Heather Waterman

Action research in healthcare

Introduction What Is Action Research? Engaging in Action Research Reviewing Literature Steps in the Action Research Process: Practical Considerations Gathering Data Analyzing Data and Generating Evidence Writing up and Publishing Action Research Glossary Useful Websites References

The NIHR collaboration for leadership in applied health research and care (CLAHRC) for Greater Manchester: combining empirical, theoretical and experiential evidence to design and evaluate a large-scale implementation strategy

BackgroundIn response to policy recommendations, nine National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) were established in England in 2008, aiming to create closer working between the health service and higher education and narrow the gap between research and its implementation in practice. The Greater Manchester (GM) CLAHRC is a partnership between the University of Manchester and twenty National Health Service (NHS) trusts, with a five-year mission to improve healthcare and reduce health inequalities for people with cardiovascular conditions. This paper outlines the GM CLAHRC approach to designing and evaluating a large-scale, evidence- and theory-informed, context-sensitive implementation programme.DiscussionThe paper makes a case for embedding evaluation within the design of the implementation strategy. Empirical, theoretical, and experiential evidence relating to implementation science and methods has been synthesised to formulate eight core principles of the GM CLAHRC implementation strategy, recognising the multi-faceted nature of evidence, the complexity of the implementation process, and the corresponding need to apply approaches that are situationally relevant, responsive, flexible, and collaborative. In turn, these core principles inform the selection of four interrelated building blocks upon which the GM CLAHRC approach to implementation is founded. These determine the organizational processes, structures, and roles utilised by specific GM CLAHRC implementation projects, as well as the approach to researching implementation, and comprise: the Promoting Action on Research Implementation in Health Services (PARIHS) framework; a modified version of the Model for Improvement; multiprofessional teams with designated roles to lead, facilitate, and support the implementation process; and embedded evaluation and learning.SummaryDesigning and evaluating a large-scale implementation strategy that can cope with and respond to the local complexities of implementing research evidence into practice is itself complex and challenging. We present an argument for adopting an integrative, co-production approach to planning and evaluating the implementation of research into practice, drawing on an eclectic range of evidence sources.

The Role of Action Research in the Investigation and Diffusion of Innovations in Health Care: The PRIDE Project

In this article, the authors discuss the role of action research in relation to the investigation and practical implementation of innovations in health care. The diffusion of innovations is an essential component of the modernization of health services worldwide. However, the literature shows that it is not an easy process to research. A paradox is noted that although action research has much to offer, it has had only a limited impact in the innovation field. Drawing on an example of a project in the United Kingdom, the authors discuss whether action research is a valuable method in the study of the diffusion of innovations. They analyze its strengths and limitations as a “whole systems approach” that combines researching with developing and diffusing innovations. They argue that it is best suited to the study of innovation diffusion where there is a need for high level of adaptation in each new setting.

Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial

PurposeTo evaluate the impact of individualised patient care, as an adjunct to standard care, on adherence to ocular hypotensive therapy.MethodsA two-arm, single-masked exploratory randomised controlled trial recruited patients newly prescribed ocular hypotensive therapy. The intervention involved an individual assessment of health-care needs and beliefs and a 1-year follow-up period according to need. The primary outcome was refill adherence, measured by collating prescription and dispensing data for 12 months. Secondary outcomes included self-reported adherence, glaucoma knowledge, beliefs about illness and medicines, quality of care, intraocular pressure (IOP) fluctuation, and changes in clinical management assessed at 12 months. The strength of the intervention was measured following withdrawal by reviewing clinical outcomes for a further 12 months.ResultsIn all, 127 patients were recruited (91% response rate). Intervention-arm patients collected significantly more prescriptions than control-arm patients. Self-report adherence was significantly better in the intervention-arm for patients who forgot drops and those who intentionally missed drops. The intervention group demonstrated significantly more glaucoma knowledge, expressed a significantly stronger belief in the necessity of eye drops and believed that they had more personal control over managing their condition. Control-arm patients had more IOP fluctuation and changes in clinical management. However, this finding only reached significance at 24 months.ConclusionModelling patient care according to health-care needs and beliefs about illness and medicines can have a significant impact on improving adherence to therapy for this patient group, with the potential benefit of improving clinical outcomes.

Crossing professional and organizational boundaries: The implementation of generic Rehabilitation Assistants within three organizations in the northwest of England

Purpose. New generic support worker roles are being developed within rehabilitation and intermediate care services throughout the UK, as a consequence of staff shortages and the policy drive to look at new ways of working to meet the needs of older people. This paper describes a joint project between a Primary Care Trust, an Acute Trust and Social Services in one region in the northwest of England. It aims to describe the process of introducing new roles within rehabilitation and evaluates the acceptability and integration within different settings. Methods. Thirty support worker staff from an Acute Trust, Primary Care Trust and Social Services were trained over a period of 18 months to become generic Rehabilitation Assistants (RAs). A total of 55 semi-structured interviews of patients, associated professionals and RAs were conducted to examine the acceptability and integration of the new role. The interviews were tape-recorded, concurrently transcribed, inductively analysed and categorized into themes. Results. Several factors appeared to influence the acceptance and integration of the new role, namely: Prior experience and the degree of role change, familiarity and inter-staff relationships, role distinction and contribution and resources and management. Despite many challenges, patients, professionals and the RAs reported huge appreciation of the new role. Conclusions. The evaluation demonstrates how an innovative, inter-organizational approach can deliver new solutions to address workforce issues. Further research is recommended nationally, to track the development and evaluate the effectiveness of similar roles.

Rethinking capacity building for knowledge mobilisation: developing multilevel capabilities in healthcare organisations

BackgroundKnowledge mobilisation in healthcare organisations is often carried out through relatively short-term projects dependent on limited funding, which raises concerns about the long-term sustainability of implementation and improvement. It is becoming increasingly recognised that the translation of research evidence into practice has to be supported by developing the internal capacity of healthcare organisations to engage with and apply research. This process can be supported by external knowledge mobilisation initiatives represented, for instance, by professional associations, collaborative research partnerships and implementation networks. This conceptual paper uses empirical and theoretical literature on organisational learning and dynamic capabilities to enhance our understanding of intentional capacity building for knowledge mobilisation in healthcare organisations.DiscussionThe discussion is structured around the following three themes: (1) defining and classifying capacity building for knowledge mobilisation; (2) mechanisms of capability development in organisational context; and (3) individual, group and organisational levels of capability development. Capacity building is presented as a practice-based process of developing multiple skills, or capabilities, belonging to different knowledge domains and levels of complexity. It requires an integration of acquisitive learning, through which healthcare organisations acquire knowledge and skills from knowledge mobilisation experts, and experience-based learning, through which healthcare organisations adapt, absorb and modify their knowledge and capabilities through repeated practice. Although the starting point for capability development may be individual-, team- or organisation-centred, facilitation of the transitions between individual, group and organisational levels of learning within healthcare organisations will be needed.SummaryAny initiative designed to build capacity for knowledge mobilisation should consider the subsequent trajectory of newly developed knowledge and skills within the recipient healthcare organisations. The analysis leads to four principles underpinning a practice-based approach to developing multilevel knowledge mobilisation capabilities: (1) moving from ‘building’ capacity from scratch towards ‘developing’ capacity of healthcare organisations; (2) moving from passive involvement in formal education and training towards active, continuous participation in knowledge mobilisation practices; (3) moving from lower-order, project-specific capabilities towards higher-order, generic capabilities allowing healthcare organisations to adapt to change, absorb new knowledge and innovate; and (4) moving from single-level to multilevel capability development involving transitions between individual, group and organisational learning.

Online collaborative learning for healthcare continuing professional development: a cross-case analysis of three case studies

There has been increasing interest in the use of computers to facilitate collaborative learning between healthcare professionals for continuing professional development but many schemes appear to be unsuccessful. The aim of the study was to identify, from a cross-case analysis of three case studies, the main factors that facilitate and inhibit online collaborative learning for healthcare continuing professional development. The intervention was an asynchronous, structured and moderated discussion board. Data were collected by semi-structured telephone interviews on a purposive sample from each case study, documentary analysis of all self-reported comments made in the discussion boards, log of technical problems and evaluation of discussion board activity. Three key factors were identified: the need for implementation based on the requirements of users, the acceptance of this approach by the user and the development of a supportive organization within which the healthcare professionals work. This study has highlighted the overall low level of activity and this would appear to be because implementation has not been based on an understanding of the healthcare context.

The Hyperemesis Impact of Symptoms Questionnaire: Development and validation of a clinical tool

BACKGROUND The Hyperemesis Impact of Symptoms Questionnaire is a clinical tool designed to assess holistically the impact of the physical and psychosocial symptoms of hyperemesis gravidarum (HG) on individuals. Its purpose is to aid planning and implementation of tailored care for women with HG. To our knowledge no similar tool exists. OBJECTIVE To assess the validity and reliability of the HIS questionnaire. DESIGN As no similar tool exists, we compared the HIS with three tools that reflect its key areas: physical impact (Pregnancy Unique Quantification of Emesis--PUQE score and markers of severity of HG), psychological impact (Hospital Anxiety and Depression Score--HADS) and social impact (SF12 quality of life score). SETTING A large regional referral, women and childrens hospital in the North West of England. PARTICIPANTS The HIS was evaluated on 50 women admitted to hospital with HG and 50 women recruited from ante-natal clinic without severe nausea and vomiting of pregnancy and with an uncomplicated pregnancy. RESULTS Good criterion validity was demonstrated by strong significant correlations with all three scores (PUQE, r=0.75, p<0.001, HADS, depression r=0.76, p<0.001, and SF12, mental component r=-0.65, p<0.001). The HIS showed good internal consistency, Cronbach alpha 0.87, split half 0.80. CONCLUSIONS There is evidence for the validity and reliability of the HIS to assess the impact of the physical and psychosocial symptoms of HG. Further research is currently underway to establish the clinical utility of the HIS questionnaire in the care of women hospitalised with HG.

Randomised controlled trial of an integrated versus an optometric low vision rehabilitation service for patients with age-related macular degeneration: study design and methodology

A number of studies have measured the outcomes of low vision care but these have usually been longitudinal case series, thus constituting very low quality of evidence for effectiveness. To date, there have been no randomised controlled trials (RCTs) which have evaluated the effectiveness and cost effectiveness of different models of care in low vision. The size of the low vision population and the paucity of systematic evaluation have created a pressing need for evidence about cost‐effectiveness in order to inform service developments for low vision rehabilitation. This paper describes the study design and methodology of a three‐arm RCT currently under way in Manchester. The baseline population recruited is also described. A traditional hospital‐based optometric service is being compared with an integrated service (comprising the addition of community‐based rehabilitation officer input) and with more generic community input (which is non‐integrated and is not vision specific). A wide range of outcome measures are being assessed at recruitment and 12 months post‐intervention, including low vision specific and generic quality of life measures, patterns of low vision aid use, and task performance. The rationale for the trial is discussed and the main study outcomes are described.

Development of an information source for patients and the public about general practice services: an action research study

Objective  The publication of information about the performance of health‐care providers is regarded as central to promoting greater accountability and empowering patients to exercise choice. The evidence suggests that the public is not very interested in accessing or using current sources of information. This study aimed to explore the information needs of patients in the context of UK primary care and to develop an information source about general practice services, designed to be usable by and useful to patients.