings and misunderstandings that arose during the two-year research process as we sought to integrate quantitative and qualitative findings from a randomized controlled trial (RCT) and an ethnographic study conducted in parallel. We identify ways in which it was possible to overcome the danger of fragmentation, which we argue may be inherent in interprofessional research. This includes a recognition that researchers from different disciplinary backgrounds may use different “key symbols” to view the world but that professional knowledge and expertise may enable researchers to transcend such disciplinary boundaries and to hear what each is saying to the other for the benefit of improved collaboration.