Nicky Britten

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.

Hearing children's voices: Methodological issues in conducting focus groups with children aged 7-11 years

Children are increasingly acknowledged to have rights in the determination of decisions that affect them. This has encouraged research to be undertaken with children themselves to understand their own views, experiences and relationships, and has demonstrated a considerable gulf from parental concerns and observations. Methods for research with children are, however, relatively under-developed. This article reflects on our experience of conducting focus groups with children aged 7-11 years to examine their experiences of living with asthma. It discusses the use of child-friendly techniques to promote participation and access children’s meanings, and raises issues about the size and composition of groups and recruitment strategies, group dynamics, tensions and sensitive moments. We conclude that focus groups are a valuable method for eliciting children’s views and experiences and complement personal interviews, while important questions relate to enhancing children’s participation in other stages of the research process.

Solutions to problematic polypharmacy: learning from the expertise of patients

A lively debate in the final plenary at last year’s Royal College of General Practitioners (RCGP) Annual Primary Care Conference considered the provocation: ‘My Doctor Makes Me Sick — what can we do about it?’. The event was run by the Heseltine Institute for Public Policy & Practice at Liverpool University, in conjunction with Mersey Faculty and the RCGP. It followed on from a public debate ‘My doctor makes me sick’ held in Liverpool at the opening of the conference. The audience were invited to propose solutions to current concerns about overmedicalisation, treatment burden, and over- and under-diagnosis. Two of the final eight proposals related to reducing prescribing. GPs called for incentives not to use medicines and for deprescribing; both seen as necessary to support the individually-tailored care that GPs and patients1 seek. But GPs have described needing help in tailoring prescribing to individual needs, particularly when individual needs may appear to be at odds with the ‘ideal’ described by guidelines for best practice.2 So how can we help professionals and patients tackle a problem of perceived overprescribing and problematic polypharmacy?

Testing Methodological Guidance on the Conduct of Narrative Synthesis in Systematic Reviews Effectiveness of Interventions to Promote Smoke Alarm Ownership and Function

The objective was to assess the impact of new guidance on the conduct of narrative synthesis in systematic reviews of effectiveness, by means of a blinded comparison of guidance-led narrative synthesis against a meta-analysis of the same study data.The conclusions of the two syntheses were broadly similar. However, differences between the approaches meant that conclusions about the impact of moderators of effect appeared stronger when derived from the meta-analysis, whereas implications for future research appeared more extensive when derived from the narrative synthesis. These findings emphasize that a rigorously conducted narrative synthesis can add meaning and value to the findings of meta-analysis.The guidance framework provided a useful vehicle for structuring a narrative synthesis and increasing transparency and rigour of the process.While there may be risks with overinterpretation of study data, the framework, tools and techniques described in the guidance appear to increase the transparency and reproducibility of narrative synthesis.

Testing methodological developments in the conduct of narrative synthesis: a demonstration review of research on the implementation of smoke alarm interventions

In the context of systematic reviews, statistical meta-analysis of findings is not always possible. Where this is the case, or where a review of implementation evidence is required, narrative synthesis of data is typically undertaken. Drawing on recently developed guidance aimed at those undertaking data synthesis - and information on the implementation of domestic smoke detectors - we present findings from a demonstration of the tools and techniques that can be used in a narrative synthesis. The work demonstrates how this process can be made more transparent, and suggests that using the tools and techniques can improve the quality of narrative synthesis.

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

In Pursuit of Patient-Centred Outcomes: A Qualitative Evaluation of the ‘Measure Yourself Medical Outcome Profile’

Objectives: To ascertain the ability of a patient-generated outcome measure, the ‘Measure Yourself Medical Outcome Profile’ (MYMOP), to reflect the outcomes of consultations which patients consider are most important, as derived from qualitative interviews. Methods: A qualitative study using a constant comparative method to analyse semistructured interviews which were then compared with the results of MYMOP questionnaires. A variable-orientated analysis was used to develop themes and a case-orientated analysis was used to develop narrative summaries called vignettes from the interviews. The MYMOP questionnaire was completed by the interviewees (n= 20), a minimum of twice and a maximum of nine times over a four-month period. The scores were displayed on individual MYMOP charts. For each individual, the outcome as measured by MYMOP was compared with the outcome data from the qualitative interviews. The interviewees were attending a variety of complementary practitioners in primary care. Results: The treatment effects which people described were encompassed by five themes: reduction in symptoms; reduction in disability; reduction in, or avoidance of, medication; gaining control and improving coping skills; and securing support and hope through the patient—practitioner relationship. The vignettes demonstrated how individuals identified and valued these various effects and weighed them up in evaluating the overall benefit of the treatment. Their MYMOP charts were able to measure some effects better than others. Conclusions: The treatment effects, as quantified using MYMOP, accorded with those described by most patients at interview, but some important limitations were identified with MYMOP, particularly an underplaying of the importance of medication avoidance or medication reduction in this patient group. This dimension is lacking in most outcome questionnaires and has been included in a new version of MYMOP. This study also showed that qualitative interview data can help in evaluating the ability of outcome questionnaires to measure the treatment effects that particular patient groups consider most important.

Prescribing and the defence of clinical autonomy

The medical profession has an almost exclusive right to prescribe medicines, but this right is being challenged by the State, patients and other health care professionals. It is argued that, in British general practice, prescribing is a battleground on which the cause of clinical autonomy is defended. It represents a particular context for assessing the theories of proletarianisation and deprofessionalisation. The historical conflicts between the State and the medical profession, and the threat posed by ‘patient demand’, are both reflected in the regulations governing prescribing and the medicolegal status of medicines. Clinical freedom is under threat from the State and peer group pressure in the form of clinical governance, while at the same time doctors’ jurisdiction over medicines is being reduced by the deregulation of prescription-only medicines. These changes, however, do not yet support the thesis of proletarianisation as the medical profession continues to dominate the clinical agenda and the responsibilities of other health care workers. Neither does the concept of patient demand support the thesis of deprofessionalisation, as it is unsupported by the research evidence. Doctors cite patients’ inappropriate demands as problematic, but do not give patients the information about their medicines that they both want and need. Patients’ resistance tends to take the form of ‘non compliance’. In fighting two adversaries, patients’ expectations (‘clinical need’) are cited in support of professional claims, while in other contexts ‘patient demand’ is seen as a threat to clinical autonomy.

Early respiratory experience and subsequent cough and peak expiratory flow rate in 36 year old men and women.

Earlier work on the respiratory health of members of the Medical Research Councils national survey of health and development (1946 birth cohort) was extended to age 36. At that age measures of peak expiratory flow rate and respiratory symptoms, elicited by the MRC chronic bronchitis questionnaire, were made in 3261 cohort members. In both men and women lower peak expiratory flow and higher respiratory morbidity were independently associated not only with current indices of poor social circumstances and cigarette smoking but also with poor home environment at age 2 years and lower respiratory tract illness before age 10. The findings provide additional evidence for a causal relation between childhood respiratory experience and adult respiratory disease.