Louise Locock

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.

Understanding the role of opinion leaders in improving clinical effectiveness.

We present findings from evaluations of two government-funded initiatives exploring the transfer of research evidence into clinical practice--the PACE Programme (Promoting Action on Clinical Effectiveness), and the Welsh Clinical Effectiveness Initiative National Demonstration Projects. We situate the findings within the context of available research evidence from healthcare and other settings on the role of opinion leaders or product champions in innovation and change--evidence which leaves a number of problems and unanswered questions. A major concern is the difficulty of achieving a single replicable description of what opinion leaders are and what they do--subjective understandings of their role differ from one setting to another, and we identify a range of very different types of opinion leadership. What makes someone a credible and influential authority is derived not just from their own personality and skills and the dynamic of their relationship with other individuals, but also from other context-specific factors. We examine the question of expert versus peer opinion leaders, and the potential for these different categories to be more or less influential at different stages in the innovation process. An often neglected area is the impact of opinion leaders who are ambivalent or hostile to an innovation. Finally, we note that the interaction between individual opinion leaders and the collective process of negotiating a change and reorienting professional norms remains poorly understood. This raises a number of methodological concerns which need to be considered in further research in this area.

Collecting data on patient experience is not enough: they must be used to improve care

The NHS has been collecting data on patients’ experience of care for over 10 years but few providers are systematically using the information to improve services. Angela Coulter and colleagues argue that a national institute of “user” experience should be set up to draw the data together, determine how to interpret the results, and put them into practice

Healthcare redesign: meaning, origins and application

Healthcare organisations are using redesign to tackle variation in the quality of care and improve public satisfaction. It is represented as a radical challenge to traditional assumptions and practices which involves thinking through the best process to achieve speedy and effective patient care, identifying delays, unnecessary steps, or potential for error, and redesigning the process to improve the quality of care. This paper explores the meaning of redesign using practical illustrations. It examines its theoretical origins, particularly total quality management (TQM)/continuous quality improvement (CQI) and re-engineering, and assesses evidence which may inform its application. This evidence suggests that clinical ownership and senior management support will be essential. Redesign seeks to balance the more gradual approach of TQM with the organisation-wide lateral thinking of re-engineering. An incremental negotiated approach seems more likely to ensure clinical ownership, but carries a risk that QI will remain small scale with little impact on the wider organisation. Inclusion of some re-engineering techniques may help to overcome this difficulty. Evidence suggests that most QI techniques achieve only partial success. This may pose difficulties for redesign, which has generated high political expectations that it can solve long term problems in health care.

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

Implementation of evidence-based medicine: evaluation of the Promoting Action on Clinical Effectiveness programme

Objectives: To evaluate the Promoting Action on Clinical Effectiveness (PACE) programme, which sought to implement clinically effective practice in 16 local sites. Methods: 182 semi-structured interviews, usually by telephone, with project team members, clinicians, and senior managers and representatives from the Department of Health and the Kings Fund. Results: The most influential factors were strong evidence, supportive opinion leaders and integration within a committed organization; without these factors, projects had little chance of success. Other factors (context analysis, professional involvement and good project management) emerged as important, supporting processes; their presence might be an additional help, but on their own they would not be enough to initiate change. A serious problem with any of them could have a strong adverse impact. Conclusions: Although there is no simple formula for the factors that ensure successful implementation of research-based improvements to clinical practice, certain principles do seem to help. Time and resource need to be devoted to a period of local negotiation and adaptation of good research evidence based on a careful understanding of the local context, in which opinion leader influence is an important component of a well managed and preferably well integrated process of change.

Personal benefit, or benefiting others? Deciding whether to take part in clinical trials.

Background Participation in clinical trials is critical for the success of evidence-based healthcare. Much previous research suggests that people take part in clinical trials mostly for altruistic reasons, and that deriving personal benefit is a secondary consideration. Purpose To investigate patients’ reasons for deciding whether to take part in clinical trials and the extent to which personal benefit may be a motivating factor. Methods A qualitative study utilizing in-depth semi-structured interviews. Participants were 42 men and women who had been asked to participate in clinical trials testing a range of interventions in different conditions, including some who did not participate or withdrew. Trials were based in either primary or secondary care. Interviews were conducted at home. Results Reasons for taking part were complex and a wide variety of personal considerations were evident. Gaining some personal benefit emerged as an important primary motivation in this group of respondents, whereas altruistic considerations appeared to be largely subsidiary. People who decided not to take part were also mainly concerned about the balance of personal risk and benefit. Limitations Public dissemination of the results may have influenced participants’ responses. Conclusions Achieving target sample sizes for clinical trials may be enhanced by an understanding of what is likely to motivate patients to take part. In this study, respondents identified a range of attractive benefits, such as care in a specialist team with expert staff, active engagement in their health monitoring or care, more frequent or intensive monitoring, and information about the latest research into their condition.

“Making it All Normal”: The Role of the Internet in Problematic Pregnancy

Women are actively encouraged to educate themselves about pregnancy from formal sources (e.g., information leaflets, antenatal classes, books). In addition, informal stories of pregnancy and birth are routinely told between women. However, increased prenatal testing means that more fetuses are diagnosed with abnormalities, shifting the information requirements during pregnancy. Traditional sources of information cannot cover all possible outcomes, and the Internet is beginning to fill this gap. In this article, we draw from interviews about experiences of antenatal screening and pregnancy to explore how the Internet provides a unique resource for problematic pregnancies. It allows access to information about rarer conditions beyond standard pregnancy texts, as well as personal narratives about conditions. Learning how others have coped or are coping in similar situations can help alleviate feelings of isolation, and also places women back in a familiar territory of shared pregnancy narratives.

Redesigning mental health services: lessons on user involvement from the Mental Health Collaborative

Objectives  To explore the involvement of mental health service users in the redesign of in‐patient mental health services in six Trusts participating in a multi‐regional NHS modernization programme.

The Effect of Joint Interviewing on the Performance of Gender

The authors report a series of controlled comparisons of fifty-eight one-to-one qualitative interviews and thirty-seven mixed-sex joint interviews on the same health-related topics. Their analysis identifies comparative keyword frequencies and is supported by qualitative investigations of keywords in context, drawing on existing relevant knowledge of common gender differences in language choice. Gender differences are reduced and womens perspectives are more prominent in joint interviews, so researchers wanting to find out about mens experiences concerning health-related topics such as those associated with fatherhood may find out more in one-to-one interviews with men. The greater readiness of men to engage in gender-stereotyped behavior in sole interviews, most of which involved a female interviewer, suggests that an interviewers gender identity is perceived as somewhat neutral by comparison with the considerable salience of the gender of a joint respondent. This finding potentially contributes to knowledge of the qualitative interview as a special form of institutional talk.