Louise Fitzgerald

Interlocking Interactions, the Diffusion of Innovations in Health Care

This article aims to provide a reassessment of the processes of diffusion of innovations into organizations, based on new empirical data. The focus of the article is the latter stages of the diffusion process. The article draws on the results of two studies, which examined the diffusion of innovations in health care in the UK. These projects were a matched pair of qualitative studies, using purposeful selections of comparative case studies. The results demonstrate the ambiguous, contested nature of new scientific knowledge. The highly interactive nature of diffusion, with active adopters is illustrated. There is no evidence of a single adoption decision. The science is socially mediated. The features of context and of actors interlock to influence diffusion.

No Magic Targets! Changing Clinical Practice to Become More Evidence Based.

This article focuses on the diffusion and adoption of innovations in clinical practice. The authors are specifically interested in underresearched questions concerning the latter stages of the creation, diffusion, and adoption of new knowledge, namely: What makes this information credible and therefore utilized? Why do actors decide to use new knowledge? And what is the significance of the social context of which actors are a part? This article first appeared in Health Care Management Review, 27(3), 35-47.

Achieving clinical behaviour change : A case of becoming indeterminate

This paper is based on an empirical study of attempts to achieve change in clinical behaviour across a United Kingdom National Health Service (NHS) Health Authority (HA). We suggest that the evidence based medicine (EBM) movement underpinning such attempts is premised upon a highly rationalistic conception of change. Here the generation and implementation of research findings into clinical practice is understood as movement between discrete entities. Drawing upon poststructural philosophy, social studies of science and technology, social anthropology, and gender studies, we challenge such linear perspectives through a more immanent alternative. We conceive of change as movement within indeterminate or ambiguous relationships. We then proceed to discuss the implications of this modality for the management of clinical behaviour change.

Moving clinicians into management. A professional challenge or threat

Examines the issue of involving clinicians in management and the management processes. Considers the effect of the changing context of practice and the pressures that are imposed on the medical profession by this involvement.

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.

Understanding Change and Innovation in Healthcare Settings: Reconceptualizing the Active Role of Context

This article discusses the ways in which ‘context’ has been formulated and explored in healthcare settings. We contend that context is an important, but poorly understood mediator of change and innovation and that there is a dearth of empirical work in healthcare studies that adequately deals with context. Drawing on extensive empirical data exploring the career of ‘evidence based’ healthcare innovations, we illustrate that context should not be seen as a backcloth to action but as an interacting element in the change process.

Clinical Management as Boundary Management, a comparative analysis of Canadian and U.K. healthcare institutions

Focuses on the critical role played by professionals in the management of healthcare institutions in the UK and Canada. Using empirical data, examines the structural models of clinical management, the roles of clinical managers and their relationships with colleague professionals. Compares the approaches taken in the UK and Canada, and explores issues of context, history and relative power. Questions the extent to which professionals are losing autonomy to other professions and management. In particular examines whether the sharing of power inter-professionally may lead to greater, overall collective professional autonomy. Develops themes of the contextual influences on the process of change, and whether professionals are more effectively managed by internal or external processes of control.

Clinicians into Management: On the Change Agenda or Not?:

This article examines the issue of drawing medical consultants into managerial decision making. It commences by examining both historically and comparatively the influences on doctors and their reluctance to adopt managerial roles and responsibilities. It progresses to an analysis of the impact of the NHS and Community Care Act particularly in relation to the separation of purchaser and providers and the development of contracting mechanisms. The argument presented suggests that the rapid adoption of the clinical directorate model, as the favoured mode of organisation in acute units, has led to clinicians assuming ‘imitation’ general manager roles. The authors question whether this is the best use of the unique skills and time of clinicians. They compare with experience in the USA and propose that collaborative working between doctors and general managers is essential in health care. The article suggests a set of tasks for clinician managers and then dicusses the issues of training support and development which will be required if clinicians are to perform these tasks effectively.

Beyond Acceptance and Resistance: Entrepreneurial Change Agency Responses in Policy Implementation

This article explores how the implementation of public policy can differ from that mandated, and argues that such departures are not necessarily a problem. Organisational change faces theoretical tension between considering non-acceptance behaviours as ‘resistance’, and requiring change recipients to tailor and adapt change agendas to fit local contexts. This tension is particularly salient in the public sector, due to the mandated nature of much public reform. We compare the implementation of policy change in four hospital case studies in two countries (Ireland and the UK). Based on interviews with 68 staff across the four cases, we identify how change recipients can react to, translate and contribute to policy change initiatives. Our findings challenge straightforward distinction between change agents and change recipients, showing how ‘first-order’ recipients can act as ‘second-order’ change agents. Entrepreneurial second-order change agents use locally contextualized change agency to tailor and embellish policy mandates. We distinguish between ‘adapters’, who make appropriate local adjustments, and ‘extrapreneurs’ who add extra dimensions to mandated change. This evidence suggests replacing the traditional ‘acceptance-resistance’ dichotomy with a continuum of responses to mandated policy, identifying how public sector actors can variously avoid, abstain, adopt, adapt, or add to those agendas.

Evidence into Practice? An Exploratory Analysis of the Interpretation of Evidence

This chapter draws on a pair of research projects, using similar methodologies which seek to explore the processes by which innovations diffuse into clinical practice. The research sets out to understand, inform and improve the processes of evidence-based medicine. Evidencebased medicine (EBM) involves the diffusion of evidence, particularly new or updated evidence, into clinical practice. As such, it includes complex processes of understanding, deciding, evaluating, communicating and agreeing. At the outset one would also stress that EBM involves change and change processes. We hope this briefly emphasises the first tenet of this chapter, that we are investigating and describing complex processes. This chapter will focus on one problematic aspect of EBM which, with a few notable exceptions (Williamson, 1992; Dawson, 1995; Berg, 1997), has been particularly neglected: the nature of ‘the evidence’ itself. Do we understand what is meant by scientific evidence? Closely associated with the nature of the evidence are the meanings ascribed to it by professionals. What are their perceptions of evidence? Are they uniform? Finally, in considering the diffusion of evidence and its use in practice, what are the attributes of evidence which make it credible and, therefore, potentially, used?