Disseminating educational innovations in health care practice: training versus social networks

Leveraging Social Networks to Integrate Depression Treatment into Primary Health and Tuberculosis Care in Brazil

Background

Tuberculosis (TB) and depression are highly comorbid and linked to higher rates of death and disability. Several evidence-based treatments for depression have been successfully implemented in low- and middle-income countries, but more knowledge is needed on how to bring these innovations to scale within complex 'real world' public health systems.

Objective

To explore whether the principles of social network analysis could be used to enhance receptivity to integrating depression treatment into primary care for individuals with and without TB in Brazil.

Methods

We used existing scales to identify settings and providers with high receptivity and connectivity within the primary care network. We trained and supervised existing staff in three primary care sites to deliver a brief evidence-based intervention over one year, coupled with active dissemination activities. Afterwards, we reassessed receptivity among individuals involved, and not involved, in the pilot.

Results

Highly significant changes were observed in mental health literacy, attitudes towards evidence-based practices, work self-efficacy, and implementation leadership supporting our hypothesis. Limited social connections between primary care clinics precluded the examination of the hypothesis that targeting settings with high connectivity could capitalize on the information flow between and transcend the decentralized structure of the network, but leveraging the centralized nature of the TB program to integrate mental health services emerged as a promising alternative.

Conclusions

The findings of this study strongly suggest that social networks may be leveraged to change individual providers' attitudes, thereby contributing to the enhanced dissemination of evidence-based interventions.

Network approaches and interventions in healthcare settings: A systematic scoping review

INTRODUCTION

The growing interest in networks of interactions is sustained by the conviction that they can be leveraged to improve the quality and efficiency of healthcare delivery systems. Evidence in support of this conviction, however, is mostly based on descriptive studies. Systematic evaluation of the outcomes of network interventions in healthcare settings is still wanting. Despite the proliferation of studies based on Social Network Analysis (SNA) tools and techniques, we still know little about how intervention programs aimed at altering existing patterns of social interaction among healthcare providers affect the quality of service delivery. We update and extend prior reviews by providing a comprehensive assessment of available evidence.

METHODS AND FINDINGS

We searched eight databases to identify papers using SNA in healthcare settings published between 1st January 2010 and 1st May 2022. We followed Chambers et al.'s (2012) approach, using a Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. We distinguished between studies relying on SNA as part of an intervention program, and studies using SNA for descriptive purposes only. We further distinguished studies recommending a possible SNA-based intervention. We restricted our focus on SNA performed on networks among healthcare professionals (e.g., doctors, nurses, etc.) in any healthcare setting (e.g., hospitals, primary care, etc.). Our final review included 102 papers. The majority of the papers used SNA for descriptive purposes only. Only four studies adopted SNA as an intervention tool, and measured outcome variables.

CONCLUSIONS

We found little evidence for SNA-based intervention programs in healthcare settings. We discuss the reasons and challenges, and identify the main component elements of a network intervention plan. Future research should seek to evaluate the long-term role of SNA in changing practices, policies and behaviors, and provide evidence of how these changes affect patients and the quality of service delivery.

Translation of surface electromyography to clinical and motor rehabilitation applications: The need for new clinical figures

Advanced sensors/electrodes and signal processing techniques provide powerful tools to analyze surface electromyographic signals (sEMG) and their features, to decompose sEMG into the constituent motor unit action potential trains, and to identify synergies, neural muscle drive, and EEG-sEMG coherence. However, despite thousands of articles, dozens of textbooks, tutorials, consensus papers, and European and International efforts, the translation of this knowledge into clinical activities and assessment procedures has been very slow, likely because of lack of clinical studies and competent operators in the field. Understanding and using sEMG-based hardware and software tools requires a level of knowledge of signal processing and interpretation concepts that is multidisciplinary and is not provided by most academic curricula in physiotherapy, movement sciences, neurophysiology, rehabilitation, sport, and occupational medicine. The chasm existing between the available knowledge and its clinical applications in this field is discussed as well as the need for new clinical figures. The need for updating the training of physiotherapists, neurophysiology technicians, and clinical technologists is discussed as well as the required competences of trainers and trainees. Indications and examples are suggested and provide a basis for addressing the problem. Two teaching examples are provided in the Supplementary Material.

Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study

OBJECTIVE

We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework.

DESIGN AND METHODS

This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies.

RESULTS

The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters.

CONCLUSIONS

The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.

Analyzing annual changes in network structures of a social media application-based information-sharing system in a Japanese community

Background

Understanding the evolution of social network services (SNSs) can provide insights into the functions of interprofessional information-sharing systems. Using social network analysis, we aimed to analyze annual changes in the network structure of SNS-based information sharing among healthcare professionals over a 3-year period in Japan.

Methods

We analyzed data on SNS-based information sharing networks with online message boards for healthcare professionals for 2018, 2019, and 2020 in a Japanese community.

These networks were created for each patient so that healthcare professionals could post and view messages on the web platform. In the social network analysis (SNA), healthcare professionals registered with a patient group were represented as nodes, and message posting and viewing relationships were represented as links. We investigated the structural characteristics of the networks using several measures for SNA, including reciprocity, assortativity and betweenness centrality, which reflect interrelational links, the prevalence of similar nodes with neighbors, and the mediating roles of other nodes, respectively. Next, to compare year-to-year trends in networks of patients overall, and between receiving nursing care levels 1–3 (lighter care requirement) and levels 4–5 (heavier care requirement), we described the annual structural differences and analyzed each measure for SNA using the Steel–Dwass test.

Results

Among 844, 940, and 1063 groups in each year, groups for analysis in care levels 1–3/4–5 were identified as 106/135, 79/89, and 57/57, respectively. The overall annual assessment showed a trend toward increased diameter and decreased density, but the differences were not significant. For those requiring care levels 1–3, assortativity decreased significantly, while for those requiring care levels 4–5, reciprocity decreased and betweenness centrality increased significantly. No significant differences were found in the other items.

Discussion

This study revealed that the network of patients with a lighter care requirement had more connections consisting of nodes with different links, whereas the network of patients with a heavier care requirement had more fixed intermediary roles and weaker interrelationships among healthcare professionals. Clarifying interprofessional collaborative mechanisms underlying development patterns among healthcare professionals can contribute to future clinical quality improvement.

Analysis of Network Characteristics to Assess Community Capacity of Latino-Serving Organizations in Philadelphia

Latino immigrants are disproportionately impacted by substance use, HIV/AIDS, domestic violence, and mental health (SAVAME). The burden of these syndemic conditions is influenced by limited access to health and social services to prevent and treat these conditions. The syndemic nature of these factors necessitates an integrated, coordinated approach to address them simultaneously. We analyzed characteristics of Latino-serving organizations in Philadelphia, PA, that provide SAVAME-related health and/or social services, and their interorganizational collaborations to meet the needs of Philadelphia's Latino communities. We surveyed Latino-serving organizations (N=43) identified through existing resource directories and key informants. Network analyses identified patterns and density of collaborative ties (i.e., referrals, administrative, or planning/advocacy) across organizations and characterized these ties by type of service. Density (expressed as percent of all possible ties) revealed a higher referral rate (40%) than administrative (29%) or planning (26%) coordination. Network sociograms display clusters of providers by geography. Examination of bonding (within-group) ties revealed comparable perceptions of high value among both South/Center Philadelphia (57%) and in North Philadelphia providers (56%), but bridging (between-group) ties suggest lower levels of high-value perceptions (24%). No evident clustering by type of service based on syndemic factor was observed. Density of bridging across types of providers was highest for referrals (38%) followed by planning (23%) and administrative coordination (20%). Interventions to promote collaboration between providers should focus on facilitating administrative and planning collaborations that leverage existing capacity of the network. Given the syndemic nature of these conditions, greater collaboration between providers of complementing SAVAME services is imperative.

Value of social network analysis for developing and evaluating complex healthcare interventions: a scoping review

OBJECTIVES

Most complex healthcare interventions target a network of healthcare professionals. Social network analysis (SNA) is a powerful technique to study how social relationships within a network are established and evolve. We identified in which phases of complex healthcare intervention research SNA is used and the value of SNA for developing and evaluating complex healthcare interventions.

METHODS

A scoping review was conducted using the Arksey and O'Malley methodological framework. We included complex healthcare intervention studies using SNA to identify the study characteristics, level of complexity of the healthcare interventions, reported strengths and limitations, and reported implications of SNA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews 2018 was used to guide the reporting.

RESULTS

Among 2466 identified studies, 40 studies were selected for analysis. At first, the results showed that SNA seems underused in evaluating complex intervention research. Second, SNA was not used in the development phase of the included studies. Third, the reported implications in the evaluation and implementation phase reflect the value of SNA in addressing the implementation and population complexity. Fourth, pathway complexity and contextual complexity of the included interventions were unclear or unable to access. Fifth, the use of a mixed methods approach was reported as a strength, as the combination and integration of a quantitative and qualitative method clearly establishes the results.

CONCLUSION

SNA is a widely applicable method that can be used in different phases of complex intervention research. SNA can be of value to disentangle and address the level of complexity of complex healthcare interventions. Furthermore, the routine use of SNA within a mixed method approach could yield actionable insights that would be useful in the transactional context of complex interventions.

Exploring the structure of social media application-based information-sharing clinical networks in a community in Japan using a social network analysis approach

OBJECTIVE

Currently, use of social networking services (SNSs) for interprofessional collaboration is increasing. However, few studies have reported on virtual interprofessional interactions in community healthcare services. Revealing such structural characteristics of the networks can provide insight into the functions of the interprofessional information-sharing network and lead to smoother collaboration. Thus, we aimed to explore the structure of SNS-based information-sharing clinical networks.

DESIGN

Social network analysis (SNA).

SETTING

We selected a community in City X in Japan.

DATA COLLECTION

We analysed SNS-based information-sharing clinical network data linked to patients receiving home medical care or care services between January and December 2018. A network was created for each patient to allow healthcare professionals to post and view messages on the web platform. In the SNA, healthcare professions registered in a patient group were represented as nodes, and message posting/viewing relationships were represented as links in the patient network. We investigated the structural characteristics of the target networks using several measures for SNA, including indegree centrality and outdegree centrality, which reflect the number of incoming and outgoing links to/from a node, respectively. Additionally, the professions forming the most central nodes were investigated based on their ranking to identify those with a central role in the networks. Finally, to compare the networks of nursing care levels 1-3 (lighter care requirement) and those with nursing care levels 4-5 (heavier care requirement), we analysed the structural differences in the networks and investigated the roles of healthcare professionals using centrality measures of nodes.

RESULTS

Among 844 groups, 247 groups with any nursing care level data were available for analysis. Increasing nursing care level showed higher density, reciprocity and lower centralisation. Healthcare professions with high indegree centrality (physicians, care workers and physical therapists) differed from those with high outdegree centrality (home care workers, physical therapists, and registered dieticians). Visiting nurses and nurses in the clinic played a central role, but visiting nurses tended to have higher indegree and outdegree centrality, while nurses in the clinic had higher closeness and betweenness centrality in networks with heavier care requirement.

CONCLUSION

The SNS-based information-sharing clinical network structure showed that different professions played some form of a central role. Associations between network structures and patient outcomes, cost effectiveness and other factors warrant further investigation.

[The Early Mobilization Network]

BACKGROUND

Since its foundation in 2011, the German Network for Early Mobilization of mechanically ventilated intensive care patients delivered, among others, more than 90 monthly newsletters, 14 research projects, and 3 national conferences.

PURPOSE

The aim of this online survey was to evaluate whether members of the Network perceived a professional benefit for themselves and their intensive cate units (ICU).

METHODS

An interprofessional online survey of 303 clinicians of the Network in German speaking countries in July 2019 was undertaken. The survey included questions about newsletters, personal benefits, perceived improvements on their workplaces, and future expectations.

RESULTS

The response rate was 48% (n = 145), mainly nurses and physiotherapists. The majority perceived the newsletter as good. Members reported that the network extended their professional knowledge and improved the quality of the ICUs regarding early mobilization, delirium management, and interprofessional goals. Participants expressed a wish for more workshops, case reports, webinars, and other educational possibilities.

CONCLUSIONS

Members of the network Early Mobilization perceived a personal and professional benefit. The network supported quality improvements projects in ICUs. The progress of the network may serve as an example for development of other professional networks.

Professional advice for primary healthcare workers in Ethiopia: a social network analysis

BACKGROUND

In an era of increasingly competitive funding, governments and donors will be looking for creative ways to extend and maximise resources. One such means can include building upon professional advice networks to more efficiently introduce, scale up, or change programmes and healthcare provider practices. This cross-sectional, mixed-methods, observational study compared professional advice networks of healthcare workers in eight primary healthcare units across four regions of Ethiopia. Primary healthcare units include a health centre and typically five satellite health posts.

METHODS

One hundred sixty staff at eight primary healthcare units were interviewed using a structured tool. Quantitative data captured the frequency of healthcare worker advice seeking and giving on providing antenatal, childbirth, postnatal and newborn care. Network and actor-level metrics were calculated including density (ratio of ties between actors to all possible ties), centrality (number of ties incident to an actor), distance (average number of steps between actors) and size (number of actors within the network). Following quantitative network analyses, 20 qualitative interviews were conducted with network study participants from four primary healthcare units. Qualitative interviews aimed to interpret and explain network properties observed. Data were entered, analysed or visualised using Excel 6.0, UCINET 6.0, Netdraw, Adobe InDesign and MaxQDA10 software packages.

RESULTS

The following average network level metrics were observed: density .26 (SD.11), degree centrality .45 (SD.08), distance 1.94 (SD.26), number of ties 95.63 (SD 35.46), size of network 20.25 (SD 3.65). Advice networks for antenatal or maternity care were more utilised than advice networks for post-natal or newborn care. Advice networks were typically limited to primary healthcare unit staff, but not necessarily to supervisors. In seeking advice, a colleague's level of training and knowledge were valued over experience. Advice exchange primarily took place in person or over the phone rather than over email or online fora. There were few barriers to seeking advice.

CONCLUSION

Informal, inter-and intra-cadre advice networks existed. Fellow primary healthcare unit staff were preferred, particularly midwives, but networks were not limited to the primary healthcare unit. Additional research is needed to associate network properties with outcomes and pilot network interventions with central actors.

Characteristics of High-Performing Primary Care Pediatric Practices: A Qualitative Study

OBJECTIVE

Performance on pediatric quality measures varies across primary care practices. Health care quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures.

METHODS

Using a positive deviance approach, semistructured interviews were conducted with pediatricians and staff (N = 35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (eg, care processes) and contextual factors (eg, teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods.

RESULTS

We identified 4 major themes (MTs): MT1, Practice Culture; MT2, Practice Structures and Quality Improvement Tools; MT3, Attitudes and Beliefs Related to Measuring Care Quality; and MT4, Perceived Barriers to Achieving High Performance on Quality Measures. MT1 subthemes included contextual factors such as teamwork, leadership, and feeling respected as an employee. MT2 subthemes included fixed characteristics such as practice size and strategies such as the use of an electronic medical record. MT3 and MT4 subthemes linked these constructs to factors external to the practices.

CONCLUSIONS

This study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver.

German Network for Early Mobilization: Impact for participants

Professional networks support health care providers in implementing evidence based knowledge. The German Network for Early Mobilization in Intensive Care Units (ICU) was founded in 2011 and serves for more than 300 critical care team members today. The mobilization network is connected to other professional networks and contributed to the development of national guidelines and quality indicators. Several research projects were conducted. Members of the mobilization network perceived benefits for themselves and their workplace. The network increased participants' knowledge and contributed to quality improvement projects on ICUs. Without having significant resources, this network development may serve as an example for other networks.

Diffusion of knowledge and behaviours among trainee doctors in an acute medical unit and implications for quality improvement work: a mixed methods social network analysis

OBJECTIVES

To describe the social networks that diffuse knowledge, attitudes and behaviours relating to different domains of practice within teams of trainee doctors in an acute hospital medical setting. The domains examined were 'clinical-technical', 'patient centredness' and 'organisation of work'.

DESIGN

Sequential mixed methods: (i) sociocentric survey of trainee consisting of questions about which colleagues are emulated or looked to for advice, with construction of social network maps, followed by (ii) semi-structured interviews regarding peer-to-peer influence, analysed using a grounded theory approach. The study took place over 24 months.

SETTING

An acute medical admissions unit, which receives admissions from the emergency department and primary care, in a National Health Service England teaching hospital.

PARTICIPANTS

Trainee medical doctors working in five consecutive rotational teams. Surveys were done by 39 trainee doctors; then 15 different participants from a maximal diversity sample were interviewed.

RESULTS

Clinical-technical behaviours spread in a dense network with rich horizontal peer-to-peer connections. Patient-centred behaviours spread in a sparse network. Approaches to non-patient facing work are seldom copied from colleagues. Highly influential individuals for clinical technical memes were identified; high influencers were not identified for the other domains.

CONCLUSION

Information and influence relating to different aspects of practice have different patterns of spread within teams of trainee doctors; highly influential individuals were important only for spread of clinical-technical practice. Influencers have particular characteristics, and this knowledge could guide leaders and teachers.

Mapping the Mission Statements of U.S. LCME-Accredited Medical Schools: An Exploration of Organizational Communalities

PURPOSE

Mission statements (MSs) express an organization's purpose and reflect the broader social environment in which they function. The authors analyze MS text to explore how medical schools can be relationally viewed and how particular thematic narratives within MSs can be deployed to associate schools in hithertofore unexplored ways.

METHOD

The authors analyzed the MSs (as of 1/1/2017) of 144 U.S. Liaison Committee on Medical Education-accredited schools. Using schools as their unit of analysis, they coded MSs using 44 themes. They employed content analysis to identify themes within MSs, factor analysis to identify core thematic dimensions embedded in MSs, and network analysis to examine relationships among schools based on these thematic dimensions. The authors used four standard school characteristics to examine the validity of their results.

RESULTS

Content analysis revealed 20 core themes. Factor analysis identified four thematic dimensions: Primary Care/Diversity; Future Learning-External; Traditional; and Learning Environment-Internal. Based on the 20 core themes and using the MSs of 125 schools with nonextreme MS code counts, the authors found that schools form a complete network, and that schools form distinctive network-based clusters based on the identified factors. The four thematic dimensions were significantly differentiated across the four standard school characteristics.

CONCLUSIONS

The authors found distinctive patterns of MS linkages among schools along with thematic linkages within MS themes, supporting the contentions that medical schools can be both differentiated and connected based on their MSs and that understanding MS content must move beyond simple frequency counts of MS attributes.

Primary care networks and team effectiveness: the case of a large-scale quality improvement disparity reduction program

Documentation of primary care teams' involvement in disparity reduction efforts exists, yet little is known about how teams interact or perceive their effectiveness. We investigated how the social network and structural ties among primary-care-clinic team members relate to their perceived team effectiveness (TE), in a large-scale disparity reduction intervention in Israel's largest insurer and provider of services. A mixed-method design of Social Network Analysis and qualitative data collection was employed. 108 interviews with medical, nursing, and administrative teams of 26 clinics and their respective managerial units were performed and information on the organizational ties, analyzing density and centrality, collected. Pearson correlations examined association between network measures and perceived TE. Clinics with strong intra-clinic density and high clinic-subregional-management density were positively correlated with perceived TE. Clinic in-degree centrality was also positively associated with perceived TE. Qualitative analyses support these findings with teamwork emerging as a factor which can impede or facilitate teams' ability to design and implement disparity reduction interventions. The study demonstrates that in an organization-wide disparity reduction initiative, cohesive intra-network structure and close relations with mid-level management increase the likelihood that teams perceive themselves as possessing the skills and resources needed to lead and implement disparity reduction efforts. List of abbreviations Team Effectiveness (TE); Clalit Health Services (Clalit); Social Network Analysis (SNA); Quality Improvement (QI); National Health Care Collaborative (NHPC); Tampa Bay Community Cancer Network (TBCCN).

Community-directed mass drug administration is undermined by status seeking in friendship networks and inadequate trust in health advice networks

Over 1.9 billion individuals require preventive chemotherapy through mass drug administration (MDA). Community-directed MDA relies on volunteer community medicine distributors (CMDs) and their achievement of high coverage and compliance. Yet, it is unknown if village social networks influence effective MDA implementation by CMDs. In Mayuge District, Uganda, census-style surveys were conducted for 16,357 individuals from 3,491 households in 17 villages. Praziquantel, albendazole, and ivermectin were administered for one month in community-directed MDA to treat Schistosoma mansoni, hookworm, and lymphatic filariasis. Self-reported treatment outcomes, socioeconomic characteristics, friendship networks, and health advice networks were collected. We investigated systematically missed coverage and noncompliance. Coverage was defined as an eligible person being offered at least one drug by CMDs; compliance included ingesting at least one of the offered drugs. These outcomes were analyzed as a two-stage process using a Heckman selection model. To further assess if MDA through CMDs was working as intended, we examined the probability of accurate drug administration of 1) praziquantel, 2) both albendazole and ivermectin, and 3) all drugs. This analysis was conducted using bivariate Probit regression. Four indicators from each social network were examined: degree, betweenness centrality, closeness centrality, and the presence of a direct connection to CMDs. All models accounted for nested household and village standard errors. CMDs were more likely to offer medicines, and to accurately administer the drugs as trained by the national control programme, to individuals with high friendship degree (many connections) and high friendship closeness centrality (households that were only a short number of steps away from all other households in the network). Though high (88.59%), additional compliance was associated with directly trusting CMDs for health advice. Effective treatment provision requires addressing CMD biases towards influential, well-embedded individuals in friendship networks and utilizing health advice networks to increase village trust in CMDs.

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Evaluation of mass drug administration implementation using social networks.

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Evidence of social biases and status-seeking from community medicine distributors.

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Coverage and compliance with mass drug administration for 16,357 individuals.

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Impact of friendship and health advice networks on treatment probability.

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Overlap of network status and formal social status in rural villages.

Informing the implementation of evidence-informed decision making interventions using a social network analysis perspective; a mixed-methods study

Background

Workforce development is an important aspect of evidence-informed decision making (EIDM) interventions. The structure of formal and informal social networks can influence, and be influenced, by the implementation of EIDM interventions.

Methods

In a mixed methods study we assessed the outcomes of a targeted training intervention to promote EIDM among the staff in three public health units in Ontario, Canada. This report focuses on the qualitative phase of the study in which key staff were interviewed about the process of engagement in the intervention, communications during the intervention, and social consequences.

Results

Senior managers identified staff to take part in the intervention. Engagement was a top-down process determined by the way organizational leaders promoted EIDM and the relevance of staff’s jobs to EIDM. Communication among staff participating in the workshops and ongoing progress meetings was influential in overcoming personal and normative barriers to implementing EIDM, and promoted the formation of long-lasting social connections among staff. Organization-wide presentations and meetings facilitated the recognition of expertise that the trained staff gained, including their reputation as experts according to their peers in different divisions.

Conclusion

Selective training and capacity development interventions can result in forming an elite versus ordinary pattern that facilitates the recognition of in-house qualified experts while also strengthening social status inequality. The role of leadership in public health units is pivotal in championing and overseeing the implementation process. Network analysis can guide and inform the design, process, and evaluation of the EIDM training interventions.

Pathways for best practice diffusion: the structure of informal relationships in Canada's long-term care sector

Background

Initiatives to accelerate the adoption and implementation of evidence-based practices benefit from an association with influential individuals and organizations. When opinion leaders advocate or adopt a best practice, others adopt too, resulting in diffusion. We sought to identify existing influence throughout Canada’s long-term care sector and the extent to which informal advice-seeking relationships tie the sector together as a network.

Methods

We conducted a sociometric survey of senior leaders in 958 long-term care facilities operating in 11 of Canada’s 13 provinces and territories. We used an integrated knowledge translation approach to involve knowledge users in planning and administering the survey and in analyzing and interpreting the results. Responses from 482 senior leaders generated the names of 794 individuals and 587 organizations as sources of advice for improving resident care in long-term care facilities.

Results

A single advice-seeking network appears to span the nation. Proximity exhibits a strong effect on network structure, with provincial inter-organizational networks having more connections and thus a denser structure than interpersonal networks. We found credible individuals and organizations within groups (opinion leaders and opinion-leading organizations) and individuals and organizations that function as weak ties across groups (boundary spanners and bridges) for all studied provinces and territories. A good deal of influence in the Canadian long-term care sector rests with professionals such as provincial health administrators not employed in long-term care facilities.

Conclusions

The Canadian long-term care sector is tied together through informal advice-seeking relationships that have given rise to an emergent network structure. Knowledge of this structure and engagement with its opinion leaders and boundary spanners may provide a route for stimulating the adoption and effective implementation of best practices, improving resident care and strengthening the long-term care advice network. We conclude that informal relational pathways hold promise for helping to transform the Canadian long-term care sector.

Information exchange networks of health care providers and evidence-based cardiovascular risk management: an observational study

BACKGROUND

Although a wide range of preventive and clinical interventions has targeted cardiovascular risk management (CVRM), outcomes remain suboptimal. Therefore, the question is what additional determinants of CVRM and outcomes can be identified and addressed to optimize CVRM. In this study, we aimed to identify new perspectives for improving healthcare delivery and explored associations between information exchange networks of health care providers and evidence-based CVRM.

METHODS

This observational study was performed parallel to a randomized clinical trial which aimed to improve professional performance of practice nurses in the Netherlands. Information exchange on medical policy for CVRM ("general information networks") and CVRM for individual patients ("specific information networks") of 180 health professionals in 31 general practices was measured with personalized questionnaires. Medical record audit was performed concerning 1620 patients in these practices to document quality of care delivery and two risk factors (systolic blood pressure (SBP) and LDL cholesterol level). Hypothesized effects of five network characteristics (density, frequency of contact, centrality of CVRM-coordinators, homophily on positive attitudes for treatment target achievement, and presence of an opinion leader for CVRM) constructed on both general and specific information exchange networks were tested and controlled for practice and patient factors using logistic multilevel analyses.

RESULTS

Odds for adequate performance were enhanced in practices with an opinion leader for CVRM (OR 2.75, p < .05). Odds for achievement of SBP targets were reduced in practices who had networks with low homophily on positive attitudes for SBP and LDL targets (homophily for SBP targets OR 0.57, p < .05 and OR 0.60, p < .05, homophily for LDL targets OR 0.59, p < .05 and OR 0.61, p < .05 in general and specific information networks, respectively). No effects of network characteristics on cholesterol were found.

CONCLUSIONS

Delivery of evidence-based CVRM is associated with homophily of clinical attitudes and presence of opinion leaders in primary care teams. These results signal the potential of social networks to be taken into account in further attempts to improve the implementation of evidence-based care for CVRM. Future research is needed to identify and formulate optimal strategies for using opinion leaders to improve CVRM. Future interventions may be more effective if they target a common vision on CVRM within practices.

The social network around influenza vaccination in health care workers: a cross-sectional study

Background

Influenza vaccination coverage remains low among health care workers (HCWs) in many health facilities. This study describes the social network defined by HCWs’ conversations around an influenza vaccination campaign in order to describe the role played by vaccination behavior and other HCW characteristics in the configuration of the links among subjects.

Methods

This study used cross-sectional data from 235 HCWs interviewed after the 2010/2011 influenza vaccination campaign at the Hospital Clinic of Barcelona (HCB), Spain. The study asked: “Who did you talk to or share some activity with respect to the seasonal vaccination campaign?” Variables studied included sociodemographic characteristics and reported conversations among HCWs during the influenza campaign. Exponential random graph models (ERGM) were used to assess the role of shared characteristics (homophily) and individual characteristics in the social network around the influenza vaccination campaign.

Results

Links were more likely between HCWs who shared the same professional category (OR 3.13, 95% CI = 2.61–3.75), sex (OR 1.34, 95% CI = 1.09–1.62), age (OR 0.7, 95% CI = 0.63–0.78 per decade of difference), and department (OR 11.35, 95% CI = 8.17–15.64), but not between HCWs who shared the same vaccination behavior (OR 1.02, 95% CI = 0.86–1.22). Older (OR 1.26, 95% CI = 1.14–1.39 per extra decade of HCW) and vaccinated (OR 1.32, 95% CI = 1.09–1.62) HCWs were more likely to be named.

Conclusions

This study finds that there is no homophily by vaccination status in whom HCWs speak to or interact with about a workplace vaccination promotion campaign. This result highlights the relevance of social network analysis in the planning of health promotion interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0522-3) contains supplementary material, which is available to authorized users.

Social networks of professionals in health care organizations: a review

In this article, we provide an overview of social network research in health care, with a focus on social interactions between professionals in organizations. We begin by introducing key concepts defining the social network approach, including network density, centrality, and brokerage. We then review past and current research on the antecedents of health care professionals' social networks-including demographic attributes, professional groups, and organizational arrangements-and their consequences-including satisfaction at work, leadership, behaviors, knowledge transfer, diffusion of innovation, and performance. Finally, we examine future directions for social network research in health care, focusing on micro-macro linkages and network dynamics.

Dissemination activities: a critical new role for substance abuse treatment organizations

The Affordable Care Act calls for integration of substance abuse treatment into medical care via medical homes and continuing specialty care. For this integration to occur in the substance abuse treatment field, substantial sharing and dissemination of information by treatment providers is required. This study explored the determinants of organizational activities directed at disseminating evidence-based practices (EBPs) undertaken by 193 community treatment programs who are members of the National Institute on Drug Abuse (NIDA) Clinical Trials Network. Using factor analysis, the research identified two generic categories reflecting different motivations for dissemination activities and explored both treatment center leadership and organizational characteristics as determinants of these different types of dissemination activities. Organizational characteristics predicting treatment center dissemination activities included size, previous involvement in research protocols, linkages with other providers, and having non-profit status. The treatment center leader's membership in professional organizations was also a significant determinant. Organization variables account for a larger portion of the variance in treatment center dissemination activities. The results suggest that the willingness of treatment providers to help disseminate EBPs within the industry may be heavily influenced through shared network connections with other treatment organizations.

Creating an interest in research and development as a means of reducing the gap between theory and practice in primary care: an interventional study based on strategic communication

Today, healthcare professionals are faced with the challenge of implementing research results in an optimal way. It is therefore important to create a climate that is conducive to research and development (R&D). For this reason, new strategies are required to enhance healthcare professionals’ interest in innovative thinking and R&D. Strategic communication with roots in sociology, psychology and political science was employed as a means of achieving long-term behavioural change. The aim of this study was to describe, follow up and evaluate a primary care intervention based on strategic communication intended to increase healthcare professionals’ interest in R&D over time. An interventional cohort study comprising all staff members (N = 1276) in a Swedish primary care area was initiated in 1997 and continued for 12 years. The intention to engage in R&D was measured on two occasions; at 7 and 12 years. Both descriptive statistics and bivariate analyses were employed. The results demonstrated that the positive attitude to R&D increased over time, representing a first step towards new thinking and willingness to change work practices for the benefit of the patient. Strategic communication has not been previously employed as a scientific tool to create a long-term interest in R&D within primary care.

Identifying the characteristics of nurse opinion leaders to aid the integration of genetics in nursing practice

AIM

To identify the characteristics of nurses opinion leaders in the context of genetics in health care and consider the findings for the integration of genetics in nursing practice.

BACKGROUND

Nurses need a basic understanding of the role genetics plays in their practice and about how best to support patients using genetic knowledge. Opinion leaders have been used previously to incorporate change initiatives and increase educational application. Identifying the characteristics of nurse opinion leaders may aid the engagement and continued integration of genetics into nursing practice.

DESIGN

A primarily quantitative approach over two phases, using online surveys conducted during 2011.

METHOD

This article focuses on Phase 2 of a wider study. Oncology and primary care nurses were surveyed to identify the characteristics and demographic indicators of nurse opinion leaders. Tests for data normality followed by the suitable test for group comparison was applied with significance level set at <0·05.

RESULTS

Nineteen respondents (n = 19/88; 21·6%) were categorized as opinion leaders and two subgroups were identified: Genetic Opinion Leaders and Opinion Leaders with an Interest in Genetics. Seven characteristics were deemed statistically significant (Mann-Whitney, Chi-Square, t-test) in identifying nurse opinion leaders, including being open to experience and having a perceived level of influence over others.

CONCLUSION

The identified characteristics could be used to enhance the integration of genetics into nursing practice through the use of opinion leaders. Further thought needs to be given to the refinement of the identified characteristics and to the use of such a unique group of nurses.

Gathering opinion leader data for a tailored implementation intervention in secondary healthcare: a randomised trial

BACKGROUND

Health professionals' behaviour is a key component in compliance with evidence-based recommendations. Opinion leaders are an oft-used method of influencing such behaviours in implementation studies, but reliably and cost effectively identifying them is not straightforward. Survey and questionnaire based data collection methods have potential and carefully chosen items can - in theory - both aid identification of opinion leaders and help in the design of an implementation strategy itself. This study compares two methods of identifying opinion leaders for behaviour-change interventions.

METHODS

Healthcare professionals working in a single UK mental health NHS Foundation Trust were randomly allocated to one of two questionnaires. The first, slightly longer questionnaire, asked for multiple nominations of opinion leaders, with specific information about the nature of the relationship with each nominee. The second, shorter version, asked simply for a list of named "champions" but no more additional information. We compared, using Chi Square statistics, both the questionnaire response rates and the number of health professionals likely to be influenced by the opinion leaders (i.e. the "coverage" rates) for both questionnaire conditions.

RESULTS

Both questionnaire versions had low response rates: only 15% of health professionals named colleagues in the longer questionnaire and 13% in the shorter version. The opinion leaders identified by both methods had a low number of contacts (range of coverage, 2-6 each). There were no significant differences in response rates or coverage between the two identification methods.

CONCLUSIONS

The low response and population coverage rates for both questionnaire versions suggest that alternative methods of identifying opinion leaders for implementation studies may be more effective. Future research should seek to identify and evaluate alternative, non-questionnaire based, methods of identifying opinion leaders in order to maximise their potential in organisational behaviour change interventions.

Problem-based learning (PBL): getting the most out of your students - their roles and responsibilities: AMEE Guide No. 84

This Guide discusses the considerable literature on the merits or shortcomings of Problem-based learning (PBL), and the factors that promote or inhibit it, when seen through the eyes of the student. It seems to be the case that PBL works best when students and faculty understand the various factors that influence learning and are aware of their roles; this Guide deals with each of the main issues in turn. One of the most important concepts to recognise is that students and Faculty share the responsibility for learning and there are several factors that can influence its success. They include student motivation for PBL and the various ways in which they respond to being immersed in the process. As faculty, we also need to consider the way in which the learning environment supports the students develop the habit of life-long learning, and the skills and attitudes that will help them become competent reflective practitioners. Each of these elements place responsibilities upon the student, but also upon the Faculty and learning community they are joining. Although all of the authors work in a European setting, where PBL is used extensively as a learning strategy in many medical schools, the lessons learned we suggest, apply more widely, and several of the important factors apply to any form of curriculum. This Guide follows on from a previous review in the AMEE Guides in Medical education series, which provided an overview of PBL and attempts to emphasise the key role that students have in mastering their subject through PBL. This should render the business of being a student a little less mystifying, and help faculty to see how they can help their students acquire the independence and mastery that they will need.

Anatomy and histology as socially networked learning environments: some preliminary findings

PURPOSE

An exploratory study to better understand the "networked" life of the medical school as a learning environment.

METHOD

In a recent academic year, the authors gathered data during two six-week blocks of a sequential histology and anatomy course at a U.S. medical college. An eight-item questionnaire captured different dimensions of student interactions. The student cohort/network was 48 first-year medical students. Using social network analysis (SNA), the authors focused on (1) the initial structure and the evolution of informal class networks over time, (2) how informal class networks compare to formal in-class small-group assignments in influencing student information gathering, and (3) how peer assignment of professionalism role model status is shaped more by informal than formal ties. In examining these latter two issues, the authors explored not only how formal group assignment persisted over time but also how it functioned to prevent the tendency for groupings based on gender or ethnicity.

RESULTS

The study revealed an evolving dynamic between the formal small-group learning structure of the course blocks and the emergence of informal student networks. For example, whereas formal group membership did influence in-class questions and did prevent formation of groups of like gender and ethnicity, outside-class questions and professionalism were influenced more by informal group ties where gender and, to a much lesser extent, ethnicity influence student information gathering.

CONCLUSIONS

The richness of these preliminary findings suggests that SNA may be a useful tool in examining an array of medical student learning encounters.

How do social networks and faculty development courses affect clinical supervisors' adoption of a medical education innovation? An exploratory study

PURPOSE

To examine the impact of social networks and a two-day faculty development course on clinical supervisors' adoption of an educational innovation.

METHOD

During 2007-2010, 571 residents and 613 clinical supervisors in four specialties in the Netherlands were invited to complete a Web-based questionnaire. Residents rated their clinical supervisors' adoption of an educational innovation, the use of structured and constructive (S&C) feedback. Clinical supervisors self-assessed their adoption of this innovation and rated their communication intensity with other clinical supervisors in their department. For each supervisor, a centrality score was calculated, representing the extent to which the supervisor was connected to departmental colleagues. The authors analyzed the effects of supervisor centrality and participation in a two-day Teach-the-Teacher course on the degree of innovation adoption using hierarchical linear modeling, adjusting for age, gender, and attitude toward the S&C feedback innovation.

RESULTS

Respondents included 370 (60%) supervisors and 357 (63%) residents. Although Teach-the-Teacher course participation (n=172; 46.5%) was significantly related to supervisors' self-assessments of adoption (P=.001), it had no effect on residents' assessments of supervisors' adoption (P=.371). Supervisor centrality was significantly related to innovation adoption in both residents' assessments (P=.023) and supervisors' self-assessments (P=.024).

CONCLUSIONS

A clinical supervisor's social network may be as important as faculty development course participation in determining whether the supervisor adopts an educational innovation. Faculty development initiatives should use faculty members' social networks to improve the adoption of educational innovations and help build and maintain communities of practice.

The cross-level impact of patient safety climate on nursing innovation: a cross-sectional questionnaire survey

AIMS AND OBJECTIVES

To explore the cross-level effects of the four dimensions of patient safety climate on nursing innovation.

BACKGROUND

Across the globe, nursing innovation is highly encouraged by nursing experts to improve nursing outcome. Nursing innovation, in turn, is affected by organisational climate, and a critical aspect of organisational climate is patient safety.

DESIGN

This is a cross-sectional study.

METHODS

We employed a questionnaire survey to collect data and selected nurses from Taiwan hospitals as samples. A total of 808 valid questionnaires in 172 teams of four hospitals were collected. Patient safety climate was aggregated by individual-level data; thus, we examined r(wg) , ICC 1 and ICC 2. Hierarchical linear modelling was used to analyse the data.

RESULTS

Of these three dimensions of nursing innovation, the level of knowledge creation was perceived by the nurses as the highest. In terms of patient safety climate, managerial practices regarding patient safety scored the highest, followed by patient safety procedures, patient safety information flow and patient safety priority. Only patient safety information flow yielded a significant positive influence on knowledge creation, innovation behaviour or innovation diffusion.

CONCLUSION

Hospital nurses do achieve better performance in knowledge creation. Patient safety information flow has positive and cross-level impact on nursing innovation; therefore, the method to increase safety information flow is the key focus of nursing innovation management.

RELEVANCE TO CLINICAL PRACTICE

Through the improvements made in patient safety climate, hospital managers could promote the development of nursing innovation. Patient safety information flow is positively associated with nursing innovation. Patient safety information could be integrated in nursing training in all levels. Rules and procedures regarding patient safety should be drafted in simple and clear terms. A procedure to review and revise the rules and procedures will also be helpful in improving patient safety information flow.

Visualising the invisible: a network approach to reveal the informal social side of student learning

World-wide, universities in health sciences have transformed their curriculum to include collaborative learning and facilitate the students' learning process. Interaction has been acknowledged to be the synergistic element in this learning context. However, students spend the majority of their time outside their classroom and interaction does not stop outside the classroom. Therefore we studied how informal social interaction influences student learning. Moreover, to explore what really matters in the students learning process, a model was tested how the generally known important constructs-prior performance, motivation and social integration-relate to informal social interaction and student learning. 301 undergraduate medical students participated in this cross-sectional quantitative study. Informal social interaction was assessed using self-reported surveys following the network approach. Students' individual motivation, social integration and prior performance were assessed by the Academic Motivation Scale, the College Adaption Questionnaire and students' GPA respectively. A factual knowledge test represented student' learning. All social networks were positively associated with student learning significantly: friendships (β = 0.11), providing information to other students (β = 0.16), receiving information from other students (β = 0.25). Structural equation modelling revealed a model in which social networks increased student learning (r = 0.43), followed by prior performance (r = 0.31). In contrast to prior literature, students' academic motivation and social integration were not associated with students' learning. Students' informal social interaction is strongly associated with students' learning. These findings underline the need to change our focus from the formal context (classroom) to the informal context to optimize student learning and deliver modern medics.

Challenges in identifying barriers to adoption in a theory-based implementation study: lessons for future implementation studies

Background

Exploring barriers to the uptake of research based recommendations into practice is an important part of the development of implementation programmes. Techniques to identify barriers can include use of theory-informed questionnaires and qualitative interviews. Conceptualising and measuring theory-informed factors, and engaging health professionals’ to uncover all potential barriers, can be a difficult task. This paper presents a case study of the process of trying to identify, systematically, the key factors influencing health professionals’ referrals for women diagnosed with mild to moderate postnatal depression for psychological treatment. The paper illustrates how the factors were conceptualised and measured and explores the real world challenges experienced, with implications for future implementation studies.

Methods

Theory-informed factors were conceptualised and measured using a questionnaire and interviews. The questionnaire was piloted, before being administered to general practitioners, practice nurses and health visitors working in general practices in one area of the UK NHS. The interviews were conducted with a small sample of general practitioners who had not completed the questionnaire, further exploring factors influencing their referral decisions in the local context.

Results

The response rate to the questionnaire was low (19%), despite selecting the recommendation to target through engagement with local stakeholders and surveying local health professionals, and despite using two reminders, an incentive prize, and phone calls to practice managers to bolster response rates.

Conclusions

Two significant challenges to achieving higher response rates and successfully exploring local context were identified: the difficulties of developing a robust- but feasible- questionnaire to explore theory-informed factors, and targeting recommendations that are important to policy makers, but which health professionals view as unimportant. This case study highlights the “trade-off” between scientifically rigorous collection of data against the pragmatism and flexibility requirements of “real world” implementation. Future implementation studies should explore different ways of identifying factors influencing the adoption of recommendations to bridge this gulf.

Social network analysis in healthcare settings: a systematic scoping review

Background

Social network analysis (SNA) has been widely used across a range of disciplines but is most commonly applied to help improve the effectiveness and efficiency of decision making processes in commercial organisations. We are utilising SNA to inform the development and implementation of tailored behaviour-change interventions to improve the uptake of evidence into practice in the English National Health Service. To inform this work, we conducted a systematic scoping review to identify and evaluate the use of SNA as part of an intervention to support the implementation of change in healthcare settings.

Methods and Findings

We searched ten bibliographic databases to October 2011. We also searched reference lists, hand searched selected journals and websites, and contacted experts in the field. To be eligible for the review, studies had to describe and report the results of an SNA performed with healthcare professionals (e.g. doctors, nurses, pharmacists, radiographers etc.) and others involved in their professional social networks. We included 52 completed studies, reported in 62 publications. Almost all of the studies were limited to cross sectional descriptions of networks; only one involved using the results of the SNA as part of an intervention to change practice.

Conclusions

We found very little evidence for the potential of SNA being realised in healthcare settings. However, it seems unlikely that networks are less important in healthcare than other settings. Future research should seek to go beyond the merely descriptive to implement and evaluate SNA-based interventions.

The hidden medical school: a longitudinal study of how social networks form, and how they relate to academic performance

BACKGROUND

UK medical schools typically have over 300 students per year, making it impossible for students to know all the others well.

AIMS

This longitudinal cohort study measured the formation of medical student social networks and their relationship to grades.

METHOD

In November 2009, 215/317 (68%) Year 2 UCL medical students reported their friendships with others in their year, by questionnaire. Multiple regression assessed the relationship between friendships, exam results and background variables (obtained from student records), with permutation testing to assess statistical significance.

RESULTS

Students of the same sex, the same ethnic group, and in the same tutor and small groups (to which they were randomly assigned at the start of medical school) were socially closer. Taking into account absolute difference in Year 1 grades, Year 2 pairs who were socially closer in November 2009 had more similar May 2010 grades. Individual student variables did not predict similarity in 2010 grades after taking friendships into account.

CONCLUSIONS

The results suggest that medical students chose friends of the same sex and ethnic group as themselves; but random allocation of students to tutor groups also influenced friendships. Most importantly, friendships related to subsequent exam performance, suggesting friendship may influence learning.

Network structure and the role of key players in a translational cancer research network: a study protocol

INTRODUCTION

Translational research networks are a deliberate strategy to bridge the gulf between biomedical research and clinical practice through interdisciplinary collaboration, supportive funding and infrastructure. The social network approach examines how the structure of the network and players who hold important positions within it constrain or enable function. This information can be used to guide network management and optimise its operations. The aim of this study was to describe the structure of a translational cancer research network (TCRN) in Australia over its first year, identify the key players within the network and explore these players' opportunities and constraints in maximising important network collaborations.

METHODS AND ANALYSIS

This study deploys a mixed-method longitudinal design using social network analysis augmented by interviews and review of TCRN documents. The study will use network documents and interviews with governing body members to explore the broader context into which the network is embedded as well as the perceptions and expectations of members. Of particular interest are the attitudes and perceptions of clinicians compared with those of researchers. A co-authorship network will be constructed of TCRN members using journal and citation databases to assess the success of past pre-network collaborations. Two whole network social network surveys will be administered 12 months apart and parameters such as density, clustering, centrality and betweenness centrality computed and compared using UCINET and Netdraw. Key players will be identified and interviewed to understand the specific activities, barriers and enablers they face in that role.

ETHICS AND DISSEMINATION

Ethics approvals were obtained from the University of New South Wales, South Eastern Sydney Northern Sector Local Health Network and Calvary Health Care Sydney. Results will be discussed with members of the TCRN, submitted to relevant journals and presented as oral presentations to clinicians, researchers and policymakers.

Is blood thicker than water? Peer effects in stent utilization among Floridian cardiologists

Variations in physician practice are pervasive and costly, and may be harmful. The objective of much policy in the West is to increase the interconnectedness of physicians, furthering the transfer of information and thus reducing variation. This study tests whether physicians are influenced by the practice of peers, or if propensity, mere context or sorting of like-minded physicians better explain similarities and differences in practice. We study US cardiologists who place coronary stents into patients with blocked arteries around the heart. Organized in locally competing physician groups and also as solo practitioners, they see patients in offices, but insert the stents at a shared production facility - the cath lab. We examine their use of the popular drug-eluting coronary stents between their launch and rapid adoption in early 2003, and through the period of late 2006 in which private and public reports of serious late side-effects eventually led to reductions in use. Our analyses use administrative claims data on nearly 1000 cardiologists and their patients in Florida, USA, merged with Florida physician licensure data. Collectively these physicians used these stents nearly a quarter of a million times in the 4 year period reviewed. Pooled and panel linear regressions for device utilization by a physicians are estimated using measures of peer utilization, physician characteristics and controls for unobservable physician characteristics, common shocks and selection effects. We find strong evidence for intra-group but against inter-group practice spillovers. Even when sharing the same lab, competing cardiologists did not appear to correlate practices. Our results are consistent with a view that policies aimed at increasing the interconnectedness of physicians must first consider the organizational barriers and competitive forces that can stymie knowledge transfer even among physicians working closely together.

Organizational factors associated with screening for military sexual trauma

PURPOSE

This exploratory study investigated organizational factors associated with receipt of military sexual trauma (MST) screening during an early timeframe of the Veterans Health Administration's (VHA) implementation of the universal MST screening policy.

METHODS

The sample consisted of all VHA patients eligible for MST screening in fiscal year 2005 at 119 VHA facilities. Analyses were conducted separately by gender and by user status (i.e., new patients to the VHA health care system in FY 2005 and continuing users who had previously used the VHA health care system in the past year). Multivariate generalized estimating equations were used to assess the effects of facility-level characteristics and adjusted for person-level covariates.

RESULTS

Facility-level mandatory universal MST screening policies were associated with increased odds of receiving MST screening among new female patients and both continuing and new male patients: Odds ratio (OR), 2.87 (95% confidence interval [CI], 1.39-5.89) for new female patients; OR, 8.15 (95% CI, 2.93-22.69) for continuing male patients; and OR, 4.48 (95% CI, 1.79-11.20) for new male patients. Facility-level audit and feedback practices was associated with increased odds of receiving MST screening among new patients: OR, 1.91 (95% CI, 1.26-2.91) for females and OR, 1.86 (95% CI, 1.22-2.84) for males. Although the facility-level effect for women's health clinic (WHC) did not emerge as significant, patient-level effects indicated that among these facilities, women who used a WHC had greater odds of being screened for MST compared with women who had not used a WHC: OR, 1.79 (95% CI, 1.18-2.71) for continuing patients and OR, 2.20 (95% CI, 1.59-3.04) for new patients.

CONCLUSION

This study showed that facility policies that promote universal MST screening, as well as audit and feedback practices at the facility, significantly improved the odds of patients receiving MST screening. Women veterans' utilization of a WHC was associated with higher odds of receiving MST screening. This study provides empirical support for the use of policies and audit and feedback practices which the VHA has used since the implementation of the MST screening directive to encourage compliance with VHA's MST screening policy and is likely associated with the present-day success in MST screening across all VHA facilities.

Culture-change training: nursing facility staff perceptions of culture change

Identifying effective alternative strategies for training staff and implementing culture change can be useful to nursing facilities striving to provide optimal resident-centered care. This study assessed the perceptions of nearly 400 nursing facility staff experiencing organizational culture change. Formal and informal training methods were used. We used a pre- and post-test to evaluate leadership practices and 6 subscales related to culture change (systemwide culture change, resident choice, organization design, empowering supervision, job design, decision making, and permanent assignments). Staff of formally trained facilities perceived improvements in all subscales; 2 were statistically significant (resident choice and organization design). Respondents for informally trained facilities identified improvement in decision making, although this was not statistically significant. Formalized culture-change training produced better outcomes than did the informal strategy. Culture change is a complex process and may continue to evolve over time. A 3-year evaluation period may be insufficient to demonstrate the full extent of these changes.

Perceptions of general practitioners towards the use of a new system for treating back pain: a qualitative interview study

BACKGROUND

Changing clinicians' behaviour is recognised as a major challenge. It is clear that behaviour change not only depends on demonstrating the proven effectiveness of clinical interventions; contextual and occupational factors, such as 'change readiness', may be central to their implementation. This paper highlights the context of behaviour change in relation to a healthcare innovation introduced within primary care, highlighting the importance of organisational and interpersonal factors that may help explain the dynamics of implementation.

METHODS

Qualitative interviews were conducted with general practitioners (GPs) before (n = 32) and after (n = 9) the introduction of a subgrouping for targeted treatment system. GPs were offered an electronic six-item subgrouping tool, to identify patients according to their risk of poor outcome ('high', 'low') in order to help inform their decision making about treatment approaches. Recruitment was based on a 'maximum diversification sample', to obtain a wide representation of views across all five practices. A coding scheme was developed based on the emergent findings, and the data were analysed using 'constant comparison', drawing upon insights and developing connections between themes. We adopted the normalisation process theory (NPT) to explain the uptake of the new system and to examine the relevance of coherence for the implementation of innovations in organisations.

RESULTS

GPs perceived back pain as a low clinical priority, and highlighted the importance of 'practical' and 'relational' coherence in decisions to adopt and engage with the new subgrouping for targeted treatment system. Health professionals often engage in 'sense making' about new innovations to 'road test' their applicability or relevance to daily clinical routines. Low back pain was generally perceived as an 'uninteresting' and clinically unchallenging health problem by GPs, which may partly explain their lack of engagement with the new subgrouping for targeted treatment system. The adoption of this new way of working by GPs was determined by the meaning that they ascribed to it in the context of their daily clinical routines.

CONCLUSIONS

We conclude that the key obstacle to implementation of the new subgrouping for targeted treatment system for low back pain in primary care was an initial failure to achieve 'coherence' of the desired practice change with GPs. Despite this, GPs used the tool to different degrees, though this signified a general commitment to participating in the study rather than a deeper attitude change towards the new system.

Interpreting social network metrics in healthcare organisations: a review and guide to validating small networks

Social network analysis is an increasingly popular sociological method used to describe and understand the social aspects of communication patterns in the health care sector. The networks studied in this area are special because they are small, and for these sizes, the metrics calculated during analysis are sensitive to the number of people in the network and the density of observed communication. Validation is of particular value in controlling for these factors and in assisting in the accurate interpretation of network findings, yet such approaches are rarely applied. Our aim in this paper was to bring together published case studies to demonstrate how a proposed validation technique provides a basis for standardised comparison of networks within and across studies. A validation is performed for three network studies comprising ten networks, where the results are compared within and across the studies in relation to a standard baseline. The results confirm that hierarchy, centralisation and clustering metrics are highly sensitive to changes in size or density. Amongst the three case studies, we found support for some conclusions and contrary evidence for others. This validation approach is a tool for identifying additional features and verifying the conclusions reached in observational studies of small networks. We provide a methodological basis from which to perform intra-study and inter-study comparisons, for the purpose of introducing greater rigour to the use of social network analysis in health care applications.