Fiona Stevenson

Using Reflexivity to Optimize Teamwork in Qualitative Research

Reflexivity is often described as an individual activity. The authors propose that reflexivity employed as a team activity, through the sharing of reflexive writing (accounts of personal agendas, hidden assumptions, and theoretical definitions) and group discussions about arising issues, can improve the productivity and functioning of qualitative teams and the rigor and quality of the research. The authors review the literature on teamwork, highlighting benefits and pitfalls, and define and discuss the role for reflexivity. They describe their own team and detail how they work together on a project investigating doctor-patient communication about prescribing. The authors present two reflexive tools they have used and show through examples how they have influenced the effectiveness of their team in terms of process, quality, and outcome.

A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance

Objectives  We draw on a systematic review of research on two‐way communication between patients and health practitioners about medicines in order to determine the extent to which concordance is, or is not, being put into practice.

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

Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews

BackgroundThis study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.DesignThis study is a systematic review of reviews.MethodsMEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis.ResultsSeventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation.ConclusionsThis comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.Systematic review registrationPROSPERO CRD42014009410

The relationship between medicine and the public: the challenge of concordance:

Concordance is based on the idea that patients and practitioners should work together towards an agreement on treatment choice. This requires a redefinition of the relations and encounters between doctors and their patients. This redefinition emphasizes the need for patient involvement and participation. In this article we examine concordance against the background of wider social change, structural as well as interpersonal. We focus in particular on challenges to trust, noting that the almost instinctive trust that people formerly had for professional experts has for many reasons diminished. One consequence of this, we suggest, is that concordance is being espoused at a time when its accomplishment may be particularly threatened. In fact there are strong grounds for claiming that support for the notion of concordance could possibly result in a growth of ‘hidden’ communication pathologies by means of what the social theorist Habermas (1984) has termed ‘systematically distorted communication’.

Health beliefs before and after participation on an exercised-based rehabilitation programme for chronic knee pain: Doing is believing

BackgroundTo explore the health beliefs, experiences, treatment and expectations of people with chronic knee pain, and investigate if, how and why these change after taking part on an integrated exercise-based rehabilitation programme - Enabling Self-management and Coping with Arthritis knee Pain through Exercise, ESCAPE-knee pain.MethodsSemi-structured interviews were conducted with people with chronic knee pain, before (n = 29) and after (n = 23) participation on the programme. Thematic analysis was used to document peoples baseline health beliefs, attitudes and cognitions, and to see if how and why these changed after completing the programme.ResultsInitially people had poor understanding and negative, fatalistic beliefs about the management or prognosis for knee pain. Following the programme the majority of participants had positive experiences describing improvement in pain, physical and psychosocial functioning, greater knowledge and understanding of their condition and treatment options, and in their ability to use exercise to control symptoms. Beliefs about the causation and prognosis of knee pain were unchanged, but their concerns about possible dangers of exercise had decreased, they appreciated how exercise could reduce symptoms (treatment beliefs) and their confidence in their ability to use exercise to effect improvements (exercise self-efficacy) increased. These improvements were attributed to the content and structure of the programme, and the care and guidance of the physiotherapist. Several expressed a need for on-going support.ConclusionsESCAPE-knee pain appears to achieve improvements by increasing peoples treatment belief in safety and the utility of exercise to control symptoms, rather than alteration in their beliefs about causation or prognosis.Trial RegistrationCurrent Controlled Trials ISRCTN94658828

Not just old and sick - the 'will to health ' in later life

ABSTRACT The end of the ‘Golden Age’ of welfare capitalism in the 1970s was the prelude to a period of greater individualisation within societies and was accompanied by an increase in the importance of consumption as a way of organising social relations. During the same period there was also an expansion in the discourses aimed at enhancing the government of the autonomous self. One such discourse operates around what has been termed the ‘will to health’: it suggests that health has become a required goal for individual behaviour and has become synonymous with health itself. The generational groups whose lifecourses were most exposed to these changes are now approaching later life. We explore the extent to which social transformations related to risk, consumption and individualisation are reflected in the construction of later-life identities around health and ageing. We examine how the growth in health-related ‘technologies of the self’ have fostered a distinction between natural and normal ageing, wherein the former is associated with coming to terms with physical decline and the latter associated with maintaining norms of self-care aimed at delaying such decline. Finally, we consider anti-ageing medicine as a developing arena for the construction of later-life identities and discuss the implications of the social changes for researching later life.

'A heartbeat moment': qualitative study of GP views of patients bringing health information from the internet to a consultation

BACKGROUND Government policy is to encourage self-help among patients. The internet is increasingly being used for health information. The literature on the role of the internet in the doctor-patient consultation remains sparse. AIM To determine the perceived responses of GPs to internet-informed patients in consultations and the strategies GPs use for dealing with information from the internet being brought into consultations. DESIGN OF STUDY A qualitative study design was used, with semi-structured interviews. SETTING GPs based in North Central London. METHOD Analysis was conducted by a multidisciplinary team of researchers. Participants were 11 GPs: five partners, three locums, and three salaried doctors; seven were white, three were Asian, and one was of Chinese origin. The median year of General Medical Council (GMC) registration was 1989. There were six women and five men; five participants worked in training practices. RESULTS GPs experienced considerable anxiety in response to patients bringing information from the internet to a consultation but were able to resolve this anxiety. The study participants learned to distance themselves from their emotional response, and used cognitive and behavioural techniques to assist them in responding appropriately to patients. These techniques included buying time in a consultation, learning from previous consultations, and using the internet as an ally, by directing patients to particular websites. The importance for doctors of feeling valued by patients was apparent, as was the effect of the prior doctor-patient relationship. CONCLUSION GPs interviewed used sophisticated mechanisms for dealing with their emotions. GPs struggling with internet-informed patients can use the mechanisms described to alleviate the difficulties.

Achieving change in primary care—effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews

Objective To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care. Design Systematic review of reviews. Data sources MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports. Eligibility criteria for selecting studies Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion. Data synthesis Extracted data were synthesised using a narrative approach. Results 91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2–9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality. Conclusions There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies. PROSPERO registration number CRD42014009410.

Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update)

BackgroundThere is a significant potential for e-health to deliver cost-effective, quality health care, and spending on e-health systems by governments and healthcare systems is increasing worldwide. However, there remains a tension between the use of e-health in this way and implementation. Furthermore, the large body of reviews in the e-health implementation field, often based on one particular technology, setting or health condition make it difficult to access a comprehensive and comprehensible summary of available evidence to help plan and undertake implementation. This review provides an update and re-analysis of a systematic review of the e-health implementation literature culminating in a set of accessible and usable recommendations for anyone involved or interested in the implementation of e-health.MethodsMEDLINE, EMBASE, CINAHL, PsycINFO and The Cochrane Library were searched for studies published between 2009 and 2014. Studies were included if they were systematic reviews of the implementation of e-health. Data from included studies were synthesised using the principles of meta-ethnography, and categorisation of the data was informed by the Consolidated Framework for Implementation Research (CFIR).ResultsForty-four reviews mainly from North America and Europe were included. A range of e-health technologies including electronic medical records and clinical decision support systems were represented. Healthcare settings included primary care, secondary care and home care. Factors important for implementation were identified at the levels of the following: the individual e-health technology, the outer setting, the inner setting and the individual health professionals as well as the process of implementation.ConclusionThis systematic review of reviews provides a synthesis of the literature that both acknowledges the multi-level complexity of e-health implementation and provides an accessible and useful guide for those planning implementation. New interpretations of a large amount of data across e-health systems and healthcare settings have been generated and synthesised into a set of useable recommendations for practice. This review provides a further empirical test of the CFIR and identifies areas where additional research is necessary.Trial registrationPROSPERO, CRD42015017661