Unlearning in health care

Designing an Intervention to Improve Medication Safety for Nursing Home Residents Based on Experiential Knowledge Related to Patient Safety Culture at the Nursing Home Front Line: Cocreative Process Study

BACKGROUND

Despite years of attention, avoiding medication-related harm remains a global challenge. Nursing homes provide essential health care for frail older individuals, who often experience multiple chronic diseases and polypharmacy, increasing their risk of medication errors. Evidence of effective interventions to improve medication safety in these settings is inconclusive. Focusing on patient safety culture is a potential key to intervention development as it forms the foundation for overall patient safety and is associated with medication errors.

OBJECTIVE

This study aims to develop an intervention to improve medication safety for nursing home residents through a cocreative process guided by integrated knowledge translation and experience-based codesign.

METHODS

This study used a cocreative process guided by integrated knowledge translation and experience-based co-design principles. Evidence on patient safety culture was used as an inspirational source for exploration of medication safety. Data collection involved semistructured focus groups to generate experiential knowledge (stage 1) to inform intervention design in a multidisciplinary workshop (stage 2). Research validation engaging different types of research expertise and municipal managerial representatives in finalizing the intervention design was essential. Acceptance of the final intervention for evaluation was aimed for through contextualization focused on partnership with a municipal advisory board. An abductive, rapid qualitative analytical approach to data analysis was chosen using elements from analyzing in the present, addressing the time-dependent, context-bound aspects of the cocreative process.

RESULTS

Experiential knowledge was represented by three main themes: (1) closed systems and gaps between functions, (2) resource interpretation and untapped potential, and (3) community of medication safety and surveillance. The main themes informed the design of preliminary intervention components in a multidisciplinary workshop. An intervention design process focused on research validation in addition to contextualization resulted in the Safe Medication in Nursing Home Residents (SAME) intervention covering (1) campaign material visualizing key roles and responsibilities regarding medication for nursing home residents and (2) "Medication safety reflexive spaces" focused on social and health care assistants.

CONCLUSIONS

The cocreative process successfully resulted in the multifaceted SAME intervention, grounded in lived experiences shared by some of the most important (but often underrepresented in research) stakeholders: frontline health care professionals and representatives of nursing home residents. This study brought attention toward closed systems related to functions in medication management and surveillance, not only informing the SAME intervention design but as opportunities for further exploration in future research. Evaluation of the intervention is an important next step. Overall, this study represents an important contribution to the complex field of medication safety.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/43538.

Process evaluation of a breastfeeding support intervention to promote exclusive breastfeeding and reduce social inequity: a mixed-methods study in a cluster-randomised trial

BACKGROUND

Breastfeeding is a powerful public health intervention that produces long-term health benefits. However, in high-income countries such as Denmark, breastfeeding rates are suboptimal and unequally distributed across socio-economic positions. The 'Breastfeeding - a good start together' intervention, to promote longer duration of exclusive breastfeeding and reduce social inequity, was implemented in a cluster-randomised trial during 2022-2023 across 21 municipalities in two Danish regions. A process evaluation was conducted to assess the implementation, mechanisms of impact, and possible contextual factors affecting the intervention.

METHODS

The study was guided by the Medical Research Council's guidance for conducting process evaluations and employed a mixed-methods approach in a convergence design. Quantitative data: contextual mapping survey (n = 20), health visitor survey (n = 284), health visitor records from 20 clusters and intervention website statistics. Qualitative data: dialogue meetings (n = 7), focus groups (n = 3) and interviews (n = 8).

RESULTS

Overall, the intervention was delivered as planned to intended recipients, with few exceptions. Health visitors responded positively to the intervention, noting that it fitted well within their usual practice and enhanced families' chances of breastfeeding. Mothers expressed having received the intervention with few exceptions, and reacted positively to the intervention. Although health visitors were concerned about the potential stigmatisation of mothers receiving the intensified intervention, none of the interviewed mothers felt stigmatised. Contextual factors impacting the intervention implementation and mechanisms included staff and management turnover, project infrastructure and mothers' context, such as resources, social networks and previous experiences. The overall fidelity of the intervention delivery was high.

CONCLUSIONS

Health visitors and families responded well to the intervention. Interventions aimed at enabling health care providers to deliver simplified and structured breastfeeding support, in alignment with support provided in other sectors of the health care system, may increase breastfeeding rates and reduce social inequity in breastfeeding, even in international contexts.

TRIAL REGISTRATION

Clinical Trials: NCT05311631. First posted April 5, 2022.

Examining Inclusive Language in Clinical Narratives in Medical Biochemistry Textbooks to Model Equitable Patient-Centered Care in Preclinical Undergraduate Medical Education

Purpose

When healthcare professionals use biased or stigmatizing language to describe people or conditions, it can impact the quality of care or erode the patient-physician relationship. It is not clear where healthcare professionals acquire biased and stigmatizing language in practice. This study focuses on examining language in educational materials used in training of medical students. Specifically, medical biochemistry textbooks were examined as they are often a first exposure to clinical narratives and communication standards. The aim of this project is to investigate whether medical biochemistry textbooks, widely recommended in preclinical UME, model inclusive language communication in clinical narratives.

Methods

To determine if educational materials follow inclusive writing guidelines, we conducted a modified document analysis on a sample of medical biochemistry textbooks when clinical scenarios were described. Three independent researchers separately reviewed the textbooks, coded the language using NVivo, and generated themes.

Results

Our results show that medical biochemistry textbooks contain language which is not in alignment with the best practices for inclusive language. Our analysis mapped codes to two primary themes of language misalignment. The first theme, "clinical language" (n = 92), included the following codes: difficult patient, general negative descriptive language, patient as failure, and questioning patient credibility. The second primary theme, "identity-first labeling" (n = 251), included 21 codes.

Conclusion

This study provides early evidence that the language used in medical biochemistry textbooks to describe people and conditions is not in alignment with inclusive language recommendations. This can reinforce the way future healthcare professionals speak to and about their patients.

Combination Therapy Use and Associated Events in Clinical Practice Following Dissemination of Trial Findings: A De-Implementation Study Using Interrupted Time Series Analysis

PURPOSE

It takes 17 years, on average, for trial results to be implemented into practice. Using data from the Department of Veterans Affairs (VA), this study assessed the potential impact on clinical practice of the dissemination of findings from a randomized, controlled trial reporting harm with the use of combination therapy. Communication between research and VA Pharmacy Benefits Management Services (PBM)  provided the impetus for communication from the PBM about the findings of the trial in accordance with policy.

METHODS

In this de-implementation study, interrupted time series analysis was used for assessing prescribing patterns and adverse clinical events before and after the dissemination of the trial findings. The de-implementation strategy was multicomponent and multilevel. Strategies were aligned with categories outlined in the Expert Recommendations for Implementing Change: train and educate stakeholders, use evaluative and iterative strategies, develop stakeholder inter-relationships, change infrastructure, provide interactive assistance, and engage consumers. VA patients with type 2 diabetes mellitus, chronic kidney disease stages 1 to 3, and a moderate or severe albuminuria who received care between July 2008 and November 2017 were included. Patients were subgrouped according to treatment with an angiotensin-converting enzyme inhibitor + angiotensin receptor blocker. The primary end point was the prevalence of combination therapy use. Secondary end points were the incidences of acute kidney injury and hyperkalemia.

FINDINGS

This study followed 712,245 patients, 9297 of whom used combination therapy. Data were available from 428,535 and 283,710 patients pre- and post-intervention, respectively; among these, 8324 and 973 patients used combination therapy, the median ages were 66 and 68 years, and 96.92% and 98.82% were men. One month following communication from the PBM, the reductions in combination therapy users, acute kidney injury events, and hyperkalemia were 331.94 (95% CI, 500.27-163.32), 36.58% (95% CI, 31.90%-41.95%), and 25.49% (95% CI, 14.17%-36.07%) per 100,000 patients per month, respectively (all, P < 0.001), whereas before the communication, these changes were +14.84 (95% CI, 10.27-19.42), -3.46% (95% CI, 3.18-3.74), and -3.27% (95% CI, 2.66%-3.87%) (all, P < 0.001).

IMPLICATIONS

The apparent speed and impact of the implementation of changes resulting from the dissemination of trial findings into VA clinical practice are encouraging. The speed of implementation was much faster than average for health care providers in the United States. Established communications between research and clinical practice, as well as established policy and communications between PBM and clinical practice, may be a model for other health care organizations.

A Meta-Analysis of Parenting Interventions for Immigrants

In light of increasing migration rates and the unique experiences of immigrants, this meta-analysis examined the effects of parenting interventions for immigrants. Specifically, we described the characteristics of parenting interventions for immigrants, examined cultural and/or linguistic adaptations made to the interventions, analyzed intervention effects, and examined potential moderating variables. Four electronic databases were searched in February 2021 for peer-reviewed articles published in English. Studies that involved immigrant parents, used an experimental design, and investigated an intervention targeting skills that parents could use directly with their children were included. Sixteen group design and two single-case design studies met inclusion criteria. The risk of publication bias was examined using funnel plots and found to be low. Overall, most parenting interventions for immigrants focused on young children and were delivered in groups. Interventions produced small to moderate effects on parent and child outcomes, which is comparable to those for the general population. All studies made cultural adaptations, with the most common being language. Moderator analyses indicate that the effects of interventions with surface structure adaptations were similar to those with deep structure adaptations. Limitations included the low methodological rigor of included studies and the exclusion of grey literature. More works of research on the relative effects of specific adaptations, such as ethnicity matching, are needed to better serve this population.

Handoffs and the challenges to implementing teamwork training in the perioperative environment

Perioperative handoffs are high-risk events for miscommunications and poor care coordination, which cause patient harm. Extensive research and several interventions have sought to overcome the challenges to perioperative handoff quality and safety, but few efforts have focused on teamwork training. Evidence shows that team training decreases surgical morbidity and mortality, and there remains a significant opportunity to implement teamwork training in the perioperative environment. Current perioperative handoff interventions face significant difficulty with adherence which raises concerns about the sustainability of their impact. In this perspective article, we explain why teamwork is critical to safe and reliable perioperative handoffs and discuss implementation challenges to the five core components of teamwork training programs in the perioperative environment. We outline evidence-based best practices imperative for training success and acknowledge the obstacles to implementing those best practices. Explicitly identifying and discussing these obstacles is critical to designing and implementing teamwork training programs fit for the perioperative environment. Teamwork training will equip providers with the foundational teamwork competencies needed to effectively participate in handoffs and utilize handoff interventions. This will improve team effectiveness, adherence to current perioperative handoff interventions, and ultimately, patient safety.

How do healthcare providers use national audit data for improvement?

BACKGROUND

Substantial resources are invested by Health Departments worldwide in introducing National Clinical Audits (NCAs). Yet, there is variable evidence on the NCAs' effectiveness and little is known on factors underlying the successful use of NCAs to improve local practice. This study will focus on a single NCA (the National Audit of Inpatient Falls -NAIF 2017) to explore: (i) participants' perspectives on the NCA reports, local feedback characteristics and actions undertaken following the feedback underpinning the effective use of the NCA feedback to improve local practice; (ii) reported changes in local practice following the NCA feedback in England and Wales.

METHODS

Front-line staff perspectives were gathered through interviews. An inductive qualitative approach was used. Eighteen participants were purposefully sampled from 7 of the 85 participating hospitals in England and Wales. Analysis was guided by constant comparative techniques.

RESULTS

Regarding the NAIF annual report, interviewees valued performance benchmarking with other hospitals, the use of visual representations and the inclusion of case studies and recommendations. Participants stated that feedback should target front-line healthcare professionals, be straightforward and focused, and be delivered through an encouraging and honest discussion. Interviewees highlighted the value of using other relevant data sources alongside NAIF feedback and the importance of continuous data monitoring. Participants reported that engagement of front-line staff in the NAIF and following improvement activities was critical. Leadership, ownership, management support and communication at different organisational levels were perceived as enablers, while staffing level and turnover, and poor quality improvement (QI) skills, were perceived as barriers to improvement. Reported changes in practice included increased awareness and attention to patient safety issues and greater involvement of patients and staff in falls prevention activities.

CONCLUSIONS

There is scope to improve the use of NCAs by front-line staff. NCAs should not be seen as isolated interventions but should be fully embedded and integrated into the QI strategic and operational plans of NHS trusts. The use of NCAs could be optimised, but knowledge of them is poor and distributed unevenly across different disciplines. More research is needed to provide guidance on key elements to consider throughout the whole improvement process at different organisational levels.

Organizational unlearning: A risky food safety strategy?

Strategically unlearning specific knowledge, behaviors, and practices facilitates product and process innovation, business model evolution, and new market opportunities and is essential to meet emergent supply chain and customer requirements. Indeed, addressing societal concerns such as climate change and net zero means elements of contemporary practice in food supply chains need to be unlearned to ensure new practices are adopted. However, unlearning is a risky process if crucial knowledge is lost, for example, if knowledge is situated in the supply base not the organization itself, or there is insufficient organizational food safety knowledge generation, curation, and management when new practices/processes are designed and implemented. An exploratory, critical review of management and food safety academic and gray literature is undertaken that aims to consider the cycle of unlearning, learning, and relearning in food organizations and supply chains with particular emphasis on organizational innovation, inertia, and the impact on food safety management systems and food safety performance. Findings demonstrate it is critical with food safety practices, such as duration date coding or refrigeration practices, that organizations "unlearn" in a way that does not increase organizational, food safety, or public health risk. This paper contributes to extant literature by highlighting the organizational vulnerabilities that can arise when strategically unlearning to promote sustainability in a food supply context. Mitigating such organizational, food safety, and public health risk means organizations must simultaneously drive unlearning, learning, and relearning as a dynamic integrated knowledge acquisition and management approach. The research implications are of value to academics, business managers, and wider industry.

Secular discernment: A process of individual unlearning and collective relearning

Through a process of action research with a non-religious organization, this article provides a foundation for the characteristics of a secular discernment process. Importantly, we argue that discernment can be conceptualized as a process of entwined individual unlearning and collective relearning. Our action research study contributes to both the discernment and the unlearning literatures by unpacking how discernment encourages a process of individual unlearning – which our study suggests entails a process of ‘setting aside’ and reflexive-distancing from a priori individual knowledge – to be more open and receptive to new ways of emergent collective re-learning. The process of unlearning – and the behavioural norms and routines that are central to discernment – underscores the collective relearning process. The article concludes with future pathways for research.

A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision

BACKGROUND

Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed.

METHODS

This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based.

RESULTS

Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus.

CONCLUSION

This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.

Printed educational materials directed at Ontario family physicians do not improve adherence to guideline recommendations for diabetes management: a pragmatic, factorial, cluster randomized controlled trial [ISRCTN72772651]

BACKGROUND

Printed educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical practice guidelines recommending antihypertensives and cholesterol-lowering agents for patients with diabetes, prescriptions remain low. We aimed to determine whether PEMs can influence physicians to intensify prescribing of these medications.

METHODS

A pragmatic, 2 × 2 factorial, cluster randomized controlled trial was designed to ascertain the effect of two PEM formats on physician prescribing: a postcard-sized message ("outsert") or a longer narrative article ("insert"). Ontario family physician practices (clusters) were randomly allocated to receive the insert, outsert, both or neither. Physicians were eligible if they were in active practice and their patients were included if they were over 65 years with a diabetes diagnosis; both were unaware of the trial. Administrative databases at ICES (formerly the Institute for Clinical Evaluative Sciences) were used to link patients to their physician and to analyse prescribing patterns at baseline and 1 year following PEM mailout. The primary outcome was intensification defined as the addition of a new antihypertensive or cholesterol-lowering agent, or dose increase of a current drug, measured at the patient level. Analyses were by intention-to-treat and accounted for the clustering of patients to physicians.

RESULTS

We randomly assigned 4231 practices (39% of Ontario family physicians) with a total population of 185,526 patients (20% of patients with diabetes in Ontario primary care) to receive the insert, outsert, both, and neither; among these, 4118 practices were analysed (n = 1025, n = 1037, n = 1031, n = 1025, respectively). No significant treatment effect was found for the outsert (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.98 to 1.04) or the insert (OR 0.99, 95% CI 0.96 to 1.02). Percent of intensification in the four arms was similar (approximately 46%). Adjustment for physician characteristics (e.g., age, sex, practice location) had no impact on these findings.

CONCLUSIONS

PEMs have no effect on physician's adherence to recommendations for the management of diabetes-related complications in Ontario. Further research should investigate the effect of other strategies to narrow this evidence-to-practice gap.

TRIAL REGISTRATION

ISRCTN72772651 . Retrospectively registered 21 July 2005.

Open organisational culture: what does it entail? Healthcare stakeholders reaching consensus by means of a Delphi technique

OBJECTIVES

Open organisational culture in hospitals is important, yet it remains unclear what it entails other than its referral to 'open communication' in the context of patient safety. This study aims to identify the elements of an open hospital culture.

METHODS

In this group consensus study with a Delphi technique, statements were constructed based on the existing patient safety literature and input of 11 healthcare professionals from different backgrounds. A final framework consisting of 36 statements was reviewed on inclusion and exclusion, in multiple rounds by 32 experts and professionals working in healthcare. The feedback was analysed and shared with the panel after the group reached consensus on statements (>70% agreement).

RESULTS

The procedure resulted in 37 statements representing tangible (ie, leadership, organisational structures and processes, communication systems, employee attitudes, training and development, and patient orientation) and intangible themes (ie, psychological safety, open communication, cohesion, power, blame and shame, morals and ethics, and support and trust). The culture themes' teamwork and commitment were not specific for an open culture, contradicting the patient safety literature. Thereby, an open mind was shown to be a novel characteristic.

CONCLUSIONS

Open culture entails an open mind-set and attitude of professionals beyond the scope of patient safety in which there is mutual awareness of each other's (un)conscious biases, focus on team relationships and professional well-being and a transparent system with supervisors/leaders being role models and patients being involved. Although it is generally acknowledged that microlevel social processes necessary to enact patient safety deserve more attention, research has largely emphasised system-level structures and processes. This study provides practical enablers for addressing system and microlevel social processes to work towards an open culture in and across teams.

Incorporating the Reflective Pause in Simulation: A Practical Guide

Many articles exist today espousing the value of debriefing following a simulation or gaming event. Although debriefing, a reflection-on-action strategy, is important, a useful reflection strategy may accentuate the reflection-in-action process that is arguably even more important than the debriefing. In this article, we explain a concept called the reflective pause and how it can be used during simulation cases to lead the learners to the objectives and enhance the learning process. We provide a review of the literature concerning reflection-in-action and ways that the reflective pause may be used during key learning events. The reflective pause is relatively absent from the simulation-based education lexicon. Used effectively, the reflective pause may become one of the most valuable learning strategies in a simulation educator's tool belt. [J Contin Educ Nurs. 2020;51(1):32-38.].

Critical reflection, unlearning, and engagement

Although individual unlearning is believed to play a critical role in promoting higher-order learning, there has been little quantitative research on this process. This article aimed to investigate the antecedents and consequences of individual unlearning based on transformative learning theory. A survey was conducted among 301 employees working in various occupations and organizations in the United States. The results of structural equation modeling indicated that unlearning mediated the relationship between critical reflection and work engagement and that critical reflection mediated reflection and unlearning. This study contributes to the literature by quantitatively demonstrating the direct and indirect influences of critical reflection on work engagement through individual unlearning, which has been discussed only conceptually and qualitatively in the extant transformative learning literature.

Factors influencing use of telegenetic counseling: perceptions of health care professionals in Sweden

Genetic counseling services are increasing in demand and limited in access due to barriers such as lack of professional genetic counselors, vast geographic distances, and physical hurdles. This research focuses on an alternative mode of delivery for genetic counseling in Sweden, in order to overcome some of the mentioned barriers. The aim of this study is to identify factors that influence the implementation and use of telegenetic counseling in clinical practice, according to health care professionals in Southeast Sweden. Telegenetic counseling refers to the use of video-conferencing as a means to provide genetic counseling. Qualitative, semi-structured interviews with 16 genetic counseling providers took place and phenomenographic analysis was applied. Significant excerpts were identified in each transcript, which led to sub-categories that constructed the main findings. Three categories emerged from the data: (1) requirements for optimal use, (2) impact on clinical practice, and (3) patient benefits. Each category consists of two or three sub-categories, in total seven sub-categories. These findings could potentially be used to improve access and uptake of telegenetic counseling in Sweden and in other countries with a similar health care system. This could benefit not only remote patient populations, as described in previous research, but also large family groups and patients experiencing obstacles in accessing genetic counseling, such as those with a psychiatric illness or time constraints, and be a useful way to make genetic counseling available in the new era of genomics.

What can we learn from simulation-based training to improve skills for end-of-life care? Insights from a national project in Israel

BACKGROUND

Simulation-based training improves residents' skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families.

METHODS

Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection - including a description of our own responses and evolution of thought as well as system effects.

RESULTS

The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas.

CONCLUSIONS

Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care.

Research utilisation and knowledge mobilisation in the commissioning and joint planning of public health interventions to reduce alcohol-related harms: a qualitative case design using a cocreation approach

Background

Considerable resources are spent on research to establish what works to improve the nation’s health. If the findings from this research are used, better health outcomes can follow, but we know that these findings are not always used. In public health, evidence of what works may not ‘fit’ everywhere, making it difficult to know what to do locally. Research suggests that evidence use is a social and dynamic process, not a simple application of research findings. It is unclear whether it is easier to get evidence used via a legal contracting process or within unified organisational arrangements with shared responsibilities.

Objective

To work in cocreation with research participants to investigate how research is utilised and knowledge mobilised in the commissioning and planning of public health services to reduce alcohol-related harms.

Design, setting and participants

Two in-depth, largely qualitative, cross-comparison case studies were undertaken to compare real-time research utilisation in commissioning across a purchaser–provider split (England) and in joint planning under unified organisational arrangements (Scotland) to reduce alcohol-related harms. Using an overarching realist approach and working in cocreation, case study partners (stakeholders in the process) picked the topic and helped to interpret the findings. In Scotland, the topic picked was licensing; in England, it was reducing maternal alcohol consumption.

Methods

Sixty-nine interviews, two focus groups, 14 observations of decision-making meetings, two local feedback workshops (n = 23 andn = 15) and one national workshop (n = 10) were undertaken. A questionnaire (n = 73) using a Behaviourally Anchored Rating Scale was issued to test the transferability of the 10 main findings. Given the small numbers, care must be taken in interpreting the findings.

Findings

Not all practitioners have the time, skills or interest to work in cocreation, but when there was collaboration, much was learned. Evidence included professional and tacit knowledge, and anecdotes, as well as findings from rigorous research designs. It was difficult to identify evidence in use and decisions were sometimes progressed in informal ways and in places we did not get to see. There are few formal evidence entry points. Evidence (prevalence and trends in public health issues) enters the process and is embedded in strategic documents to set priorities, but local data were collected in both sites to provide actionable messages (sometimes replicating the evidence base).

Conclusions

Two mid-range theories explain the findings. If evidence hassaliency(relates to ‘here and now’ as opposed to ‘there and then’) andimmediacy(short, presented verbally or visually and with emotional appeal) it is more likely to be used in both settings. A second mid-range theory explains how differing tensions pull and compete as feasible and acceptable local solutions are pursued across stakeholders. Answering what works depends on answering for whom and where simultaneously to find workable (if temporary) ‘blends’. Gaining this agreement across stakeholders appeared more difficult across the purchaser–provider split, because opportunities to interact were curtailed; however, more research is needed.

Funding

This study was funded by the Health Services and Delivery Research programme of the National Institute for Health Research.

The process of individual unlearning: A neglected topic in an under-researched field

In a contemporary business environment where change is often regarded as continuous, the ability of people or organizations to be able to successfully adapt and respond to change is key. Change often involves not only the learning of new behaviours, ideas, or practices but also giving up or abandoning some established ones. Despite both these elements generally being important to change, academic focus on processes of abandoning or giving up established knowledge and practices, that is, unlearning, is lacking. This conceptual article draws on a range of literature to suggest that the process of individual unlearning may have particular features. The review defines the concept of unlearning, differentiates between two different types of individual unlearning, and suggests that each type of individual unlearning may have its own distinctive features and dynamics. This article builds from this insight through developing a typology, which distinguishes between four types of individual unlearning. It concludes with an agenda for future empirical research to examine and validate the concepts presented.

The role of nurse informaticists in the emerging field of clinical intelligence

Clinical intelligence (CI) is an emerging field in health care arising from the proliferation of electronic data being generated through the increasing use of healthcare information technology (HIT). It is defined as the electronic aggregation of accurate, relevant and timely data into meaningful information and actionable knowledge in order to achieve optimal healthcare structures, processes and outcomes. Clinical intelligence will dramatically change the discipline of nursing informatics in the future. This presentation describes the role of nurse informaticists (NI) today in building clinical intelligence, including communicating the vision, designing systems, educating clinicians, preparing themselves, and supporting research.

Clinical audit and quality improvement - time for a rethink?

RATIONALE AND AIM

Evidence of the benefits of clinical audit to patient care is limited, despite its longevity. Additionally, numerous attitudinal, professional and organizational barriers impede its effectiveness. Yet, audit remains a favoured quality improvement (QI) policy lever. Growing interest in QI techniques suggest it is timely to re-examine audit. Clinical audit advisors assist health care teams, so hold unique cross-cutting perspectives on the strategic and practical application of audit in NHS organizations. We aimed to explore their views and experiences of their role in supporting health care teams in the audit process.

METHOD

Qualitative study using semi-structured and focus group interviews. Participants were purposively sampled (n = 21) across health sectors in two large Scottish NHS Boards. Interviews were audio-taped, transcribed and a thematic analysis performed.

RESULTS

Work pressure and lack of protected time were cited as audit barriers, but these hide other reasons for non-engagement. Different professions experience varying opportunities to participate. Doctors have more opportunities and may dominate or frustrate the process. Audit is perceived as a time-consuming, additional chore and a managerially driven exercise with no associated professional rewards. Management failure to support and resource changes fuels low motivation and disillusionment. Audit is regarded as a 'political' tool stifled by inter-professional differences and contextual constraints.

CONCLUSIONS

The findings echo previous studies. We found limited evidence that audit as presently defined and used is meeting policy makers' aspirations. The quality and safety improvement focus is shifting towards 'alternative' systems-based QI methods, but research to suggest that these will be any more impactful is also lacking. Additionally, identified professional, educational and organizational barriers still need to be overcome. A debate on how best to overcome the limitations of audit and its place alongside other approaches to QI is necessary.

[Anaesthetists learn--do institutions also learn? Importance of institutional learning and corporate culture in clinics]

In only a few contexts is the need for substantial learning more pronounced than in health care. For a health care provider, the ability to learn is essential in a changing environment. Although individual humans are programmed to learn naturally, organisations are not. Learning that is limited to individual professions and traditional approaches to continuing medical education is not sufficient to bring about substantial changes in the learning capacity of an institution. Also, organisational learning is an important issue for anaesthesia departments. Future success of an organisation often depends on new capabilities and competencies. Organisational learning is the capacity or processes within an organisation to maintain or improve performance based on experience. Learning is seen as a system-level phenomenon as it stays in the organisation regardless of the players involved. Experience from other industries shows that learning strategies tend to focus on single loop learning, with relatively little double loop learning and virtually no meta-learning or non-learning. The emphasis on team delivery of health care reinforces the need for team learning. Learning organisations make learning an intrinsic part of their organisations and are a place where people continually learn how to learn together. Organisational learning practice can help to improve existing skills and competencies and to change outdated assumptions, procedures and structures. So far, learning theory has been ignored in medicine, due to a wide variety of complex political, economic, social, organisational culture and medical factors that prevent innovation and resist change. The organisational culture is central to every stage of the learning process. Learning organisations move beyond simple employee training into organisational problem solving, innovation and learning. Therefore, teamwork and leadership are necessary. Successful organisations change the competencies of individuals, the systems, the organisation, the strategy and the culture.

The Learning Practice Inventory: diagnosing and developing Learning Practices in the UK

BACKGROUND AND SETTING

This paper outlines the development of a diagnostic tool to help Primary Care general practitioner (GP) Practices diagnose the extent to which they are developing effective techniques for collective learning and if their Practice culture supports innovation. This project is undertaken by the University of St Andrews and NHS Education for Scotland.

METHODS

Based on Learning Organization and Organizational Learning theory, and using a modified Behaviourally Anchored Rating Scale, the Learning Practice Inventory (LPI) identifies attitudes, behaviours, processes, systems and organizational arrangements associated with being a Learning Practice. The LPI is a self-assessment, fixed-choice, survey-feedback tool that surveys all Practice members.

RESULTS

The survey-feedback tool empowers Practice members to view, assess and prioritize the developments they wish to make collectively to Practice life. The LPI assumes complexity and non-linearity in change processes, used longitudinally it tracks the impact of change on Practice life through time. Practitioners and Practices involved in its development give favourable feedback on the tool, and its potential usefulness.

DISCUSSION

This contributes to our wider understanding in three main ways: first, it applies the ideas of Learning Organizations and Organizational Learning to health care settings. Second, as a practical advance, the tool assumes complexity, non-linearity and systemic knock-on effects during change in Primary Care. Third, it offers practitioners who work together the opportunity to share knowledge and learning in practical ways helping them to change by themselves and for themselves and their patients.