10 years of mindlines: a systematic review and commentary

Learning to make a difference for chILD: Value creation through network collaboration and team science

Addressing the recognized challenges and inequalities in providing high quality healthcare for rare diseases such as children's interstitial lung disease (chILD) requires collaboration across institutional, geographical, discipline, and system boundaries. The Children's Interstitial Lung Disease Respiratory Network of Australia and New Zealand (chILDRANZ) is an example of a clinical network that brings together multidisciplinary health professionals for collaboration, peer learning, and advocacy with the goal of improving the diagnosis and management of this group of rare and ultra-rare conditions. This narrative review explores the multifaceted benefits arising from social learning spaces within rare disease clinical networks by applying the value creation framework. The operation of the chILDRANZ network is used as an example across the framework to highlight how value is generated, realized, and transferred within such collaborative clinical and research networks. The community of practice formed in the chILDRANZ multidisciplinary meetings provides a strong example of social learning that engages with the uncertainty inherent in rare disease diagnosis and management and pays attention to generate new knowledge and best practice to make a difference for children and families living with chILD. This review underscores international calls for further investment in, and support of, collaborative clinical networks and virtual centers of excellence for rare disease.

From prescribing dilemma to knowledge in practice: The ontological politics of benzodiazepines and Z-drugs

The discrepancy between official guidelines and clinical practice is hardly more pronounced than in the case of benzodiazepines and Z-drugs, also known as benzodiazepine receptor agonists (BZRA). Using social-constructionist positioning theory, we unravel how health care professionals deal with the dilemma of prescribing this medication. Our results reveal a prescribing spectrum that is discursively organised around four different storylines used by professionals. The storylines are organised along three axes that are related to a) prescribers' opinions on prescribing and the negotiation of the related risks, b) the power dynamics between provider and patient in the prescribing process and c) the rhetorical use of arguments. The discerned storylines allow us to explore the emotional and moral side of prescribing and demarcate clinical mindlines -internalised tacit guidelines-that professionals adhere to when they prescribe. By relying on Annemarie Mol's conceptualisation of ontological politics, we explain how these storylines enact multiple versions of this class of medication and justify seemingly contradictory prescribing practices.

A qualitative study of infection prevention and control practices in the maternal units of two Ghanaian hospitals

INTRODUCTION

Healthcare-associated infections (HAIs) remain a common challenge in healthcare delivery, with a significant burden in low- and middle-income countries. Preventing HAIs has gained enormous attention from policy makers and healthcare managers and providers, especially in resource-limited settings. Despite policies to enforce infection prevention and control (IPC) measures to prevent HAIs, IPC compliance remains a challenge in hospital settings. In this study, we explore the experiences of healthcare providers and women in the post-natal phase and investigate factors influencing IPC practices in two hospitals in Ghana.

METHODS

The study used a qualitative approach involving semi-structured interviews, focus group discussions, and observations among healthcare providers and women in the postnatal phase in two maternity units from January 2019 to June 2019. Interviews were recorded and transcribed verbatim for thematic analysis. The data sets were uploaded into the qualitative software NVivo 12 to facilitate coding and analysis.

FINDINGS

Healthcare providers were driven by the responsibility to provide medical care for their patients and at the same time, protect themselves from infections. IPC facilitators include leadership commitment and support, IPC training and education. Women were informed about IPC in educational talks during antenatal care visits, and their practices were also shaped by their background and their communities. IPC barriers include the poor documentation or 'invisibility' of HAIs, low prioritization of IPC tasks, lack of clear IPC goals and resources, discretionary use of guidelines, and communication-related challenges. The findings demonstrate the need for relevant power holders to position themselves as key drivers of IPC and develop clear goals for IPC. Hospital managers need to take up the responsibility of providing the needed resources and leadership support to facilitate IPC. Patient engagement should be more strategic both within the hospital and at the community level.

What's the low back pain problem represented to be? An analysis of discourse of the Australian policy directives

PURPOSE

Low back pain (LBP) directives provide information about how LBP should be managed, communicated and navigated in complex health systems, making them an important form of policy. This study aimed to examine how LBP is problematised (represented) in Australian directives.

MATERIALS AND METHODS

We employed an analysis of discourse of LBP directives drawing on Bacchi's "What's the problem represented to be?" policy problematisation approach.

RESULTS

Our analysis suggests that LBP is problematised as a symptom that tends to improve when individuals take responsibility for themselves, but may require care at times. The way in which LBP is represented in the directives excludes important aspects, such as the uncertainties of scientific knowledge, paradigms other than (post)positivist, multimorbidity, social and structural determinants of health.

CONCLUSION

LBP directives may benefit from problematisations of LBP that consider the ongoing nature of LBP and broader contextual factors that impact on both LBP outcomes and care, beyond individual responsibility. Consideration of a wider range of paradigms and expanded evidence base may also be beneficial, as these are likely to enable individuals, clinicians and the Australian healthcare system to address LBP while dealing with its complexities, enabling real-world changes to lessen the LBP burden.IMPLICATIONS FOR REHABILITATIONHealthcare professionals who work with people who experience low back pain (LBP) may benefit from critically reflecting about discourses embedded in policy directives.Healthcare professionals may consider engaging in policy changes processes to expand the discourses on which LBP policy directives rely.Healthcare professionals' ability to enact policy recommendations may be enhanced by consideration of the fluctuating nature of LBP, uncertainties, multimorbidity and determinants of health.

'Dopesick'; why a critical view of the literature may save your patient's life

INTRODUCTION

Teaching critical literature appraisal is challenging. Providing a compelling clinical context using 'cinemeduation' stimulates interest in the topic.

METHODS

After watching the first episode of the mini-series 'Dopesick', where the scope, timeline and extent of the problem of opioid abuse are clearly seen, abstracts of the period literature strongly supporting the use of Oxycontin for use in chronic pain are shown. All were published in highly ranked medical journals. A simple paper evaluation structure is suggested. It is PPICOREAD which stands for the following questions: Who Paid for the study? What was the Population studied? What was the Intervention given in the study? What was the Control group used? What was the Outcome and was it of clinical significance to you? Was the trial Registered? Was there an Educational element for you? Was there anything Applicable to your practice? What was the Duration of the trial? Is this duration sufficient to reassure you that the trial is relevant to your practice?

RESULTS

The very poor quality and dishonest nature of the conclusions of these papers are quickly and easily uncovered in a supervised workshop. The causes for these clear discrepancies are discussed. The devastating consequences are described.

Keeping up with evidence-based recommendations - a qualitative interview study with general practitioners in Germany on information-seeking behaviour in cardiovascular care

BACKGROUND

Due to the nature of their work, general practitioners (GPs) need to be up to date with evidence in various medical domains. While much synthesised research evidence is easily accessible nowadays, in practice, the time to search for and review this evidence proposes a challenge. In German primary care, the knowledge infrastructure is rather fragmented, leaving GPs with relatively few primary care specific resources of information and many resources from other medical fields. This study aimed to explore GPs information-seeking behaviour regarding evidence-based recommendations in cardiovascular care in Germany.

METHODS

To explore views of GPs a qualitative research design was chosen. Data was collected through semi-structured interviews. In total, 27 telephone interviews with GPs were conducted between June and November 2021.Verbatim transcript interviews were then analysed using thematic analysis, deriving at themes inductively.

RESULTS

Two broad strategies of information-seeking behaviour in GP could be distinguished: (a) generic information-seeking behaviour and (b) casuistic information-seeking. The first referring to strategies GPs apply to keep up with medical developments such as new medication and the second referring to purposeful information exchange regarding individual patients, such as referral letters. The second strategy was also used to keep up with medical developments in general.

CONCLUSION

In a fragmented information landscape, GPs used information exchange on individual patients to remain informed about medical developments in general. Initiatives to implement recommended practices need to take this into account, either by using these sources of influence or by making GPs aware of possible bias and risks. The findings also emphasize the importance of systematic evidence-based sources of information for GPs.

TRAIL REGISTRATION

We registered the study prospectively on 07/11/2019 at the German Clinical Trials Register (DRKS, www.drks.de ) under ID no. DRKS00019219.

Primary care physicians' perceptions of social determinants of health recommendations: a qualitative study

BACKGROUND

Several organisations have called for primary care professionals to address social determinants of health (SDoH) in clinical settings. For primary care physicians to fulfill their community health responsibilities, the implications of the SDoH recommendations need to be clarified.

AIM

To describe primary care physicians' views about being asked to address SDoH in clinical settings, from both positive and negative perspectives.

DESIGN & SETTING

A qualitative study in Japan. Twenty-one physicians were purposively recruited.

METHOD

'Love and breakup letter' methodology was used to collect qualitative data that contained both positive and negative feelings. Participants wrote love and breakup letters about being asked to address SDoH in a clinical setting, then undertook an in-depth online interview. Data were analysed via thematic analysis using the framework approach.

RESULTS

The following themes were identified: (i) primary care physicians take pride in being expected to address SDoH; (ii) primary care physicians rely on the recommendations as a partner, even in difficult situations; (iii) primary care physicians consider the recommendations to be bothersome, with unreasonable demands and challenges, especially when supportive surroundings are lacking; and (iv) primary care physicians reconstruct the recommendations on the basis of their experience.

CONCLUSION

Primary care physicians felt both sympathy and antipathy towards recommendations asking them to address SDoH in their clinical practice. The recommendations were not followed literally, instead contributing to physicians' clinical mindlines. Professional organisations that plan to develop and publish recommendations about SDoH should consider how their recommendations might be perceived by their target audience.

A critical appraisal of professional competency frameworks: What guidance is provided for stroke rehabilitation clinicians managing 'complexity'?

Background

Given current health system trends, clinicians increasingly care for patients with complex care needs. There is a recognized lack of evidence to support clinician decision-making in these situations, as complex or multimorbid patients have been historically excluded from the types of research that inform clinical practice guidelines. However, expert clinicians at sites of excellence (e.g., Stroke Distinction sites) provide measurably excellent care. We sought to review profession-specific competency frameworks to locate information that may be supporting the development of clinician expertise when managing the care of patients with complex care needs.

Methods

We conducted a review of the professional competency frameworks for core members of the inpatient stroke rehabilitation team, to determine the degree of guidance and/or preparation for the management of patients with complex care needs. We developed and applied an assessment rubric to locate references to patient complexity, multimorbidity and complexity theory.

Results

Across the professional competency frameworks, there are some references to complexity at patient- and team-levels; there are fewer references to system-level complexity. We noted a lack of clear guidance for clinicians regarding the management of patients with complex care needs.

Conclusion

Further research is needed to explore how clinicians develop expertise in the management of patients with complex care needs, as we noted minimal guidance in the professional competency frameworks. However, we suggest that integrating complexity-related language into professional competency frameworks could better prime novice clinicians for new learning in the workplace and ease their transition into working in a complex context.

Examining the Impact of Dialogic Learning on Critically Reflective Practice

PURPOSE

While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies.

METHOD

In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective.

RESULTS

The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences.

CONCLUSIONS

The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

Pre-implementation evaluation for an HPV vaccine provider communication intervention among primary care clinics

OBJECTIVES

Interventions to improve health care provider communication about HPV vaccination can increase vaccine acceptance. Our objectives were to (1) identify clinics in locations with high HPV-associated cancer and low HPV-vaccination rates that would potentially benefit from dissemination of a proposed HPV Provider Communication intervention and (2) use qualitative interviews and a dissemination and implementation framework to assess readiness for change and fit of the HPV Provider Communication intervention to the context of these clinics.

METHODS

Local HPV-associated cancer and HPV vaccination rates were assigned to Practice-Based Research Network clinics using data from the Colorado Central Cancer Registry, the Colorado Immunization Information System, and the American Community Survey. Staff from 38 clinics located in areas with high numbers of adolescents not up-to-date for HPV vaccine and high rates of HPV-associated cancers were recruited for qualitative interviews. Interview questions used the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework and addressed the proposed intervention, current vaccination practices and prior quality improvement (QI) experience.

RESULTS

Twenty-seven interviews were completed with clinicians, clinic managers, and other staff across 17 clinics (9 pediatric, 5 family medicine, 3 public/school-based health). Most clinics had some prior QI experience and there were few thematic differences between sites with more or less foundation for QI/immunization work. Participants were motivated to improve the health of their patients and valued both guidelines and local experience as important evidence to consider adopting an intervention. Interviewees were more interested in implementing the proposed intervention if it aligned with existing priorities and fit within clinic workflows. Facilitation needs included adequate time and external facilitation support for data tracking and analysis.

CONCLUSIONS

Qualitative interviews to understand clinic context and fit of an HPV Provider Communication intervention can inform implementation in settings with the highest potential for clinical impact.

How do health professionals translate evidence on early childhood allergy prevention into health literacy-responsive practice? A protocol for a mixed-method study on the views of German health professionals

INTRODUCTION

Paediatricians, general practitioners (GPs) and midwives in primary care are important sources of information for parents on early childhood allergy prevention (ECAP). Research has shown that preventive counselling by health professionals can be effective in improving patients' health literacy (HL) and health behaviour. Providing effective advice relies on two factors. First, health professionals need be up-to-date with research evidence on ECAP, to consider popular misconceptions and fears and to translate this knowledge into clear recommendations for parents (knowledge translation). Second, they need to know and apply counselling techniques and create a practice setting which accommodates parental HL needs (health literacy-responsive care). The objective of this study is to explore and assess how German health professionals take up and translate ECAP evidence into appropriate recommendations for parents, how they consider HL in counselling and practice organisation and what barriers and enablers they find in their performance of HL-responsive ECAP.

METHODS AND ANALYSIS

The study has a sequential mixed-method design, in two phases. In the first phase, qualitative semi-structured expert interviews will be conducted with health professionals (paediatricians, GPs and midwives) at primary care level and professional policy level. Data collection is ongoing until January 2022. In the second phase, based on the qualitative results, a standardised questionnaire will be developed, and pilot-tested in a wider population of German health professionals. The findings of both phases will be integrated.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Ethics Committee of the University of Regensburg (18-1205-101). The results will be published in international peer-reviewed open access journals and via presentations at scientific conferences. The results will also be shared with German health professionals, decision-makers and potential funders of interventions.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice

BACKGROUND

Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments.

AIM

Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts.

METHODS

We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented.

RESULTS

A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives.

CONCLUSIONS

Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

Socializing the evidence for diabetes control to develop "mindlines": a qualitative pilot study

BACKGROUND

Evidence on specific interventions to improve diabetes control in primary care is available, but this evidence is not always well-implemented. The concept of "mindlines" has been proposed to explain how clinicians integrate evidence using specifics of their practices and patients to produce knowledge-in-practice-in-context. The goal of this pilot study was to operationalize this concept by creating a venue for clinician-staff interaction concerning evidence. The research team attempted to hold "mindlines"-producing conversations in primary care practices about evidence to improve diabetes control.

METHODS

Each of four primary care practices in a single health system held practice-wide conversations about a simple diabetes intervention model over a provided lunch. The conversations were relatively informal and encouraged participation from all. The research team recorded the conversations and took field notes. The team analyzed the data using a framework adapted from the "mindlines" research and noted additional emergent themes.

RESULTS

While most of the conversation concerned barriers to implementation of the simple diabetes intervention model, there were examples of practices adopting and adapting the evidence to suit their own needs and context. Performance metrics regarding diabetes control for the four practices improved after the intervention.

CONCLUSION

It appears that the type of conversations that "mindlines" research describes can be generated with facilitation around evidence, but further research is required to better understand the limitations and impact of this intervention.

GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

Background

Optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines — tacit, internalised guidelines developed over time from multiple sources — may be of particular importance in such situations.

Aim

To explore GPs’ decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines.

Design and setting

Qualitative interview study set in English general practice.

Method

Thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension.

Results

GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making.

Conclusion

In the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop ‘mindlines’ over time through practicebased experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice.

The provision of dementia care in general practice: practice nurse perceptions of their role

Background

Primary care nurses can assist General Practitioner’s to identify cognition concerns and support patient health self-management for those experiencing cognitive impairment or dementia. This support may lead to more appropriate care and better health outcomes for this group. Consequently, there is a need to identify the role of the primary care nurse in dementia care provision, nurse perceptions of this role and to also understand the barriers and enablers that may influence any current or potential primary care nurse role in dementia care provision.

Methods

Eight focus groups were conducted with a total of 36 primary care nurses. Data was transcribed verbatim and thematically analysed.

Results

There was a high level of agreement between primary care nurses that they had a role in provision of dementia care. This role was largely attributed to the strong therapeutic relationship between nurses and patients. However, dementia care provision was not without its challenges, including a perceived lack of knowledge, limited resources and the hierarchical nature of general practice. Three main themes were identified: personal attributes of the primary care nurse; professional attributes of the primary care nurse role and the context of practice. Six sub-themes were identified: knowing the person; overcoming stigma; providing holistic care; knowing what to do; team culture and working in the system.

Conclusions

The findings of this study suggest primary care nurses have a role in dementia care provision and, there is a need to provide support for the nurse to deliver person-centred health care in the context of cognitive impairment. As the demand for good quality primary care for people living with dementia increases, the role of the primary care nurse should be considered in primary care policy discussions. The knowledge gained from this study could be useful in informing dementia training content, to provide better prompts in the health assessment and care planning templates used by primary care nurses to better identify the care needs of people with a cognitive impairment and to develop dementia care guidelines for primary care nurses.

Re-visioning clinical reasoning, or stepping out from the skull

THE PROBLEM

Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts.

A SOLUTION

Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, 'extended' cognition is configured as an outside-in process of 'sensemaking' or 'adaptive expertise'.

THE FUTURE

Current 'predictive processing' cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an 'ecological perception' or 'externalistic' model provides a counter to the current dominant paradigm of 'ego-logical' cognitive reasoning - the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.

GP trainee responses to using SHERPA for multimorbidity consultations

UK general practitioner (GP) trainees are taught a consultation model which elicits the patients' main reason for consulting 'today'. This approach will often miss important issues for the increasing number of patients with multimorbidity. We developed the SHERPA model as a person-centred biopsychosocial framework for consulting patients with multimorbidity to address this. We aimed to examine GPs trainees' responses to SHERPA when integrated into their vocational training. The research design was qualitative and participants were GPs trainees in vocational training from one UK training location. GP trainees were introduced to the SHERPA model through interactive workshops. Qualitative data were collected from 16 participants, through four hours of teaching observation, 24 feedback templates, six practical applications of SHERPA and eight one-to-one interviews. Data were transcribed, and, using the Framework approach, systematically analysed, focussing on trainees' learning and application of the model. The results demonstrated that all participants engaged well with the teaching sessions, brought observations from their own experience, and reflected on particularly complex consultations. Half of the participants applied SHERPA successfully with their patients, particularly repeat attenders. Barriers to this approach were: selecting appropriate patients; perceived time pressure; lack of familiarity using the model; viewing SHERPA as 'additional', rather than integral, to shared decision-making in complex situations. The SHERPA model was viewed as helpful by these GP trainees for patients with whom they had established a relationship. Earlier introduction and regular support from trainers, where trainees reflect on experience of SHERPA, could increase confidence in using this method.

Clinical guidelines and the pursuit of reducing epistemic uncertainty. An ethnographic study of guideline development panels in three countries

PURPOSE

To explore, from a philosophy of knowledge perspective, the contribution of the guideline development process to reducing epistemic uncertainty in clinical decision-making - defined as the challenge of applying evidence to patients, dealing with conflicting information and determining the level of confidence in a medical conclusion.

METHODS

Longitudinal ethnographic study of national guideline development panels. Fieldnotes were collected from 19 panel meetings in UK, Netherlands and Norway (~120 h of observation) between September 2016 and February 2019. Draft guidelines, review protocols and background material were collated (~200 documents). Data were analyzed thematically to gain familiarity and then theorized using concepts of knowledge development and use and clinical decision-making.

RESULTS

Guideline development panels in all three countries wrestled with epistemic tensions - notably between the desire to "purify" an assumed external truth (for example by limiting included evidence to high-quality randomized controlled trials) and a more pragmatic and pluralist approach that drew on a wider range of evidence including qualitative research, real-world data, clinical experience and patient testimony. Detailed analysis of the process by which particular guideline recommendations were constructed allowed us to draw out the implications of these tensions for guideline users in clinical practice.

CONCLUSION

Guideline development panels apply multiple - often conflicting - understandings of knowledge, inference and truth in an attempt to reduce epistemic uncertainty. Guidelines makers, clinicians, scientists and students should engage critically and reflexively with the philosophical assumptions that underpin guideline development and inductive inference to build capability to deal with clinical complexity.

Use of Acute Psychiatric Hospitalisation: A Study of the Factors Influencing Decisions to Arrange Acute Admission to Inpatient Mental Health Facilities

Background: Human decision-making involves a complex interplay of intra- and inter-personal factors. The decisions clinicians make in practise are subject to a wide range of influences. Admission to a psychiatric hospital is a major clinical intervention, but the decision-making processes involved in admissions remain unclear. Aims: To delineate the range of factors influencing clinicians' decisions to arrange acute psychiatric admissions. Methods: We undertook six focus groups with teams centrally involved in decisions to admit patients to hospital (crisis resolution home treatment, liaison psychiatry, approved mental health practitioners and consultant psychiatrists). The data were analysed using qualitative thematic analysis. Results: Our analysis of the data show a complex range of factors influencing decision-making that were categorised as those related to: (i) clinical and risk factors; (ii) fear/threat factors; (iii) interpersonal dynamics; (iv) contextual factors. Conclusions: Decisions to arrange acute admission to hospital are not just based on an appraisal of clinical and risk-related information. Emotional, interpersonal and contextual factors are also critical in decision-making. Delineating the breadth of factors that bear on clinical decision-making can inform approaches to (i) clinical decision-making research, (ii) the training and supervision of clinicians, and (iii) service delivery models.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study

BACKGROUND

The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake.

METHODS

Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups.

RESULTS

Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols.

CONCLUSIONS

Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).

Care of peripheral intravenous catheters in three hospitals in Spain: Mapping clinical outcomes and implementation of clinical practice guidelines

Background

Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices worldwide. Up to 42% of PIVCs are prematurely removed during intravenous therapy due to failure. To date, there have been few systematic attempts in European hospitals to measure adherence to recommendations to mitigate PIVC failures.

Aim

To analyse the clinical outcomes from clinical practice guideline recommendations for PIVC care on different hospital types and environments.

Methods

We conducted an observational study in three hospitals in Spain from December 2017 to April 2018. The adherence to recommendations was monitored via visual inspection in situ evaluations of all PIVCs inserted in adults admitted. Context and clinical characteristics were collected by an evaluation tool, analysing data descriptively.

Results

646 PIVCs inserted in 624 patients were monitored, which only 52.7% knew about their PIVC. Regarding PIVC insertion, 3.4% (22/646) patients had at least 2 PIVCs simultaneously. The majority of PIVCs were 20G (319/646; 49.4%) and were secured with transparent polyurethane dressing (605/646; 93.7%). Most PIVCs (357/646; 55.3%) had a free insertion site during the visual inspection at first sight. We identified 342/646 (53%) transparent dressings in optimal conditions (clean, dry, and intact dressing). PIVC dressings in medical wards were much more likely to be in intact conditions than those in surgical wards (234/399, 58.7% vs. 108/247, 43.7%). We identified 55/646 (8.5%) PIVCs without infusion in the last 24 hours and 58/646 (9.0%) PIVCs without infusion for more than 24 hours. Regarding PIVC failure, 74 (11.5%) adverse events were identified, all of them reflecting clinical manifestation of phlebitis.

Conclusions

Our findings indicate that the clinical outcome indicators from CPG for PIVC care were moderate, highlighting differences between hospital environments and types. Also, we observed that nearly 50% of patients did not know what a PIVC is.

Knowledge mobilisation: a UK co-creation study to devise strategies to amend lay and practitioner atopic eczema mindlines to improve consultation experiences and self-management practices in primary care

OBJECTIVE

To devise strategies to amend lay and practitioner atopic eczema mindlines 'collectively reinforced, internalised tacit guidelines', to improve consultation experiences and self-management practices in primary care.

DESIGN

Co-creation workshops informed by the Co:Create Coproduction Matrix.

SETTING

Conference centre in central England and via remote communication.

PARTICIPANTS

Lay people with, and parents of children with, atopic eczema, practitioners, a researcher and a facilitator (n=22).

RESULTS

Eczema mindline amendment needs to address people and parents of children with the condition, practitioners and wider society in parallel. For lay people trust and 'realness' of amendment activity was vital and practitioners wanted practical, locally relevant, hints and tips, tailored, 'no faff' approaches. To improve consultation experiences and self-management practices, five key, consistent, evidence-based messages need to be instilled into eczema mindlines: (1) eczema is more than just dry skin, (2) eczema does not just go away, (3) moisturisers are for every day, (4) steroid creams are okay when you need them and (5) you know your child's eczema best.

CONCLUSION

This co-creation study provides original insights into what eczema knowledge should be mobilised, who needs to have this knowledge, how this should be achieved to amend existing mindlines to improve consultation experiences and self-management practices in primary care.The remaining challenge is to refine, implement and evaluate the effectiveness of strategies developed to instil the five core messages and erase outdated or inaccurate information.

Uncovering the processes of knowledge transformation: the example of local evidence-informed policy-making in United Kingdom healthcare

BACKGROUND

Healthcare policy-makers are expected to develop 'evidence-based' policies. Yet, studies have consistently shown that, like clinical practitioners, they need to combine many varied kinds of evidence and information derived from divergent sources. Working in the complex environment of healthcare decision-making, they have to rely on forms of (practical, contextual) knowledge quite different from that produced by researchers. It is therefore important to understand how and why they transform research-based evidence into the knowledge they ultimately use.

METHODS

We purposively selected four healthcare-commissioning organisations working with external agencies that provided research-based evidence to assist with commissioning; we interviewed a total of 52 people involved in that work. This entailed 92 interviews in total, each lasting 20-60 minutes, including 47 with policy-making commissioners, 36 with staff of external agencies, and 9 with freelance specialists, lay representatives and local-authority professionals. We observed 25 meetings (14 within the commissioning organisations) and reviewed relevant documents. We analysed the data thematically using a constant comparison method with a coding framework and developed structured summaries consisting of 20-50 pages for each case-study site. We iteratively discussed and refined emerging findings, including cross-case analyses, in regular research team meetings with facilitated analysis. Further details of the study and other results have been described elsewhere.

RESULTS

The commissioners' role was to assess the available care provision options, develop justifiable arguments for the preferred alternatives, and navigate them through a tortuous decision-making system with often-conflicting internal and external opinion. In a multi-transactional environment characterised by interactive, pressurised, under-determined decisions, this required repeated, contested sensemaking through negotiation of many sources of evidence. Commissioners therefore had to subject research-based knowledge to multiple 'knowledge behaviours'/manipulations as they repeatedly re-interpreted and recrafted the available evidence while carrying out their many roles. Two key 'incorporative processes' underpinned these activities, namely contextualisation of evidence and engagement of stakeholders. We describe five Active Channels of Knowledge Transformation - Interpersonal Relationships, People Placement, Product Deployment, Copy, Adapt and Paste, and Governance and Procedure - that provided the organisational spaces and the mechanisms for commissioners to constantly reshape research-based knowledge while incorporating it into the eventual policies that configured local health services.

CONCLUSIONS

Our new insights into the ways in which policy-makers and practitioners inevitably transform research-based knowledge, rather than simply translate it, could foster more realistic and productive expectations for the conduct and evaluation of research-informed healthcare provision.

An ethnographic exploration of the social organisation of general practice nurses' knowledge use: more than 'mindlines'?

AIM

To explore contextual, organisational and educational issues impacting on access to, and application of knowledge to everyday practice by general practice nurses, working in two rural primary-care practices in the UK.

BACKGROUND

Changes in primary-care healthcare delivery have resulted in substantive changes to practice nurses' roles. Practice nurses have taken on enhanced roles for which they were not prepared for in their initial training, little is known about how they access and apply knowledge.

METHODS

Ethnographic methods were used to gather data.

RESULTS

Practice nurses take a blended approach to knowledge use, using elements of evidence-based practice to support professional judgement. This is subject to several contextual influences, organisational, educational and from individual patients. Tensions exist between the position in which general practice nurses are situated and the nature in which knowledge is disseminated and used in primary care. Whilst examples of clinical mindlines were evident, these differed to those previously observed in general practitioners, practice nurses did not always have the mindline on which to draw and used an approach to practice that resembled 'bricoleur activity'.

CONCLUSIONS

The way in which general practice is structured results in variance in organisational structural arrangements for sharing and disseminating of knowledge. Despite a supportive organisational culture towards knowledge sharing, the position in which practice nurses are situated limits opportunities for discussion and reformulation of knowledge. Practice nurses are, however, prepared to adapt knowledge to meet the needs of individual patients.

Experiential knowledge in clinical medicine: use and justification

Within the evidence-based medicine (EBM) construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians' primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the "best" evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients.

GP trainees' perceptions on learning EBM using conversations in the workplace: a video-stimulated interview study

BACKGROUND

To be able to practice evidence-based medicine (EBM) when making decisions for individual patients, it is important to learn how to combine the best available evidence with the patient's preferences and the physician's clinical expertise. In general practice training, these skills can be learned at the workplace using learning conversations: meetings between the supervising general practitioner (GP) and GP trainee to discuss medical practice, selected topics or professional performance. This study aimed to give insight into the perceptions of GP trainees on their EBM learning processes during learning conversations.

METHODS

We held semi-structured video-stimulated elicitation interviews (n = 22) with GP trainees affiliated to GP training institutes in the Netherlands and Belgium. GP trainees were shown fragments of their learning conversations, enabling reflection during the interview. Taking an inductive approach, interview recordings were transcribed verbatim and analysed with NVivo software.

RESULTS

GP trainees perceived learning conversations as useful for learning and discussing EBM. Multiple EBM learning activities were identified, such as discussing evidence together, relating evidence to cases in daily practice and discussing the supervisor's experience and the specific local context in the light of what the evidence recommends. However, for learning to occur, trainees need and expect specific behaviour, both from their supervisors and themselves. Supervisors should supply well-substantiated answers that are applicable in practice and give the trainee confirmation. In turn, the trainee needs to prepare well in order to ask focused, in-depth questions. A safe space allowing equal and open discussion between trainee and supervisor is perceived as an essential context for optimal EBM learning.

CONCLUSIONS

Our findings show that trainees find learning conversations useful for EBM learning in general practice. To bring EBM learning to its full potential, attention should be paid to optimising the behavioural and contextual factors found relevant to enhancing EBM learning.

Islamophobia in the National Health Service: an ethnography of institutional racism in PREVENT's counter-radicalisation policy

In 2015, the UK government made its counter-radicalisation policy a statutory duty for all National Health Service (NHS) staff. Staff are now tasked to identify and report individuals they suspect may be vulnerable to radicalisation. Prevent training employs a combination of psychological and ideological frames to convey the meaning of radicalisation to healthcare staff, but studies have shown that the threat of terrorism is racialised as well. The guiding question of our ethnography is: how is counter-radicalisation training understood and practiced by healthcare professionals? A frame analysis draws upon 2 years of ethnographic fieldwork, which includes participant observation in Prevent training and NHS staff interviews. This article demonstrates how Prevent engages in performative colour-blindness - the active recognition and dismissal of the race frame which associates racialised Muslims with the threat of terrorism. It concludes with a discussion of institutional racism in the NHS - how racialised policies like Prevent impact the minutia of clinical interactions; how the pretence of a 'post-racial' society obscures institutional racism; how psychologisation is integral to the performance of colour-blindness; and why it is difficult to address the racism associated with colourblind policies which purport to address the threat of the Far-Right.

Rural healthcare delivery: Navigating a complex ecosystem

Clinical Practice Guidelines (CPGs) provide evidence-based recommendations for Healthcare Providers (HCPs) to utilize when making patient care decisions. Rural providers face challenges in the provision of evidence-based care, including the use of guidelines. The aim of this article is to explore the complexities of providing healthcare in rural areas. This article will focus on a specific aspect of rural maternity care with well-established CPGs, the prevention of Rhesus D factor alloimmunization. An applied health research approach, interpretive description, utilized semistructured interviews with HCPs across the vast geographic region of northern British Columbia. The study found that HCPs are aware of guidelines but face various barriers during implementation. In order to implement guidelines within practice, rural HCPs adapt processes to overcome local barriers. These process adaptations need to be identified and shared across a large health authority with a complex geography and healthcare system to ensure quality of care.

Intensive care nurses on social media: An exploration of knowledge exchange on an intensive care virtual community of practice

Aims and objectives

To explore the nature of knowledge exchange on a multi‐disciplinary Australasian intensive care virtual community of practice, “ICUConnect.”

Background

Current organisational structures and cultures constrain the social networks of healthcare professionals, limiting access to contemporary best practice knowledge. While virtual communities can facilitate knowledge and clinical expertise exchange in professional networks, their effectiveness has not been established.

Design

A sequential mixed‐methods design with a quantitative core and qualitative supplementary component was used to explore the content of discussions from an intensive care virtual community. SRQR has been used to report this study.

Methods

Email archives of an intensive care listserv (2003–2013) were mined using a two‐stage sampling technique to identify discussion threads (with >2 posts) concerning ventilator or airway practices (cluster) and two sets of 20 threads (stratified across years). Summative content analysis was used to examine both manifest and latent content.

Results

Forty threads containing 326 emails posted by 133 individuals from 80 organisations were analysed. Nurses contributed 68% (55% were in clinical leadership roles) and physicians 27%. Three subject areas were identified: clinical practices (71%); equipment (23%); and clinical governance (6%). “Knowledge‐requested” and “knowledge‐supplied” posts were categorised as follows: experiential and explicit (33% and 16%, respectively); experiential (27% and 35%); or explicit (40% and 17%). Knowledge supplied was also categorised as “know‐how” (20%); “know‐why” (5%) or “no knowledge” exchanged (6%). The central construct of virtual community work was identified with six elements that facilitated participation and knowledge exchange including: (a) the discussion thread; (b) sharing of artefacts; (c) community; (d) cordiality; (e) maven work; and (f) promotion of the VC. Members asked questions to benchmark their practice, while those who answered were focused on ensuring that best practices were delivered.

Conclusions

ICUConnect reflected characteristics of a virtual community of practice, enabling key benefits for members and the broader Australasian intensive care community, especially access to best practice knowledge from clinical experts.

Relevance to clinical practice

This study demonstrated that a practice‐based VC can function effectively as a VCoP to establish an effective professional network where members have access to up‐to‐date best practice knowledge. Healthcare organisations could leverage VCs to support the professional development of HCPs and ensure that local clinical practices are based on contemporaneous knowledge. Participation by nurses in these communities facilitates individual professional development and access to important clinical knowledge and expertise, and ultimately reinforcing the unique position of nursing in delivering effective, consistent high‐quality patient care.

Dissonances and disconnects: the life and times of community based accountability in the national rural health mission in Tamilnadu, India

Background

There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. However, implementation of these processes have shown mixed results over time and geography. The Community Action for Health (CAH) project was introduced as part of India’s National Rural Health Mission (now National Health Mission) to strengthen community-based accountability through community monitoring and planning. In this study we trace the implementation process of this project from its piloting, implementation and abrupt termination in the South Indian state of Tamil Nadu.

Methods

We framed CAH as an innovation introduced into the health system. We use the framework on integration of innovations in complex systems developed by Atun and others. We used qualitative approaches to study the implementation. We conducted interviews among a range of individuals who were directly involved in the implementation, focusing on the policy making organizational level.

Results

We uncover what we have termed “dissonances” and “disconnects” at the state level among individuals with key responsibility of implementation. By dissonances we refer to the diversity of perspective on the concept of community-based accountability and its perceived role. By disconnects we refer to the lack of spaces and processes for “sense-making” in a largely hierarchically functioning system. These constructs we believe contributes significantly to making sense of the initial uptake and the subsequent abrupt termination of the project.

Conclusions

This study contributes to the overall field of policy implementation, especially the phase between the emergence on the policy agenda and its incorporation into the day to day functioning of a system. It focuses on the implementation of contested interventions like community-based accountability, in Low- and Middle-income country settings undergoing transitions in governance. It highlights the importance of “problematization” a dimension not included in most currently popular frameworks to study the uptake and spread of innovations in the health system. It points not only to the importance of diverse perspectives present among individuals at different positions in the organization, but equally importantly the need for spaces and process of collective sense-making to ensure that a contested policy intervention is integrated into a complex system.

Applying evidence-based medicine in general practice: a video-stimulated interview study on workplace-based observation

Background

Evidence-based medicine (EBM) in general practice involves applying a complex combination of best-available evidence, the patient’s preferences and the general practitioner’s (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other’s consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other’s EBM behaviour through observation, and by identifying aspects that influence their recognition.

Methods

We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n = 22) were shown fragments of their own and their partner’s consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner’s actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other’s considerations well with those who did not, we developed a model describing the aspects that influence the observer’s recognition of an actor’s EBM behaviour.

Results

Overall, there was moderate similarity between an actor’s EBM behaviour and the observer’s recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role.

Conclusions

GP trainees and supervisors do not fully recognise EBM behaviour through observing each other’s consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decision-making is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines.

Growing Disparities in Patient-Provider Messaging: Trend Analysis Before and After Supportive Policy

BACKGROUND

Public policy introduced since 2011 has supported provider adoption of electronic medical records (EMRs) and patient-provider messaging, primarily through financial incentives. It is unclear how disparities in patients' use of incentivized electronic health (eHealth) tools, like patient-provider messaging, have changed over time relative to disparities in use of eHealth tools that were not directly incentivized.

OBJECTIVE

This study examines trends in eHealth disparities before and after the introduction of US federal financial incentives. We compare rates of patient-provider messaging, which was directly incentivized, with rates of looking for health information on the Web, which was not directly incentivized.

METHODS

We used nationally representative Health Information National Trends Survey data from 2003 to 2018 (N=37,300) to describe disparities in patient-provider messaging and looking for health information on the Web. We first reported the percentage of individuals across education and racial and ethnic groups who reported using these tools in each survey year and compared changes in unadjusted disparities during preincentive (2003-2011) and postincentive (2011-2018) periods. Using multivariable linear probability models, we then examined adjusted effects of education and race and ethnicity in 3 periods-preincentive (2003-2005), early incentive (2011-2013), and postincentive (2017-2018)-controlling for sociodemographic and health factors. In the postincentive period, an additional model tested whether internet adoption, provider access, or providers' use of EMRs explained disparities.

RESULTS

From 2003 to 2018, overall rates of provider messaging increased from 4% to 36%. The gap in provider messaging between the highest and lowest education groups increased by 10 percentage points preincentive (P<.001) and 22 additional points postincentive (P<.001). The gap between Hispanics and non-Hispanic whites increased by 3.2 points preincentive (P=.42) and 11 additional points postincentive (P=.01). Trends for blacks resembled those for Hispanics, whereas trends for Asians resembled those for non-Hispanic whites. In contrast, education-based disparities in looking for health information on the Web (which was not directly incentivized) did not significantly change in preincentive or postincentive periods, whereas racial disparities narrowed by 15 percentage points preincentive (P=.008) and did not significantly change postincentive. After adjusting for other sociodemographic and health factors, observed associations were similar to unadjusted associations, though smaller in magnitude. Including internet adoption, provider access, and providers' use of EMRs in the postincentive model attenuated, but did not eliminate, education-based disparities in provider messaging and looking for health information on the Web. Racial and ethnic disparities were no longer statistically significant in adjusted models.

CONCLUSIONS

Disparities in provider messaging widened over time, particularly following federal financial incentives. Meanwhile, disparities in looking for health information on the Web remained stable or narrowed. Incentives may have disproportionately benefited socioeconomically advantaged groups. Future policy could address disparities by incentivizing providers treating these populations to adopt messaging capabilities and encouraging patients' use of messaging.

Perspectives of general dental practitioners on preventive, patient-centred, and evidence-based oral healthcare-A Q-methodology study

Objective

In the last 30 years, innovations in oral healthcare (OHC), such as advanced restorative techniques, shifts towards preventive and evidence-based care and changes in patients’ expectations, have increased the complexity of clinical decision-making in OHC. Little is known about the perspectives of general dental practitioners (GDPs) on the value of providing preventive, patient-centred and evidence-based OHC. This study aimed to explore the range of perspectives present amongst GDPs on OHC.

Method

Q-methodology was used to explore perspectives among 78 GDPs working in the Netherlands. Participants were asked to sort 50 statements representing three central domains in OHC: i.) restorative versus preventative OHC, ii.) disease-centred versus patient-centred OHC and iii.) expertise-based versus evidence-based OHC. Opinion statements about delivering OHC were formulated on the basis of published literature and input from OHC professionals. By-person factor analysis was used to reveal clusters of communality in statement rankings, which were interpreted and formed perspectives on OHC.

Results

Four perspectives, explaining 47% of variance, on OHC were identified amongst GDPs: ‘the patient-focused dentist who values prevention’, ‘the outcome-oriented dentist who values learning from colleagues’, ‘the team player with ultimate care responsibility’ and ‘the dentist who considers oral health the responsibility of the patient.’

Conclusion

Q-methodology can be effectively used to describe the different perspectives that GDPs have on the challenges of preventive, patient-centred and evidence-based OHC. GDPs should not be seen as a homogenous group; rather they have different views and approaches to the care they provide. This has implications for health systems; awareness of the heterogeneity of practitioners’ perspectives can potentially be used to develop bespoke quality of care improvement strategies that constructively engage with each of these different groups.

Organizational transformation in health care: an activity theoretical analysis

PURPOSE

Older patients are at high risk of hospital readmission, which has led to an increasing number of screening and intervention programs. Knowledge on implementing screening tools for preventing readmissions in emergency department (ED), where the primary focus is often the present-day flow of patients, is scant. The purpose of this paper is to explore whether a new screening tool for predicting readmissions and functional decline in medical patients>65 years of age could be implemented and its influence on cross-continuum collaborations between the primary and secondary sectors.

DESIGN/METHODOLOGY/APPROACH

The study took place in an ED in Denmark, in collaboration with the surrounding municipalities. An evaluation workshop with nurses and leaders from the ED and the surrounding municipalities took place with the aim of investigating the organizational changes that occurred in daily practice after the implementation of the screening tool. The workshop was designed and analyzed using cultural historical activity theory (CHAT).

FINDINGS

The results showed that it was possible to develop collaboration between the two sectors during the test period. However, the screening tool created different transformations for the municipality employees and in the ED. The contradictions indicated that the screening tool did not mediate a general and sustained transformation in the cross-continuum collaboration.

RESEARCH LIMITATIONS/IMPLICATIONS

Screening tools are not objective, neutral or "acontexual" artifacts and must always be adapted to the local context and sectors. CHAT offers a perspective to understand the collective object when working with organizational transformations and implementation.

PRACTICAL IMPLICATIONS

The study have shown that screening tools are not objective, neutral or "acontexual" artifacts and must always be adapted to the local context. This is called adaption process. This adaption requires time and resources that should be taken into consideration from the beginning of introduction of new screens.

ORIGINALITY/VALUE

This paper contributes with knowledge about CHAT which offers a way to understand the leading collective object when working with organizational transformations and implementation. CHAT focuses not only on the structural changes but also on the cultural aspects of organizational changes, which is important if we want to reach a sustained change and implement the new screening tool in different sectors.

Knowledge mobilisation: an ethnographic study of the influence of practitioner mindlines on atopic eczema self-management in primary care in the UK

OBJECTIVE

To explore how atopic eczema specific mindlines are developed by primary care practitioners.

DESIGN

Ethnographic study.

SETTING

One large, urban general practice in central England.

PARTICIPANTS

In observation, all practitioners and support staff in the practice and in interviews a diverse group of practitioners (n=16).

RESULTS

Observation of over 250 hours and interview data were combined and analysed using an ethnographic approach through the lenses of mindlines and self-management. Three themes were identified: beliefs about eczema, eczema knowledge and approaches to self-management. Eczema mindlines are set against a backdrop of it being a low priority and not managed as a long-term condition. Practitioners believed that eczema is simple to manage with little change in treatments available and prescribing limited by local formularies. Practice is largely based on tacit knowledge and experience. Self-management is expected but not often explicitly facilitated. Clinical decisions are made from knowledge accumulated over time. Societal and technological developments have altered the way in which practitioner mindlines are developed; in eczema, for most, they are relatively static.

CONCLUSIONS

The outstanding challenge is to find novel, profession and context-specific, simple, pragmatic strategies to revise or modify practitioner mindlines by adding reliable and useful knowledge and by erasing outdated or inaccurate information thus potentially improve quality of eczema care.

Irreversible Pulpitis - A Source of Antibiotic Over-Prescription?

Antibiotic resistance is a growing public health concern. Antibiotics continue to be prescribed by some clinicians to resolve dental pain even though research indicates that antibiotics are not effective for treating conditions such as irreversible pulpitis. The objective of this study was to determine the extent to which current research and evidence around irreversible pulpitis has been translated into dental practice and the gaps in dentists' knowledge. An on-line clinical vignette format survey questionnaire about treatment of irreversible pulpitis was distributed to the members of the Academy of Operative Dentistry and Academy of General Dentistry (US based international dental bodies). Their responses were recorded and evaluated. A total of 403 dentists participated in the survey. Over a third (39.3%) indicated they would prescribe antibiotics for symptomatic irreversible pulpitis in a permanent tooth occurring without any signs of systemic infection. The rest indicated they would not prescribe antibiotics; most of them would prescribe an analgesic combined with pulpectomy. Those who had undertaken advanced education training achieved a significantly higher mean knowledge score compared to those with just a primary dental degree (p=0.011). Similarly, full or part time academicians had a higher mean knowledge score than the clinicians who work only in private practice (p=0.014). Some dentists continue to prescribe antibiotics inappropriately for alleviating pain due to irreversible pulpitis. Antibiotic prescribing practices of dentists with advanced education or academic engagement were better as compared to the other participants. There is clear evidence of antibiotic over-prescribing for irreversible pulpitis which needs to be addressed urgently.

Knowledge mobilisation: an exploratory qualitative interview study to confirm and envision modification of lay and practitioner eczema mindlines to improve consultation experiences and self-management in primary care in the UK

OBJECTIVES

To investigate whether initial eczema mindlines, 'collectively reinforced, internalised, tacit guidelines', are an accurate representation of the experiences of lay people and practitioners in primary care and to explore how these mindlines may best be revised to improve eczema care.

DESIGN

Exploratory qualitative interviews with constant comparative analysis and data mining.

SETTING

UK, primary care.

PARTICIPANTS

People with eczema or parents of children with eczema (n=19) and primary care practitioners (n=13).

RESULTS

Interview data were analysed using constant comparison of new data with existing initial eczema mindlines to identify areas of agreement and disagreement. Data were mined for participant's thoughts about whose mindlines should be modified, how this may be achieved and what core content is essential. Eczema mindlines and the spiral of knowledge creation, from which they evolved, intuitively made sense. Participants offered examples of how their eczema knowledge is continually produced and transformed as they interact with others. They reported diverse and wide-ranging influences on their thinking and recognised the critical relationship between lay and practitioner mindlines. For this reason they advocated modifying lay and practitioner mindlines in parallel. Participants advised amendment based on consistent information directed to all who influence eczema care. Information should come from trusted sources and be easy to access, distilled, practical, contextually relevant and amenable to assimilation.

CONCLUSIONS

The purpose here is to improve primary care consultation experiences and self-management in eczema. The remaining challenge is to find novel, simple and pragmatic methods of modifying eczema mindlines to instil shared and consistent understanding. Given the prevalence of eczema and the scope of people who influence self-care, interventions should transcend patient-practitioner boundaries and address the wider community. One conceptually congruent approach is to create a Ba, which in this case would be a virtual space for generating and sharing eczema knowledge.

Comparing methods of grouping hospitals

OBJECTIVE

To compare the performance of widely used approaches for defining groups of hospitals and a new approach based on network analysis of shared patient volume.

STUDY SETTING

Non-federal acute care hospitals in the United States.

STUDY DESIGN

We assessed the measurement properties of four methods of grouping hospitals: hospital referral regions (HRRs), metropolitan statistical areas (MSAs), core-based statistical areas (CBSAs), and community detection algorithms (CDAs).

DATA EXTRACTION METHODS

We combined data from the 2014 American Hospital Association Annual Survey, the Census Bureau, the Dartmouth Atlas, and Medicare data on interhospital patient travel patterns. We then evaluated the distinctiveness of each grouping, reliability over time, and generalizability across populations.

PRINCIPLE FINDINGS

Hospital groups defined by CDAs were the most distinctive (modularity = 0.86 compared to 0.75 for HRRs and 0.83 for MSAs; 0.72 for CBSA), were reliable to alternative specifications, and had greater generalizability than HRRs, MSAs, or CBSAs. CDAs had lower reliability over time than MSAs or CBSAs (normalized mutual information between 2012 and 2014 CDAs = 0.93).

CONCLUSIONS

Community detection algorithm-defined hospital groups offer high validity, reliability to different specifications, and generalizability to many uses when compared to approaches in widespread use today. They may, therefore, offer a better choice for efforts seeking to analyze the behaviors and dynamics of groups of hospitals. Measures of modularity, shared information, inclusivity, and shared behavior can be used to evaluate different approaches to grouping providers.

Exploring How Evidence is Used in Care Through an Organizational Ethnography of Two Teaching Hospitals

Background

Numerous published articles show that clinicians do not follow clinical practice guidelines (CPGs). However, a few studies explore what clinicians consider evidence and how they use different forms of evidence in their care decisions. Many of these existing studies occurred before the advent of smartphones and advanced Web-based information retrieval technologies. It is important to understand how these new technologies influence the ways clinicians use evidence in their clinical practice. Mindlines are a concept that explores how clinicians draw on different sources of information (including context, experience, medical training, and evidence) to develop collectively reinforced, internalized tacit guidelines.

Objective

The aim of this paper was to explore how evidence is integrated into mindline development and the everyday use of mindlines and evidence in care.

Methods

We draw on ethnographic data collected by shadowing internal medicine teams at 2 teaching hospitals. Fieldnotes were tagged by evidence category, teaching and care, and role of the person referencing evidence. Counts of these tags were integrated with fieldnote vignettes and memos. The findings were verified with an advisory council and through member checks.

Results

CPGs represent just one of several sources of evidence used when making care decisions. Some forms of evidence were predominately invoked from mindlines, whereas other forms were read to supplement mindlines. The majority of scientific evidence was accessed on the Web, often through smartphones. How evidence was used varied by role. As team members gained experience, they increasingly incorporated evidence into their mindlines. Evidence was often blended together to arrive at shared understandings and approaches to patient care that included ways to filter evidence.

Conclusions

This paper outlines one way through which the ethos of evidence-based medicine has been incorporated into the daily work of care. Here, multiple Web-based forms of evidence were mixed with other information. This is different from the way that is often articulated by health administrators and policy makers whereby clinical practice guideline adherence is equated with practicing evidence-based medicine.

The dark side of coproduction: do the costs outweigh the benefits for health research?

Background

Coproduction, a collaborative model of research that includes stakeholders in the research process, has been widely advocated as a means of facilitating research use and impact. We summarise the arguments in favour of coproduction, the different approaches to establishing coproductive work and their costs, and offer some advice as to when and how to consider coproduction.

Debate

Despite the multiplicity of reasons and incentives to coproduce, there is little consensus about what coproduction is, why we do it, what effects we are trying to achieve, or the best coproduction techniques to achieve policy, practice or population health change. Furthermore, coproduction is not free risk or cost. Tensions can arise throughout coproduced research processes between the different interests involved. We identify five types of costs associated with coproduced research affecting the research itself, the research process, professional risks for researchers and stakeholders, personal risks for researchers and stakeholders, and risks to the wider cause of scholarship. Yet, these costs are rarely referred to in the literature, which generally calls for greater inclusion of stakeholders in research processes, focusing exclusively on potential positives. There are few tools to help researchers avoid or alleviate risks to themselves and their stakeholders.

Conclusions

First, we recommend identifying specific motivations for coproduction and clarifying exactly which outcomes are required for whom for any particular piece of research. Second, we suggest selecting strategies specifically designed to enable these outcomes to be achieved, and properly evaluated. Finally, in the absence of strong evidence about the impact and process of coproduction, we advise a cautious approach to coproduction. This would involve conscious and reflective research practice, evaluation of how coproduced research practices change outcomes, and exploration of the costs and benefits of coproduction. We propose some preliminary advice to help decide when coproduction is likely to be more or less useful.

Facilitators and barriers to brokering between research and care by senior clinical-scientists in general practice and elderly care medicine

BACKGROUND

Clinician-scientists (CSs) are physicians who work in daily care and have an academic role in research or education. They may act as knowledge brokers and help to connect research and clinical practice. There is no data available on CSs' brokering activities and the perceived barriers and facilitators to optimising their role in general practice (GP) and elderly care medicine (EM).

AIM

To identify the brokering activities of CSs in these fields and the barriers and facilitators they come across whilst sharing knowledge and connecting people in research and frontline health care.

DESIGN AND SETTING

Qualitative interview study among 17 Dutch senior CSs.

METHOD

Interview data were audio recorded, transcribed verbatim and thematic interpretative analysis was used to identify themes.

RESULTS

CSs facilitate collaboration between researchers and practitioners. They exchange knowledge on both sides, make use of extensive networks and constantly and actively involve care in research and research in care. CSs come across barriers as well as facilitators that influence their brokering activities. Some barriers and facilitators are at the individual level, other are related more to the job context and workplace.

CONCLUSIONS

This study reveals barriers to overcome and facilitators to develop related to the brokering role of CSs. To make the best use of CSs, brokering activities and the added value of CSs should be recognised and supported. Awareness of what CSs need to function effectively in demanding work settings could be important for the future impact of the role on the fields of GP and EM.

Embracing complexity and uncertainty to create impact: exploring the processes and transformative potential of co-produced research through development of a social impact model

The potential use, influence and impact of health research is seldom fully realised. This stubborn problem has caused burgeoning global interest in research aiming to address the implementation ‘gap’ and factors inhibiting the uptake of scientific evidence. Scholars and practitioners have questioned the nature of evidence used and required for healthcare, highlighting the complex ways in which knowledge is formed, shared and modified in practice and policy. This has led to rapid expansion, expertise and innovation in the field of knowledge mobilisation and funding for experimentation into the effectiveness of different knowledge mobilisation models. One approach gaining prominence involves stakeholders (e.g. researchers, practitioners, service users, policy-makers, managers and carers) in the co-production, and application, of knowledge for practice, policy and research (frequently termed integrated knowledge translation in Canada). Its popularity stems largely from its potential to address dilemmas inherent in the implementation of knowledge generated using more reductionist methods. However, despite increasing recognition, demands for co-produced research to illustrate its worth are becoming pressing while the means to do so remain challenging. This is due not only to the diversity of approaches to co-production and their application, but also to the ways through which different stakeholders conceptualise, measure, reward and use research. While research co-production can lead to demonstrable benefits such as policy or practice change, it may also have more diffuse and subtle impact on relationships, knowledge sharing, and in engendering culture shifts and research capacity-building. These relatively intangible outcomes are harder to measure and require new emphases and tools. This opinion paper uses six Canadian and United Kingdom case studies to explore the principles and practice of co-production and illustrate how it can influence interactions between research, policy and practice, and benefit diverse stakeholders. In doing so, we identify a continuum of co-production processes. We propose and illustrate the use of a new ‘social model of impact’ and framework to capture multi-layered and potentially transformative impacts of co-produced research. We make recommendations for future directions in research co-production and impact measurement.

Rethinking bias and truth in evidence-based health care

In modern philosophy, the concept of truth has been problematized from different angles, yet in evidence-based health care (EBHC), it continues to operate hidden and almost undisputed through the linked concept of "bias." To prevent unwarranted relativism and make better inferences in clinical practice, clinicians may benefit from a closer analysis of existing assumptions about truth, validity, and reality. In this paper, we give a brief overview of several important theories of truth, notably the ideal limit theorem (which assumes an ultimate and absolute truth towards which scientific inquiry progresses), the dominant way truth is conceptualized in the discourse and practice of EBHC. We draw on Belgian philosopher Isabelle Stengers' work to demonstrate that bias means one thing if one assumes a world of hard facts "out there," waiting to be collected. It means something different if one takes a critical view of the knowledge-power complex in research trials. Bias appears to have both an unproductive aspect and a productive aspect as argued by Stengers and others: Facts are not absolute but result from an interest, or interesse: a bias towards a certain line of questioning that cannot be eliminated. The duality that Stengers' view invokes draws attention to and challenges the assumptions underlying the ideal limit theory of truth in several ways. Most importantly, it casts doubt on the ideal limit theory as it applies to the single case scenario of the clinical encounter, the cornerstone of EBHC. To the extent that the goal of EBHC is to support inferencing in the clinical encounter, then the ideal limit as the sole concept of truth appears to be conceptually insufficient. We contend that EBHC could usefully incorporate a more pluralist understanding of truth and bias and provide an example how this would work out in a clinical scenario.

Knowledge mobilisation: an ethnographic study of the influence of lay mindlines on eczema self-management in primary care in the UK

OBJECTIVE

To investigate the way in which mindlines, 'collectively reinforced, internalised tacit guidelines', are constructed among lay people with eczema in primary care.

DESIGN

Ethnographic study.

SETTING

Observation in one general practice in the UK and interviews across central England.

PARTICIPANTS

In observation, patients in the participating general practice regardless of presenting complaint and in interviews, people with eczema or parents of children with eczema (n=16).

RESULTS

Observation of over 250 hours and interview data were combined and analysed using an ethnographic approach through the lenses of mindlines and self-management. Four themes were identified: doctor knows best; not worth bothering the doctor; I need to manage this myself; and how I know what to do. Themes were set within the context of four broad typologies of lay people's approach to self-management: content to self-manage; content to accept practitioner management; self-managing by default; and those referred to secondary care.

CONCLUSIONS

This study is the first to examine how lay eczema mindlines are developed and to recognise typologies of people with different need for, and receptiveness to, information. Lay eczema mindlines are constructed in many ways. The outstanding challenge is to find strategies to revise or modify these mindlines by adding reliable and useful knowledge and by erasing outdated or inaccurate information.