Sandra Nutley

Using evidence: how research can inform public services.

There is widespread commitment across public service agencies in the UK and elsewhere to ensuring that the best available evidence is used to improve public services. The challenge is not only making research evidence accessible and available, but also getting it used. This book provides a timely and novel contribution to understanding and enhancing evidence use. It builds on and complements the popular and best-selling What Works?: Evidence-Based Policy and Practice in Public Services by drawing together current knowledge from the education, health care, social care, and criminal justice fields.

Organisational culture and quality of health care

“ A student of management and organisation theory could only be stunned by how little the efforts to improve quality [in health care] have learnt from current thinking in management and from the experience of other industries .” Christian Koeck BMJ 1998; 317: 1267–8. Health policy in much of the developed world is concerned with assessing and improving the quality of health care. The USA, in particular, has identified specific concerns over quality issues12 and a recent report from the Institute of Medicine pointed to the considerable toll of medical errors.3 In the UK a series of scandals has propelled quality issues to centre stage45 and made quality improvement a key policy area.6 But how are quality improvements to be wrought in such a complex system as health care? A recent issue of Quality in Health Care was devoted to considerations of organisational change in health care, calling it “the key to quality improvement”.7 In discussing how such change can be managed, the authors of one of the articles asserted that cultural change needs to be wrought alongside structural reorganisation and systems reform to bring about “a culture in which excellence can flourish”.8 A review of policy changes in the UK over the past two decades shows that these appeals for cultural change are not new but have appeared in various guises (box 1). However, talk of “culture” and “culture change” beg some difficult questions about the nature of the underlying substrate to which change programmes are applied. What is “organisational culture” anyway? It is to this issue that this paper is addressed.Many previous policy reforms in the National Health Service (NHS) have invoked the notion of cultural change. In the early 1980s the reforms inspired by Sir Roy Griffiths led …

From Knowing to Doing: A Framework for Understanding the Evidence-into-Practice Agenda

The past decade has witnessed widespread interest in the development of policy and practice that is better informed by evidence. Enthusiasm has, however, been tempered by recognition of the difficulties of devising effective strategies to ensure that evidence is integrated into policy and utilized in practice. There is already a rich but diverse and widely dispersed literature that can be drawn upon to inform such strategies. This article offers a guide to this literature by focusing on six main interrelated concerns: (1) the types of knowledge relevant to understanding research utilization/evidence-based practice (RU/EBP) implementation; (2) the ways in which research knowledge is utilized; (3) models of the process of utilization; (4) the conceptual frameworks that enable us to understand the process of RU/EBP implementation; (5) the main ways of intervening to increase evidence uptake and the effectiveness of these; (6) different ways of conceptualizing what RU/EBP means in practice.

Developing learning organisations in the new NHS

The governments quality strategy represents a bold blueprint for the new NHS. It embodies the view that managing the organisational culture in tandem with improved learning (albeit overseen by close external monitoring) will deliver substantial gains in performance. The avowed aim is “to create a culture in the NHS which celebrates and encourages success and innovation … a culture which recognises … scope for acknowledging and learning from past mistakes.”1 Although learning is something undertaken and developed by individuals, organisational arrangements can foster or inhibit the process. The organisational culture within which individuals work shapes their engagement with the learning process. More than this, there are serious questions about whether and how the organisation can harness the learning achieved by its individual members. Thus, although continuing professional development has long been a part of the NHS, evidence from other sectors suggests that learning needs to take a more central role. Organisations that position learning as a core characteristic have been termed “learning organisations,”2–4 and this concept is an important one in the context of organisational development.5 This paper explores organisational learning and the characteristics of the organisational cultures needed to underpin this learning. We have drawn on existing publications in this area and have used informal synthesis to summarise the key elements of learning organisations and relate these to recent developments in the NHS. Our aim is to encourage the transference of some of these ideas to the NHS. #### Summary points The national quality strategy for the new NHS highlights lifelong learning as a way of improving health care Learning is something achieved by individuals, but “learning organisations” can configure themselves to maximise, mobilise, and retain this learning potential Learning occurs at different levels—single loop learning is about incremental improvements to existing practice; double loop learning occurs …

Why ‘knowledge transfer’ is misconceived for applied social research

‘Knowledge transfer’ has become established as shorthand for a wide variety of activities linking the production of academic knowledge to the potential use of such knowledge in non-academic environments. While welcoming the attention now being paid to non-academic applications of social research, we contend that terms such as knowledge transfer (and its subordinate sibling, knowledge translation) misrepresent the tasks that they seek to support. By articulating the complex and contested nature of applied social research, and then highlighting the social and contextual complexities of its use, we can see that other terms may serve us better. Following from this analysis, we suggest that ‘knowledge interaction’ might more appropriately describe the messy engagement of multiple players with diverse sources of knowledge, and that ‘knowledge intermediation’ might begin to articulate some of the managed processes by which knowledge interaction can be promoted. While it might be hard to shift the terminology of knowledge transfer in the short term, awareness of its shortcomings can enhance understanding about how social research can have wider impacts.

Making a reality of evidence-based practice: some lessons from the diffusion of innovations

The 1990s saw an upsurge of interest in using research evidence to inform public sector policy and practice. Yet, if such evidence is to have impact, ways must be found to move beyond the simple dissemination of research findings. Strategies need to be developed which encourage the uptake and utilisation of evidence. In exploring ways in which evidence-based practice might be achieved, the lessons gleaned from an examination of the literature on the diffusion of innovations are presented. The implications of these lessons for ongoing organizational learning are also outlined.

Flows of Knowledge, Expertise and Influence: A Method for Assessing Policy and Practice Impacts from Social Science Research

Social science research undoubtedly does impact on public policy and practice but such non-academic impacts are rarely amenable to precise, quantitative metrics. In the interests of accountability, it is however possible to find proxy indicators of connectivity with research users and these may form steps toward impacts. Understanding these connections can lead to a deeper appreciation of the factors that shape the processes leading to research uptake. This study adopted a detailed and largely qualitative approach to identify the flows of knowledge, expertise and influence that take place during the process of knowledge transfer in order to trial a method for assessing policy and practice impacts from social science research. As a corollary to this assessment, the study further identified five factors that can influence and enhance the process of knowledge exchange between researchers and users. Copyright , Beech Tree Publishing.

Increasing research impact through partnerships: evidence from outside health care

There is growing interest in using closer partnerships between researchers and research users to increase the appropriate application of research evidence in policy and practice. While this supplement reports and assesses a number of these initiatives in health care, this article reviews the evidence in support of partnerships from elsewhere. Drawing on a substantial cross-sector review of research impact initiatives, we extract lessons for health care from partnership evaluations in social care, education and criminal justice services. A reasonable and robust evidence base supports the use of partnerships as one means of increasing research uptake. Although requiring substantial investments of time, resources and commitment, and suffering from a number of possible pitfalls, we conclude that such partnerships offer great potential for increasing research use.

Developing organizational learning in the NHS

Learning has been identified as a central concern for a modernized NHS. Continuing professional development has an important role to play in improving learning but there is also a need to pay more attention to collective (organizational) learning. Such learning is concerned with the way organizations build and organize knowledge. Recent emphasis within the NHS has been on the codification of individual and collective knowledge – for example, guidelines and National Service Frameworks. This needs to be balanced by more personalized knowledge management strategies, especially when dealing with innovative services that rely on tacit knowledge to solve problems. Having robust systems for storing and communicating knowledge is only one part of the challenge. It is also important to consider how such knowledge gets used, and how routines become established within organizations that structure the way in which knowledge is deployed. In many organizations these routines favour the adaptive use of knowledge, which helps organizations to achieve incremental improvements to existing practices. However, the development of organizational learning in the NHS needs to move beyond adaptive (single loop) learning, to foster skills in generative (double loop) learning and meta‐learning. Such learning leads to a redefinition of the organization’s goals, norms, policies, procedures or even structures. This paper argues that moving the NHS in this direction will require attention to the cultural values and structural mechanisms that facilitate organizational learning.

The Rise and Rise of Evidence in Health Care

Health care practitioners (especially doctors) have always given assurances that what they do is efficacious. But in the past 50 years justification of the effectiveness of health care interventions has attained a new prominence. Evidence, at least notionally, now lies at the heart of health care policy and practice. This article provides an overview of the generation and use of evidence on effectiveness in health care. It explains why rigorous methodologies have taken hold and describes the major preoccupation with trying to ensure that research evidence has an impact on clinical practice. The strengths and weaknesses of evidence-based health care are explored to identify the opportunities for profitable transfer of experience across the public sector.