Impact of research activity on performance of general practices: a qualitative study

BACKGROUND

There is evidence that engaging in research is directly associated with better performance. If this relationship is to be strengthened, it is necessary to understand the mechanisms which might underlie that relationship.

AIM

To explore the perspectives of staff and wider stakeholders about mechanisms by which research activity might impact on the performance of general practices.

DESIGN & SETTING

Qualitative study using semi-structured interviews with general practice professionals and wider stakeholders in England.

METHOD

Individual interviews with 41 purposively sampled staff in 'research ready' or 'research active' general practices and 21 other stakeholders. Interviews were independently coded by three researchers using a Framework approach.

RESULTS

Participants described potential 'direct' and 'indirect' impacts on their work. 'Direct' impacts included research changing practice work (eg, additional records searches for particular conditions), bringing in additional resources (eg, access to investigations or staff) and improving relationships with patients. 'Indirect' impacts included job satisfaction (eg, perception of practice as a centre of excellence and innovation, and the variety afforded by research activity reducing burnout) and staff recruitment (increasing the attractiveness of the practice as a place to work). Respondents identified few negative impacts.

CONCLUSIONS

Staff and stakeholders identified a range of potential impacts of research activity on practice performance, with impacts on their working lives most salient. Negative impacts were not generally raised. Nevertheless, respondents generally discussed potential impacts rather than providing specific examples of those impacts. This may reflect the type of research activity conducted in general practice, often led by external collaborators.

A modified action framework to develop and evaluate academic-policy engagement interventions

BACKGROUND

There has been a proliferation of frameworks with a common goal of bridging the gap between evidence, policy, and practice, but few aim to specifically guide evaluations of academic-policy engagement. We present the modification of an action framework for the purpose of selecting, developing and evaluating interventions for academic-policy engagement.

METHODS

We build on the conceptual work of an existing framework known as SPIRIT (Supporting Policy In Health with Research: an Intervention Trial), developed for the evaluation of strategies intended to increase the use of research in health policy. Our aim was to modify SPIRIT, (i) to be applicable beyond health policy contexts, for example encompassing social, environmental, and economic policy impacts and (ii) to address broader dynamics of academic-policy engagement. We used an iterative approach through literature reviews and consultation with multiple stakeholders from Higher Education Institutions (HEIs) and policy professionals working at different levels of government and across geographical contexts in England, alongside our evaluation activities in the Capabilities in Academic Policy Engagement (CAPE) programme.

RESULTS

Our modifications expand upon Redman et al.'s original framework, for example adding a domain of 'Impacts and Sustainability' to capture continued activities required in the achievement of desirable outcomes. The modified framework fulfils the criteria for a useful action framework, having a clear purpose, being informed by existing understandings, being capable of guiding targeted interventions, and providing a structure to build further knowledge.

CONCLUSION

The modified SPIRIT framework is designed to be meaningful and accessible for people working across varied contexts in the evidence-policy ecosystem. It has potential applications in how academic-policy engagement interventions might be developed, evaluated, facilitated and improved, to ultimately support the use of evidence in decision-making.

'It depends': what 86 systematic reviews tell us about what strategies to use to support the use of research in clinical practice

BACKGROUND

The gap between research findings and clinical practice is well documented and a range of strategies have been developed to support the implementation of research into clinical practice. The objective of this study was to update and extend two previous reviews of systematic reviews of strategies designed to implement research evidence into clinical practice.

METHODS

We developed a comprehensive systematic literature search strategy based on the terms used in the previous reviews to identify studies that looked explicitly at interventions designed to turn research evidence into practice. The search was performed in June 2022 in four electronic databases: Medline, Embase, Cochrane and Epistemonikos. We searched from January 2010 up to June 2022 and applied no language restrictions. Two independent reviewers appraised the quality of included studies using a quality assessment checklist. To reduce the risk of bias, papers were excluded following discussion between all members of the team. Data were synthesised using descriptive and narrative techniques to identify themes and patterns linked to intervention strategies, targeted behaviours, study settings and study outcomes.

RESULTS

We identified 32 reviews conducted between 2010 and 2022. The reviews are mainly of multi-faceted interventions (n = 20) although there are reviews focusing on single strategies (ICT, educational, reminders, local opinion leaders, audit and feedback, social media and toolkits). The majority of reviews report strategies achieving small impacts (normally on processes of care). There is much less evidence that these strategies have shifted patient outcomes. Furthermore, a lot of nuance lies behind these headline findings, and this is increasingly commented upon in the reviews themselves.

DISCUSSION

Combined with the two previous reviews, 86 systematic reviews of strategies to increase the implementation of research into clinical practice have been identified. We need to shift the emphasis away from isolating individual and multi-faceted interventions to better understanding and building more situated, relational and organisational capability to support the use of research in clinical practice. This will involve drawing on a wider range of research perspectives (including social science) in primary studies and diversifying the types of synthesis undertaken to include approaches such as realist synthesis which facilitate exploration of the context in which strategies are employed.

What interventions should we implement in England's mental health services? The mental health implementation network (MHIN) mixed-methods approach to rapid prioritisation

Introduction

Setting mental health priorities helps researchers, policy makers, and service funders improve mental health services. In the context of a national mental health implementation programme in England, this study aims to identify implementable evidence-based interventions in key priority areas to improve mental health service delivery.

Methods

A mixed-methods research design was used for a three step prioritisation approach involving systematic scoping reviews (additional manuscript under development), expert consultations and data triangulation. Groups with diverse expertise, including experts by experience, worked together to improve decision-making quality by promoting more inclusive and comprehensive discussions. A multi-criteria decision analysis (MCDA) model was used to combine participants' varied opinions, data and judgments about the data's relevance to the issues at hand during a decision conferencing workshop where the priorities were finalised.

Results

The study identified mental health interventions in three mental health priority areas: mental health inequalities, child and adolescent mental health, comorbidities with a focus on integration of mental and physical health services and mental health and substance misuse problems. Key interventions in all the priority areas are outlined. The programme is putting some of these evidence-based interventions into action nationwide in each of these three priority mental health priority areas.

Conclusion

We report an inclusive attempt to ensure that the list of mental health service priorities agrees with perceived needs on the ground and focuses on evidence-based interventions. Other fields of healthcare may also benefit from this methodological approach if they need to make rapid health-prioritisation decisions.

Exploring the issues that influence how people with rare neurological conditions engage in physical activity

PURPOSE

People with rare neurological conditions (RNCs) struggle to achieve regular physical activity (PA). This study explored experiences of people with RNC engaging in PA, their carers, and health care professionals (HCPs) working with them.

MATERIALS & METHODS

We developed three surveys: for individuals living with RNCs, their carers, and HCPs working with them. Themes from interviews with RNC charity representatives were used to co-design questions, together with people living with RNCs, their representatives, and an expert panel. Surveys were disseminated via charity mailing lists, social media accounts, and professional networks (HCPs).

RESULTS

We received 436 responses (225 people with RNC, 94 carers, 117 HCPs). Most respondents with RNC achieved some level of regular PA but needed motivation to maintain it. Many felt they lacked knowledge on starting and staying active, with scarce resources and support. Most HCP respondents worked in specialist services, and overwhelmingly agreed that people with RNC should be physically active, while acknowledging lack of evidence and resources.

CONCLUSIONS

We identified key barriers at environmental/organisational, interpersonal, and intrapersonal levels, highlighting a critical lack of support for people with RNC across UK health services. These factors can be targeted to increase engagement in PA.Implications for rehabilitationPeople living with rare neurological conditions experience barriers to engaging in physical activity, with some common to more prevalent neurological diseases, e.g. access and facilities, but some notable differences due to the rarity of the conditionFor people living with rare neurological conditions, and their carers, there is a lack of knowledge on safe and appropriate engagement in physical activityIncreasing the knowledge of health and exercise professionals may improve how they support people with rare neurological disease to engage with physical activity.Evidence based resources and recommendations for people living with rare neurological conditions, and professionals working with them, may facilitate engagement in physical activity.

Peer coaching, implementation support and organisational power

This article looks at the effects of power (conceived as complex and multi-directional) on the collaborative, interprofessional relationships of peer coaches when delivering implementation support. The study conducted ethnographic observations, semi-structured interviews and documentary analysis to evaluate the dynamics of peer coaching during the implementation of an evidence-based programme, Patient and Family Centred Care (PFCC), to improve 24 end-of-life care services. The article draws on perspectives from critical management studies to offer insights on the effect of organisational power on collaborations during the administration of peer coaching. This article details the difficulties that organisational power structures posed to interprofessional peer-coaching collaborations. Many of the peer coaches found it difficult to place their advice in the existing ethos of organisations, existing organisational hierarchies, or collaborate in the midst of staff turnover and general time management outside of their control. These considerations meant that successful peer-coaching collaborations and the success of the implementation programme were often divergent.

Development and psychometric evaluation of the Implementation Science Research Project Appraisal Criteria (ImpResPAC) tool: a study protocol

INTRODUCTION

The need for quantitative criteria to appraise the quality of implementation research has recently been highlighted to improve methodological rigour. The Implementation Science Research development (ImpRes) tool and supplementary guide provide methodological guidance and recommendations on how to design high-quality implementation research. This protocol reports on the development of the Implementation Science Research Project Appraisal Criteria (ImpResPAC) tool, a quantitative appraisal tool, developed based on the structure and content of the ImpRes tool and supplementary guide, to evaluate the conceptual and methodological quality of implementation research.

METHODS AND ANALYSIS

This study employs a three-stage sequential mixed-methods design. During stage 1, the research team will map core domains of the ImpRes tool, guidance and recommendations contained in the supplementary guide and within the literature, to ImpResPAC. In stage 2, an international multidisciplinary expert group, recruited through purposive sampling, will inform the refinement of ImpResPAC, including content, scoring system and user instructions. In stage 3, an extensive psychometric evaluation of ImpResPAC, that was created in stage 1 and refined in stage 2, will be conducted. The scaling assumptions (inter-item and item-total correlations), reliability (internal consistency, inter-rater) and validity (construct and convergent validity) will be investigated by applying ImpResPAC to 50 protocols published in Implementation Science. We envisage developing ImpResPAC in this way will provide implementation research stakeholders, primarily grant reviewers and educators, a comprehensive, transparent and fair appraisal of the conceptual and methodological quality of implementation research, increasing the likelihood of funding research that will generate knowledge and contribute to the advancement of the field.

ETHICS AND DISSEMINATION

This study will involve human participants. This study has been registered and minimal risk ethical clearance granted by The Research Ethics Office, King's College London (reference number MRA-20/21-20807). Participants will receive written information on the study via email and will provide e-consent if they wish to participate. We will use traditional academic modalities of dissemination (eg, conferences and publications).

Theory-based evaluation of three research-practice partnerships designed to deliver novel, sustainable collaborations between adult social care research and practice in the UK: a research protocol for a 'layered' contributions analysis and realist evaluation

INTRODUCTION

Research-practice partnerships (RPPs) are long-term collaborations between research and practice that aim to conduct research that can be used to make practice-based improvements. They intentionally bring together diverse experience in decision making and seek to shift power dynamics so that all partners have a say. The Creating Care Partnerships project aims to explore whether the RPP approach developed within the US educational context can be successfully applied to the English care home context. The project involves a programme of codesign, implementation and evaluation within three case study sites. This protocol set outs the aims, research design and governance of the evaluation.

METHODS AND ANALYSIS

The evaluation takes a theory-based approach to explore how, why and in what circumstances RPPs in the care home context contribute to enhancing research and research use in local care homes and informing wider improvement efforts. A mixed-methods design will be used for each case study, including semistructured interviews, observations of RPP events and meetings, an online survey, activity diary and review of local data and documents. Data collection will proceed in waves, with the theory of change (ToC) being continually refined and used to guide further data collection and analysis. Insights will be drawn using Contribution Analysis, Realist Evaluation and systems perspectives to assess the contribution made by the case study sites to achieving outcomes and the influence of contextual factors. Economic consequences will be identified through the ToC, using a narrative economic analysis to assess costs, consequences and value for money.

ETHICS AND DISSEMINATION

The study has undergone ethics review by HRA Research Ethics Committee. It does not pose major ethical issues. A final report will be published and articles will be submitted to international journals.

Defining, conceptualizing and evaluating pragmatic qualities of quantitative instruments measuring implementation determinants and outcomes: a scoping and critical review of the literature and recommendations for future research

The pragmatic (i.e., practical) quality of quantitative implementation measures has received increased attention in the implementation science literature in recent years. Implementation measures that are judged to be pragmatic by implementation stakeholders are thought to be more likely to be applied in research and practice. Despite the need for pragmatic implementation measures, ambiguity and uncertainty regarding what constitutes a pragmatic measure remains. This study sought to identify and critically appraise the published literature to understand (i) how pragmatism is defined as a measurement construct/quality of implementation determinants and outcome instruments; (ii) how pragmatic qualities of instruments are evaluated; (iii) identify key gaps and limitations of the current evidence-base and (iv) identify recommendations for future research. We conducted a scoping review of the literature also employing methods of critical review. PubMed and PsycINFO databases, using the OVID interface, were searched for relevant articles published between January 2010 and September 2020. Articles that contained a definition and/or described characteristics of "pragmatism" as a measurement construct of quantitative implementation outcomes (as defined by Proctor's Implementation Outcomes taxonomy) and/or implementation determinants were eligible for inclusion. Nine articles met inclusion criteria. A degree of overlap in definitions and terms used to describe the pragmatic qualities of quantitative implementation determinant and outcome instruments were found. The most frequently cited descriptors of pragmatism were "not burdensome", "brief", "reliable", "valid" and "sensitive to change". 3 of the 9 included articles involved international implementation stakeholders in defining and conceptualizing pragmatism and employed specific methods to do so, including a systematic literature review, stakeholder interviews, concept mapping, and a Delphi process. All other articles defined pragmatism, with or without citing relevant literature. One article objectively assessed the pragmatic qualities, above and beyond the psychometric qualities, of implementation measures, using the Psychometric and Pragmatic Evidence Rating Scale (PAPERS). The evidence base within the implementation instrumentation literature on what pragmatism is and how it might be assessed is limited. Some of the research identified in the review provides a strong foundation to build upon, by testing its applicability in other settings (including healthcare areas and countries) and among a more diverse group of stakeholders. We discuss directions for further development of the concept of pragmatism relating to the measurement of implementation determinants and outcomes.

Building trusting relationships to support implementation: A proposed theoretical model

This paper presents a theory of change that articulates (a) proposed strategies for building trust among implementation stakeholders and (b) the theoretical linkages between trusting relationships and implementation outcomes. The theory of change describes how trusting relationships cultivate increases in motivation, capability, and opportunity for supporting implementation among implementation stakeholders, with implications for commitment and resilience for sustained implementation, and ultimately, positive implementation outcomes. Recommendations related to the measurement of key constructs in the theory of change are provided. The paper highlights how the development of a testable causal model on trusting relationships and implementation outcomes can provide a bridge between implementation research and implementation practice.

What funders are doing to assess the impact of their investments in health and biomedical research

As pressures to maximize research funding grow, biomedical research funders are increasingly tasked with demonstrating the long-term and real-world impacts of their funded research investments. Over the past three decades, research impact assessments (RIA) have emerged as an important tool for analysing the impacts of research by incorporating logic models, frameworks and indicators to track measures of knowledge production, capacity-building, development of research products, adoption of research into clinical guidelines and policies, and the realization of health, economic and social benefits. While there are currently several models for RIA within the literature, less attention has been paid to how funders can practically select and implement a RIA model to demonstrate the impacts of their own research portfolios. In this paper, a literature review was performed to understand (1) which research funders have performed RIAs of their research portfolios to date; (2) how funders have designed their assessments, including the models and tools they have used; (3) what challenges to and facilitators of success have funders found when adopting the RIA model to their own portfolio; and (4) who participates in the assessments. Forty-four papers from both published and grey literature were found to meet the review criteria and were examined in detail. There is a growing culture of RIA among funders, and included papers spanned a diverse set of funders from 10 countries or regions. Over half of funders (59.1%) used a framework to conduct their assessment, and a variety of methods for collecting impact data were reported. Issues of methodological rigour were observed across studies in the review, and this was related to numerous challenges funders faced in designing timely RIAs with quality impact data. Over a third of articles (36.4%) included input from stakeholders, yet only one article reported surveying patients and members of the public as part of the assessment. To advance RIA among funders, we offer several recommendations for increasing the methodological rigour of RIAs and suggestions for future research, and call for a careful reflection of the voices needed in an impact assessment to ensure that RIAs are having a meaningful impact on patients and the public.

Intervening for sustainable change: Tailoring strategies to align with values and principles of communities

This paper presents a rationale for tailoring implementation strategies within a values-driven implementation approach. Values-driven implementation seeks to organize implementers around clarifying statements of their shared values in ways that harmonize implementation dynamics related to individual and group mental models, relationships among implementers, and the implementation climate. The proposed approach to tailoring strategies is informed by systems theory and emphasizes the need to focus on both tangible events and behaviors, as well deeper patterns, structures, relationships, and mental models, in order to increase the likelihood of sustaining implementation efforts and improving outcomes for people and communities. We offer for consideration three specific sets of context determinants that are under-represented in the implementation literature and that emerge as especially relevant within a systems approach to identifying and successfully tailoring implementation strategies in the implementation setting including relationships, mental models, and implementation climate.

Is implementation research out of step with implementation practice? Pathways to effective implementation support over the last decade

Background: There is growing interest in the lived experience of professionals who provide implementation support (i.e., implementation support practitioners). However, there remains limited knowledge about their experiences and how those experiences can contribute to the knowledge base on what constitutes successful and sustainable implementation support models. This study aimed to examine pathways of implementation support practice, as described by experienced professionals actively supporting systems' uptake and sustainment of evidence to benefit children and families. Methods: Seventeen individuals with extensive experience providing implementation support in various settings participated in semi-structured interviews. Data were analyzed using qualitative content analysis and episode profile analysis approaches. Iterative diagramming was used to visualize the various pathways of implementation support practitioners' role reflection and transformation evidenced by the interview data. Results: Findings highlighted rich pathways of implementation support practitioners' role reflection and transformation. Participants described their roots in providing implementation support as it relates to implementing and expanding the use of evidence-based programs and practices in child and family services. Almost all participants reflected on the early stages of their careers providing implementation support and described a trajectory starting with the use of "push models," which evolved into "pull models" and eventually "co-creation or exchange models" of implementation support involving both technical and relational skills. Conclusions: Developing an implementation support workforce will require a deeper understanding of this lived experience to prevent repeated use of strategies observed to be unsuccessful by those most proximal to the work. The pathways for implementation practice in this study highlight impressive leaps forward in the field of implementation over the last 15 years and speaks to the importance of the professionals leading change efforts in this growth.

Plain Language Summary

Over the past few years, professionals in the field of implementation science have identified a growing gap between implementation research and implementation practice. While this issue has been highlighted informally, the field is lacking a shared understanding and clear way forward to reconcile this gap. In this paper, the authors describe how professionals providing implementation support have shifted their implementation practice over time through systematic observations of what works (and what does not work) for supporting and sustaining evidence use in service systems to improve population outcomes. The authors share the impressive leaps forward made in the field of implementation practice - from didactic training to responsive and tailored implementation strategies to co-created and relationship-based implementation solutions. The paper concludes with a call to action to the field for the creation of a virtuous learning cycle between professionals conducting implementation research and professionals providing implementation support to change practice as a way to produce a more robust and relevant science of implementation.

Maximising engagement and participation of intellectual disability staff in research: Insights from conducting a UK-wide survey

AIM

This article explores ways of maximising engagement of intellectual disability staff as research participants, research advisers and research implementers.

METHOD

The authors describe and reflect on a three-phased strategy in recruiting front-line staff (n = 690) working for intellectual disability service providers (n = 25) to participate in a UK-wide anonymous online survey about death, dying and bereavement.

RESULTS

Important elements in engaging participants were: involving stakeholders at all stages of the research process, which includes: building relationships with participating organisations; enlisting organisational management support at all levels; an attractive and well laid-out collection tool; a well-structured recruitment strategy; time and flexibility; and a varied and targeted dissemination strategy. However, the recruitment method had limitations, in particular around representativeness, bias and generalisability.

CONCLUSIONS

Staff in intellectual disability services can be enthusiastic and invaluable research participants. Active engagement between researchers, participating organisations and stakeholder groups is key to ensuring involvement of intellectual disability staff with research.

Proposing a Core Outcome Set for Physical Activity and Exercise Interventions in People With Rare Neurological Conditions

Rare neurological conditions (RNCs) encompass a variety of diseases that differ in progression and symptoms but typically include muscle weakness, sensory and balance impairment and difficulty with coordinating voluntary movement. This can limit overall physical activity, so interventions to address this are recommended. The aim of this study was to agree a core outcome measurement set for physical activity interventions in people living with RNCs. We followed established guidelines to develop core outcome sets. Broad ranging discussions in a series of stakeholder workshops led to the consensus that (1) physical well-being; (2) psychological well-being and (3) participation in day-to-day activities should be evaluated in interventions. Recommendations were further informed by a scoping review of physical activity interventions for people living with RNCs. Nearly 200 outcome measures were identified from the review with a specific focus on activities or functions (e.g, on lower limb function, ability to perform daily tasks) but limited consideration of participation based outcomes (e.g., social interaction, work and leisure). Follow on searches identified two instruments that matched the priority areas: the Oxford Participation and Activities Questionnaire and the Sources of Self-Efficacy for Physical Activity. We propose these scales as measures to assess outcomes that are particularly relevant to assess when evaluating physical activity interventions mong people with RNCs. Validation work across rare neurological conditions is now required to inform application of this core outcome set in future clinical trials to facilitate syntheses of results and meta-analyses.

Influence of commissioning arrangements on implementing and sustaining a complex healthcare intervention (ESCAPE-pain) for osteoarthritis: a qualitative case study

OBJECTIVES

Funding in health care has a critical impact on the implementation and sustainability of evidence-based interventions. This study explored the perspectives of physiotherapists on the influence of commissioning arrangements on the implementation and sustainability of a group rehabilitation programme for osteoarthritis (ESCAPE-pain).

DESIGN

A qualitative case study approach using in-depth interviews.

SETTING

National Health Service (NHS) musculoskeletal (MSK) outpatient departments in England.

PARTICIPANTS

Thirty physiotherapists in clinical and senior management roles from 11 NHS MSK providers.

RESULTS

Five themes were identified: (1) clinical perspectives of ESCAPE-pain - MSK services wanted to implement and sustain ESCAPE-pain because it provided evidence-based, quality care; (2) focusing on clinical activity over outcomes - commissioners were perceived as prioritising activity-based performance over delivering clinical outcomes; (3) rationing availability - patient access to ESCAPE-pain could be limited due to rationing resources; (4) absorbing costs - contracts did not always cover the activities associated with delivering ESCAPE-pain meaning that providers bore the costs; and (5) relationship between commissioners and providers - physiotherapists perceived a disconnect with commissioners and had little power to influence decisions.

CONCLUSIONS

Commissioning arrangements for MSK physiotherapy services can impede providers from implementing and sustaining a clinically and cost-effective intervention. To be implemented and sustained, an intervention needs to integrate into clinical practice and the wider healthcare system. Commissioning arrangements for MSK physiotherapy need to allow providers the flexibility to deliver interventions that best meet the needs of their patients. The move to more strategic, integrated, outcome-based commissioning has the potential to facilitate the spread and sustainability of interventions.

Leading the spread and adoption of innovation at scale: an Academic Health Science Network’s perspective

Background

There is virtually no limit to the number of innovations being developed, tested and piloted at any one time to improve the quality and safety of care. The perennial problem is spreading innovations that are proven to be effective on a smaller scale or under controlled conditions. Much of the literature on spread refers to the important role played by external agencies in supporting the spread of innovations.

Academic Health Science Networks and the spread of innovation

External agencies can provide additional capacity and capabilities to adopter organisations, such as technical expertise, resources and tools to assist with operational issues. In England, the National Health Service (NHS) established 15 Academic Health Science Networks (AHSNs) to help accelerate the spread and adoption of innovation in healthcare. However, formal clinical-academic networks (such as AHSNs) themselves will not deliver positive, tangible outcomes on the ground (ie, evidence-based innovations embedded at scale across a system). This begs the question of how do AHSNs practically go about achieving this change successfully? We provide an AHSN’s perspective on how we conceptualise and undertake our work in leading implementation of innovation at scale.

An AHSN's perspective

Our approach is a collaborative process of widening understanding of the innovation and its implementation. At its core, the implementation and spread of innovation into practice is a collective social process. Healthcare comprises complex adaptive systems, where contexts need to be negotiated for implementation to be successful. As AHSNs, we aim to lead this negotiation through facilitating knowledge exchange and production across the system to mobilise the resources and collective action necessary for achieving spread.

How far does an emphasis on stakeholder engagement and co-production in research present a threat to academic identity and autonomy? A prospective study across five European countries

There is a growing recognition that needs more to be done to ensure that research contributes to better health services and patient outcomes. Stakeholder engagement in research, including co-production, has been identified as a promising mechanism for improving the value, relevance and utilization of research. This article presents findings from a prospective study which explored the impact of stakeholder engagement in a 3-year European tobacco control research project. That research project aimed to engage stakeholders in the development, testing and dissemination of a return-on-investment tool across five EU countries (the Netherlands, Spain, Hungary, Germany and the UK). The prospective study comprised interviews, observations and document review. The analysis focused on the extent to which the project team recognized, conceptualized and operationalized stakeholder engagement over the course of the research project. Stakeholder engagement in the European research project was conceptualized as a key feature of pre-designated spaces within their work programme. Over the course of the project, however, the tool development work and stakeholder engagement activities decoupled. While the modelling and tool development became more secluded, stakeholder engagement activities subtly transformed from co-production, to consultation, to something more recognizable as research participation. The contribution of this article is not to argue against the potential contribution of stakeholder engagement and co-production, but to show how even well-planned engagement activities can be diverted within the existing research funding and research production systems where non-research stakeholders remain at the margins and can even be seen as a threat to academic identify and autonomy.

Scaling-up an evidence-based intervention for osteoarthritis in real-world settings: a pragmatic evaluation using the RE-AIM framework

Background

Scaling-up and sustaining effective healthcare interventions is essential for improving healthcare; however, relatively little is known about these processes. In addition to quantitative experimental designs, we need approaches that use embedded, observational studies on practice-led, naturally occurring scale-up processes. There are also tensions between having adequately rigorous systems to monitor and evaluate scale-up well that are proportionate and pragmatic in practice. The study investigated the scale-up of an evidence-based complex intervention for knee and hip osteoarthritis (ESCAPE-pain) within ‘real-world’ settings by England’s 15 Academic Health Science Networks (AHSNs).

Methods

A pragmatic evaluation of the scale-up of ESCAPE-pain using the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance. The evaluation used routine monitoring data collected from April 2014 to December 2018 as part of a national scale-up programme.

Results

Between 2014 and 2018, ESCAPE-pain was adopted by over 110 clinical and non-clinical sites reaching over 9000 people with osteoarthritis. The programme showed sustained clinical effectiveness (pain, function and quality of life) and high levels of adherence (78.5% completing 75% of the programme) within a range of real-world settings. Seven hundred seventy people (physiotherapists and exercise professionals) have been trained to deliver ESCAPE-pain, and 84.1% of sites have continued to deliver the programme post-implementation.

Conclusions

ESCAPE-pain successfully moved from being an efficacious “research intervention” into an effective intervention within ‘real-world’ clinical and non-clinical community settings. However, scale-up has been a gradual process requiring on-going, dedicated resources over 5 years by a national network of Academic Health Science Networks (AHSNs). Whilst the collection of monitoring and evaluation data is critical in understanding implementation and scale-up, there remain significant challenges in developing systems sufficiently rigorous, proportionate and locally acceptable.

The role of leadership in implementing and sustaining an evidence-based intervention for osteoarthritis (ESCAPE-pain) in NHS physiotherapy services: a qualitative case study

PURPOSE

To explore the role of leadership by physiotherapists in implementing and sustaining an evidence-based complex intervention (ESCAPE-pain) for osteoarthritis.

MATERIALS AND METHODS

A qualitative case study approach using in-depth interviews with 23 clinicians and managers from 4 National Health Service (NHS) physiotherapy providers in England between 2016 and 2017. Data were analysed using thematic analysis.

RESULTS

Different leadership roles and actions were characterised with four themes: (1) Clinical champions - clinicians driving the sustainability of ESCAPE-pain; (2) Supporters - junior clinicians directly supporting clinical champions' efforts to sustain ESCAPE-pain; (3) Senior Manager - clinical champions' senior managers influence on sustainability; (4) Decision-making - (in)formal processes underpinning decisions to (not) sustain the programme.

CONCLUSIONS

The study characterises the role of leadership in physiotherapy to sustain an evidence-based intervention for osteoarthritis (OA) within the NHS. Sustaining the intervention required on-going leadership, it did not stop at implementation. Senior specialist physiotherapists (as Champions) had a critical leadership role in driving sustainability. Their structural position (bridging the operational and strategic) and personal attributes allowed them to integrate different levels of leadership (i.e., senior managers and operational staff) to mobilise the collective, on-going work required for sustaining the programme.IMPLICATIONS FOR REHABILITATIONSenior managers and clinicians in practice settings need to be aware that sustaining an intervention is an on-going, collective effort that continues post-implementation.Senior managers need to enable senior clinicians (who straddle strategic and operational functions) to have sufficient autonomy to access and mobilise resources and scope to restructure local systems and practice to support intervention sustainability.Operational staff need to be supported to have the practical know-how to deliver evidence-based intervention, which includes instilling the value of and a commitment for the interventions.Managers need to utilise dispersed leadership to empower and enthuse frontline clinicians to participate fully in the work to refine and sustain interventions, because it cannot be achieved by lone individuals.

How to strengthen a health research system: WHO's review, whose literature and who is providing leadership?

BACKGROUND

Health research is important for the achievement of the Sustainable Development Goals. However, there are many challenges facing health research, including securing sufficient funds, building capacity, producing research findings and using both local and global evidence, and avoiding waste. A WHO initiative addressed these challenges by developing a conceptual framework with four functions to guide the development of national health research systems. Despite some progress, more is needed before health research systems can meet their full potential of improving health systems. The WHO Regional Office for Europe commissioned an evidence synthesis of the systems-level literature. This Opinion piece considers its findings before reflecting on the vast additional literature available on the range of specific health research system functions related to the various challenges. Finally, it considers who should lead research system strengthening.

MAIN TEXT

The evidence synthesis identifies two main approaches for strengthening national health research systems, namely implementing comprehensive and coherent strategies and participation in partnerships. The literature describing these approaches at the systems level also provides data on ways to strengthen each of the four functions of governance, securing financing, capacity-building, and production and use of research. Countries effectively implementing strategies include England, Ireland and Rwanda, whereas West Africa experienced effective partnerships. Recommended policy approaches for system strengthening are context specific. The vast literature on each function and the ever-growing evidence-base are illustrated by considering papers in just one key journal, Health Research Policy and Systems, and analysing the contribution of two national studies. A review of the functions of the Iranian system identifies over 200 relevant and mostly national records; an analysis of the creation of the English National Institute for Health Research describes the key leadership role played by the health department. Furthermore, WHO is playing leadership roles in helping coordinate partnerships within and across health research systems that have been attempting to tackle the COVID-19 crisis.

CONCLUSIONS

The evidence synthesis provides a firm basis for decision-making by policy-makers and research leaders looking to strengthen national health research systems within their own national context. It identifies five crucial policy approaches - conducting situation analysis, sustaining a comprehensive strategy, engaging stakeholders, evaluating impacts on health systems, and partnership participation. The vast and ever-growing additional literature could provide further perspectives, including on crucial leadership roles for health ministries.

The accuracy and accessibility of cited evidence: a study examining mental health policy documents

PURPOSE

Evidence-based policy making is increasingly being advocated by governments and scholars. To show that policies are informed by evidence, policy-related documents that cite external sources should ideally provide direct access to, and accurately represent, the referenced source and the evidence it provides. Our aim was to find a way to systematically assess the prevalence of referencing accuracy and accessibility issues in referenced statements selected from a sample of mental health-related policy documents.

METHOD

236 referenced statements were selected from 10 mental health-related policy documents published between 2013 and 2018. Policy documents were chosen as the focus of this investigation because of their relative accessibility and impact on clinical practice. Statements were rated against their referenced sources in terms of the (i) content accuracy in relation to the information provided by the referenced source and (ii) degree of accessibility of the source and the required evidence from the references provided.

RESULTS

Of the 236 statements, 141 (59.7%) accurately represented the referenced source, 45 (19.1%) contained major errors and 50 (21.2%) contained minor errors in accuracy. For accessibility, 126 (53.4%) directly referenced primary sources of evidence that supported the claims made, 36 (15.3%) contained indirect references, 18 (7.6%) provided 'dead-end' references, and 11 (4.7%) references were completely inaccessible.

CONCLUSIONS

With only slightly over half of all statements assessed providing fully accessible references and accurately representing the referenced source, these components of referencing quality deserve further attention if evidence-informed policy goals are to be achieved. The rating framework used in the current study proved to be a simple and straightforward method to assess these components and can provide a baseline against which interventions can be designed to improve referencing quality.

Correction to: The accuracy and accessibility of cited evidence: a study examining mental health policy documents

In the original publication of the article there was an error in the results section of the abstract. The first sentence should have read.

The emotional labour of quality improvement work in end of life care: a qualitative study of Patient and Family Centred Care (PFCC) in England

Background

There is a growing emphasis on understanding patient experience in order to inform efforts to support improvement. This paper reports findings from an implementation study of an evidence-based intervention called Patient and Family Centred Care (PFCC) designed to tap into patient experiences as a basis for improvement. In this study the PFCC intervention was spread to a new service area (end of life care) and delivered at scale in England. The findings presented here focus specifically on one key aspect of the intervention: staff shadowing of patients, and the experiences of staff carrying out shadowing for the purposes of service improvements.

Methods

The study methods were ethnographic observations of key events, semi-structured interviews with members of participating teams and the programme implementation support team and managers, and a review of the documents used in the set up and running of the programme.

Results

One of the key strengths of the PFCC approach is to encourage staff through shadowing to engage with patient experience of services. Many staff described the process of shadowing as a transformative experience that alerted them to immediate areas where their services could be improved. However, engaging with patient experience of end of life care services also had unintended consequences for some staff in the form of emotional labour. Furthermore, we observed difficulties encountered by staff that are not accounted for in the existing PFCC literature relating to how care service structures may unevenly distribute the amount of ‘emotional labour’ that staff members need to invest in implementing the programme.

Conclusions

Connecting with patient experience is a crucial aspect of a number of quality improvement interventions that aim to help staff to engage with the lived experience of their services and reconnect their motivations for working in the health care system. However, there may be unintended consequences for health care service staff, particularly in sensitive areas of service delivery such as end of life care. The ‘emotional labour’ for staff of engaging in quality improvement work informed by patient experience should be considered in planning and supporting patient experience led quality improvement.

Influence of external contextual factors on the implementation of health and social care interventions into practice within or across countries-a protocol for a 'best fit' framework synthesis

BACKGROUND

The widespread implementation of interventions is often hindered by a decline and variability in effectiveness across implementation sites. It is anticipated that variations in the characteristics of the external context in different sites, such as the political and funding environment, socio-cultural context, physical environment or population demographics can influence implementation outcome. However, there is only a limited understanding about which and how external contextual factors influence implementation. We aim to develop a comprehensive framework conceptualising the influence of external contextual factors on implementation, particularly when spreading health and social care interventions within or across countries.

METHODS

The review will use the 'best fit' framework synthesis approach. In the first stage of the review, we will examine existing frameworks, models, concepts and theories on external contextual factors and their influence on implementation from a variety of sectors and disciplines including health and social care, education, environmental studies and international development fields. The resulting a priori meta-framework will be tested and refined in the second review stage by analysing evidence from empirical studies focusing on the implementation of health and social care interventions within or across countries. Searches will be conducted in bibliographic databases such as MEDLINE, ERIC, HMIC and IBSS, grey literature sources and on relevant websites. We will also search reference lists, relevant journals, perform citation searches and ask experts in the field. There is no restriction to study type, setting, intervention type or implementation strategy to enable obtaining a broad and in-depth knowledge from various sources of evidence.

DISCUSSION

The review will lead to a comprehensive framework for understanding the influence of external contextual factors on implementation, particularly when spreading health and social care interventions within or across countries. The framework is anticipated to help identify factors explaining the decline and variability in effectiveness of interventions and assessing the prospects of implementation effectiveness, when spreading interventions. We do not intend to only develop another stand-alone implementation framework but one that can be used in conjunction with existing frameworks. The framework can be honed and validated in future empirical research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084485.

Biopolitics, space and hospital reconfiguration

Major service change in healthcare - whereby the distribution of services is reconfigured at a local or regional level - is often a contested, political and poorly understood set of processes. This paper contributes to the theoretical understanding of major service change by demonstrating the utility of interpreting health service reconfiguration as a biopolitical intervention. Such an approach orients the analytical focus towards an exploration of the spatial and the population - crucial factors in major service change. Drawing on a qualitative study from 2011-12 of major service change in the English NHS combining documentary analyses of historically relevant policy papers and contemporary policy documentation (n = 125) with semi-structured interviews (n = 20) we highlight how a particular 'geography of stroke' in London was created building upon multiple types of knowledge: medical, epidemiological, economic, demographic, managerial and organisational. These informed particular spatial practices of government providing legitimation for the significant political upheaval that accompanies NHS service reconfiguration by problematizing existing variation in outcomes and making these visible. We suggest that major service change may be analysed as a 'practice of security' - a way of redefining a case, conceiving of risks and dangers, and averting potential crises in the interests of the population.

The contribution of ethnography to the evaluation of quality improvement in hospital settings: reflections on observing co-design in intensive care units and lung cancer pathways in the UK

Ethnography is increasingly being used in the evaluation of quality improvement and change initiatives in healthcare settings, particularly in the form of 'focused' and 'rapid' ethnographies. This new ethnographic genre is tailored to suit narrower enquiries within clinical pathways. However, the application of ethnography to the evaluation of quality improvement is not straightforward or free from reductionist bias, particularly in hospital settings where interventions take place during a limited period of time and instigate change in busy and sensitive settings. This paper discusses problems and emergent solutions involved in conducting an ethnographic process evaluation of co-design projects in lung cancer and intensive care unit services in two hospitals in England. The mixed-methods ethnographic evaluation consisted of observations of the co-design process and triangulation of findings with interviews, questionnaires, participant reflective diaries and service improvement logs. Limitations of observational time and distance from 'the field' were overcome by making most of the pre- and post-event observational periods, situating quality improvement within the wider context of clinical practice, achieving attunement with local clinical cultures and engaging participants in collaboratively guiding observational and interview design. This approach led to a focused ethnographic evaluation that accommodated ethnographic principles to obtain rich insights into quality improvement processes despite the limitations of short-timeframes and the hospital setting.

How to engage stakeholders in research: design principles to support improvement

Background

Closing the gap between research production and research use is a key challenge for the health research system. Stakeholder engagement is being increasingly promoted across the board by health research funding organisations, and indeed by many researchers themselves, as an important pathway to achieving impact. This opinion piece draws on a study of stakeholder engagement in research and a systematic literature search conducted as part of the study.

Main body

This paper provides a short conceptualisation of stakeholder engagement, followed by ‘design principles’ that we put forward based on a combination of existing literature and new empirical insights from our recently completed longitudinal study of stakeholder engagement. The design principles for stakeholder engagement are organised into three groups, namely organisational, values and practices. The organisational principles are to clarify the objectives of stakeholder engagement; embed stakeholder engagement in a framework or model of research use; identify the necessary resources for stakeholder engagement; put in place plans for organisational learning and rewarding of effective stakeholder engagement; and to recognise that some stakeholders have the potential to play a key role. The principles relating to values are to foster shared commitment to the values and objectives of stakeholder engagement in the project team; share understanding that stakeholder engagement is often about more than individuals; encourage individual stakeholders and their organisations to value engagement; recognise potential tension between productivity and inclusion; and to generate a shared commitment to sustained and continuous stakeholder engagement. Finally, in terms of practices, the principles suggest that it is important to plan stakeholder engagement activity as part of the research programme of work; build flexibility within the research process to accommodate engagement and the outcomes of engagement; consider how input from stakeholders can be gathered systematically to meet objectives; consider how input from stakeholders can be collated, analysed and used; and to recognise that identification and involvement of stakeholders is an iterative and ongoing process.

Conclusion

It is anticipated that the principles will be useful in planning stakeholder engagement activity within research programmes and in monitoring and evaluating stakeholder engagement. A next step will be to address the remaining gap in the stakeholder engagement literature concerned with how we assess the impact of stakeholder engagement on research use.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0337-6) contains supplementary material, which is available to authorized users.

'Holding the line': a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London

BACKGROUND

Health service reconfigurations are of international interest but remain poorly understood. This article focuses on the use of evidence by senior managerial decision-makers involved in the reconfiguration of stroke services in London 2008-2012. Recent work comparing stroke service reconfiguration in London and Manchester emphasises the ability of senior managerial decision-makers in London to 'hold the line' in the crucial early phases of the stroke reconfiguration programme. In this article, we explore in detail how these decision-makers 'held the line' and ask what the broader power implications of doing so are for the interaction between evidence, health policy and system redesign.

METHODS

The research combined semi-structured interviews (n = 20) and documentary analysis of historically relevant policy papers and contemporary stroke reconfiguration documentation published by NHS London and other interested parties (n = 125). We applied a critical interpretive and reflexive approach to the analysis of the data.

RESULTS

We identified two forms of power which senior managerial decision-makers drew upon in order to 'hold the line'. Firstly, discursive power, which through an emphasis on evidence, better patient outcomes, professional support and clinical credibility alongside a tightly managed consultation process, helped to set an agenda that was broadly receptive to the overall decision to change stroke services in the capital in a radical way. Secondly, once the essential parameters of the decision to change services had been agreed, senior managerial decision-makers 'held the line' through hierarchical New Public Management style power to minimise the traditional pressures to de-radicalise the reconfiguration through 'top down' decision-making.

CONCLUSIONS

We problematise the concept of 'holding the line' and explore the power implications of such managerial approaches in the early phases of health service reconfiguration. We highlight the importance of evidence for senior managerial decision-makers in agenda setting and the limitations of clinical research findings in guiding politically sensitive policy decisions which impact upon regional healthcare systems.

What patients do and their impact on implementation

PURPOSE

The potential for including patients in implementation processes has received limited attention in the literature. The purpose of this paper is to explore the different roles adopted by 63 patients that emerged during and after four participatory quality improvement interventions, and the nature of their impact upon implementation processes and outcomes.

DESIGN/METHODOLOGY/APPROACH

A cross-case ethnographic comparison of Experience-based Co-design in two clinical pathways in two UK NHS Trusts.

FINDINGS

Two key themes emerge from the data. First, the authors found a range of different roles adopted by patients within and across the four projects; some were happy to share their experiences, others also helped to identify improvement priorities alongside staff whilst others were also involved in developing potential solutions with the staff who had cared for them. A few participants also helped implement those solutions and became "experts by experience" through engaging in the whole co-design process. Second, in terms of the impact of patient engagement with the co-design process whilst the changes championed by patients and carers were often small scale, as co-designers patients provided innovative ideas and solutions. Through their involvement and contributions they also acted as catalysts for broader change in the attitudes of staff by providing a motivation for wider organisational and attitudinal changes.

RESEARCH LIMITATIONS/IMPLICATIONS

The research was conducted in two clinical pathways in two NHS trusts. However, the findings complement and add to the growing body of knowledge on experience based co-design.

PRACTICAL IMPLICATIONS

Patient engagement is likely to require support and facilitation to ensure that patients can play a meaningful role as partners and co-designers in service improvement and implementation. Different roles suited particular individuals, with participants stepping in and out of the co-design process at various stages as suited their needs, capacities and (albeit sometimes perceptions re) skills. In this context, facilitation needs to be sensitive to individual needs and flexible to support involvement.

SOCIAL IMPLICATIONS

Patients and carers can play active roles in service improvement, particularly where the approach facilitate active engagement as co-designers.

ORIGINALITY/VALUE

Analysis of the role patients and carers in implementation and improvement.

Whose voices? Patient and public involvement in clinical commissioning

Aim

This paper aims to explore patient and public representation in a NHS clinical commissioning group and how this is experienced by staff and lay members involved.

Background

Patient and public involvement is believed to foster greater public representativeness in the development and delivery of health care services. However, there is widespread debate about what representation is or what it should be. Questions arise about the different constructions of representation and the representativeness of patients and the public in decision‐making structures and processes.

Design

Ethnographic, two‐phase study involving twenty‐four observations across two types of clinical commissioning group meetings with patient and public involvement, fourteen follow‐up interviews with NHS staff and lay members, and a focus group with five lay members.

Results

Perceptions of what constitutes legitimate representativeness varied between respondents, ranging from representing an individual patient experience to reaching large numbers of people. Consistent with previous studies, there was a lack of clarity about the role of lay members in the work of the clinical commissioning group.

Conclusions

Unlike previous studies, it was lay members, not staff, who raised concerns about their representativeness and legitimacy. Although the clinical commissioning group provides resources to support patient and public involvement, there continues to be a lack of clarity about roles and scope for impact. Lay members are still some way from constituting a powerful voice at the table.

Does the 'diffusion of innovations' model enrich understanding of research use? Case studies of the implementation of thrombolysis services for stroke

OBJECTIVE

To test whether the model of 'diffusion of innovations' enriches understanding of the implementation of evidence-based thrombolysis services for stroke patients.

METHODS

Four case studies of the implementation of evidence on thrombolysis in stroke services in England and Sweden. Semistructured interviews with 95 staff including doctors, nurses and managers working in stroke units, emergency medicine, radiology, the ambulance service, community rehabilitation services and commissioners.

RESULTS

The implementation of thrombolysis in acute stroke management benefited from a critical mass of the factors featured in the model including: the support of national and local opinion leaders; a strong evidence base and financial incentives. However, while the model provided a starting point as an organizational framework for mapping the critical factors influencing implementation, to understand properly the process of implementation and the importance of the different factors identified, more detailed analyses of context and, in particular, of the human and social dimensions of change was needed.

CONCLUSIONS

While recognising the usefulness of the model of diffusion of innovations in mapping the processes by which diffusion occurs, the use of methods that lend themselves to in-depth analysis, such as ethnography and the application of relevant bodies of social theory, are needed.

Does the engagement of clinicians and organisations in research improve healthcare performance: a three-stage review

OBJECTIVE

There is a widely held assumption that engagement by clinicians and healthcare organisations in research improves healthcare performance at various levels, but little direct empirical evidence has previously been collated. The objective of this study was to address the question: Does research engagement (by clinicians and organisations) improve healthcare performance?

METHODS

An hourglass-shaped review was developed, consisting of three stages: (1) a planning and mapping stage; (2) a focused review concentrating on the core question of whether or not research engagement improves healthcare performance; and (3) a wider (but less systematic) review of papers identified during the two earlier stages, focusing on mechanisms.

RESULTS

Of the 33 papers included in the focused review, 28 identified improvements in health services performance. Seven out of these papers reported some improvement in health outcomes, with others reporting improved processes of care. The wider review demonstrated that mechanisms such as collaborative and action research can encourage some progress along the pathway from research engagement towards improved healthcare performance. Organisations that have deliberately integrated the research function into organisational structures demonstrate how research engagement can, among other factors, contribute to improved healthcare performance.

CONCLUSIONS

Current evidence suggests that there is an association between the engagement of individuals and healthcare organisations in research and improvements in healthcare performance. The mechanisms through which research engagement might improve healthcare performance overlap and rarely act in isolation, and their effectiveness often depends on the context in which they operate.

Methods of Implementation of Evidence-Based Stroke Care in Europe: European Implementation Score Collaboration

BACKGROUND AND PURPOSE

Differences in stroke care and outcomes reported in Europe may reflect different degrees of implementation of evidence-based interventions. We evaluated strategies for implementing research evidence into stroke care in 10 European countries.

METHODS

A questionnaire was developed and administered through face-to-face interviews with key informants. Implementation strategies were investigated considering 3 levels (macro, meso, and micro, eg, policy, organization, patients/professionals) identified by the framing analysis, and different settings (primary, hospital, and specialist) of stroke care. Similarities and differences among countries were evaluated using the categorical principal components analysis.

RESULTS

Implementation methods reported by ≥7 countries included nonmandatory policies, public financial incentives, continuing professional education, distribution of educational material, educational meetings and campaigns, guidelines, opinion leaders', and stroke patients associations' activities. Audits were present in 6 countries at national level; national and regional regulations in 4 countries. Private financial incentives, reminders, and educational outreach visits were reported only in 2 countries. At national level, the first principal component of categorical principal components analysis separated England, France, Scotland, and Sweden, all with positive object scores, from the other countries. Belgium and Lithuania obtained the lowest scores. At regional level, England, France, Germany, Italy, and Sweden had positive scores in the first principal component, whereas Belgium, Lithuania, Poland, and Scotland showed negative scores. Spain was in an intermediate position.

CONCLUSIONS

We developed a novel method to assess different domains of implementation in stroke care. Clear variations were observed among European countries. The new tool may be used elsewhere for future contributions.

Research activity and the association with mortality

Introduction

The aims of this study were to describe the key features of acute NHS Trusts with different levels of research activity and to investigate associations between research activity and clinical outcomes.

Methods

National Institute for Health Research (NIHR) Comprehensive Clinical Research Network (CCRN) funding and number of patients recruited to NIHR Clinical Research Network (CRN) portfolio studies for each NHS Trusts were used as markers of research activity. Patient-level data for adult non-elective admissions were extracted from the English Hospital Episode Statistics (2005-10). Risk-adjusted mortality associations between Trust structures, research activity and, clinical outcomes were investigated.

Results

Low mortality Trusts received greater levels of funding and recruited more patients adjusted for size of Trust (n = 35, 2,349 £/bed [95% CI 1,855–2,843], 5.9 patients/bed [2.7–9.0]) than Trusts with expected (n = 63, 1,110 £/bed, [864–1,357] p<0.0001, 2.6 patients/bed [1.7–3.5] p<0.0169) or, high (n = 42, 930 £/bed [683–1,177] p = 0.0001, 1.8 patients/bed [1.4–2.1] p<0.0005) mortality rates. The most research active Trusts were those with more doctors, nurses, critical care beds, operating theatres and, made greater use of radiology. Multifactorial analysis demonstrated better survival in the top funding and patient recruitment tertiles (lowest vs. highest (odds ratio & 95% CI: funding 1.050 [1.033–1.068] p<0.0001, recruitment 1.069 [1.052–1.086] p<0.0001), middle vs. highest (funding 1.040 [1.024–1.055] p<0.0001, recruitment 1.085 [1.070–1.100] p<0.0001).

Conclusions

Research active Trusts appear to have key differences in composition than less research active Trusts. Research active Trusts had lower risk-adjusted mortality for acute admissions, which persisted after adjustment for staffing and other structural factors.

Working to establish 'normality' post-transplant: a qualitative study of kidney transplant patients

OBJECTIVES

To explore patients' perceptions and experiences of 'normality' and the influences on this at three time points post-transplant.

METHODS

In-depth interviews with 25 patients at three months, one year and more than three years following kidney transplant. Patients' accounts were compared with Sanderson et al.'s typology of types of normality.

FINDINGS

Post-transplant, patients worked hard to re-establish normality, albeit in a 'reset' form. This normality was a very personal construct, shaped by a wide range of factors including age, gender and personal circumstances. Some patients encountered significant challenges in regaining normality, both at three months for those experiencing acute and distressing side effects, and later relating to the long-term side effects of transplant medication and co-morbidities. However, the most dramatic threat to normality (disrupted normality) came from episodes of rejection and transplant failure.

CONCLUSIONS

The main types of normality achieved vary for different conditions. Moreover, despite improvements in health post-transplant and opportunities to build a new, reset normality, the participants recognised the need to pay careful attention to the spectre of future ill health and transplant failure. Transplant failure was therefore a source of disruption that was central to their illness narratives and perceived as an ever present risk.

Rethinking the relationship between science and society: Has there been a shift in attitudes to Patient and Public Involvement and Public Engagement in Science in the United Kingdom?

Background

The policy imperative to engage the public and patients in research can be seen as part of a wider shift in the research environment. This study addresses the question: Has there been a shift in attitudes to Patient and Public Involvement (PPI) and Public Engagement in Science (PES) amongst researchers?

Methods

Attitudes to PPI and PES within a cluster of three NIHR supported Biomedical Research Centres were explored through in‐depth interviews with 19 researchers.

Results

Participants distinguished PPI (as an activity involving patients and carers in research projects and programmes) from PES (as an activity that aims to communicate research findings to the public, engage the public with broader issues of science policy or promote a greater understanding of the role of science in society). While participants demonstrated a range of attitudes to these practices, they shared a resistance to sharing power and control of the research process with the public and patients.

Conclusion

While researchers were prepared to engage with the public and patients and listed the advantages of engagement, the study revealed few differences in their underlying attitudes towards the role of society in science (and science in society) to those reported in previous studies. To the participants science remains the preserve of scientists, with patients and the public invited to ‘tinker at the edges’.

Public participation: more than a method?: Comment on "Harnessing the potential to quantify public preferences for healthcare priorities through citizens' juries"

While it is important to support the development of methods for public participation, we argue that this should not be at the expense of a broader consideration of the role of public participation. We suggest that a rights based approach provides a framework for developing more meaningful approaches that move beyond public participation as synonymous with consultation to value the contribution of lay knowledge to the governance of health systems and health research.

Using a national archive of patient experience narratives to promote local patient-centered quality improvement: an ethnographic process evaluation of 'accelerated' experience-based co-design

OBJECTIVES

To evaluate an accelerated form of experience-based co-design (EBCD), a type of participatory action research in which patients and staff work together to improve quality; to observe how acceleration affected the process and outcomes of the intervention.

METHODS

An ethnographic process evaluation of an adapted form of EBCD was conducted, including observations, interviews, questionnaires and documentary analysis. Whilst retaining all components of EBCD, the adapted approach replaced local patient interviews with secondary analysis of a national archive of patient experience narratives to create national trigger films; shortened the timeframe; and employed local improvement facilitators. It was tested in intensive care and lung cancer in two English National Health Service (NHS) hospitals. A total of 96 clinical staff (primarily nursing and medical), and 63 patients and family members participated in co-design activities.

RESULTS

The accelerated approach proved acceptable to staff and patients; using films of national rather than local narratives did not adversely affect local NHS staff engagement, and may have made the process less threatening or challenging. Local patients felt the national films generally reflected important themes although a minority felt they were more negative than their own experience. However, they served their purpose of 'triggering' discussion between patients and staff, and the resulting 48 co-design (improvement) activities across the four pathways were similar to those in EBCD, but achieved more quickly and at lower cost.

CONCLUSIONS

Accelerated EBCD offers a rigorous and relatively cost-effective patient-centered quality improvement approach.

Testing accelerated experience-based co-design: a qualitative study of using a national archive of patient experience narrative interviews to promote rapid patient-centred service improvement

Background

Measuring, understanding and improving patients’ experiences is of central importance to health care systems, but there is debate about the best methods for gathering and understanding patient experiences and how to then use them to improve care. Experience-based co-design (EBCD) has been evaluated as a successful approach to quality improvement in health care, drawing on video narrative interviews with local patients and involving them as equal partners in co-designing quality improvements. However, the time and cost involved have been reported as a barrier to adoption. The Health Experiences Research Group at the University of Oxford collects and analyses video and audio-recorded interviews with people about their experiences of illness. It now has a national archive of around 3000 interviews, covering around 75 different conditions or topics. Selected extracts from these interviews are disseminated for a lay audience onwww.healthtalkonline.org. In this study, we set out to investigate whether or not this archive of interviews could replace the need for discovery interviews with local patients.

Objectives

To use a national video and audio archive of patient experience narratives to develop, test and evaluate a rapid patient-centred service improvement approach (‘accelerated experience-based co-design’ or AEBCD). By using national rather than local patient interviews, we aimed to halve the overall cycle from 12 to 6 months, allowing for EBCD to be conducted in two clinical pathways rather than one. We observed how this affected the process and outcomes of the intervention.

Design

The intervention was an adapted form of EBCD, a participatory action research approach in which patients and staff work together to identify and implement quality improvements. The intervention retained all six components of EBCD, but used national trigger films, shortened the time frame and employed local service improvement facilitators. An ethnographic process evaluation was conducted, including observations, interviews, questionnaires, cost and documentary analysis including previous EBCD evaluation reports.

Setting

Intensive care and lung cancer services in two English NHS hospital trusts (Royal Berkshire and Royal Brompton and Harefield).

Participants

Ninety-six clinical staff (primarily nursing and medical) and 63 patients and family members.

Intervention

For this accelerated intervention, the trigger film was derived from pre-existing national patient experience interviews. Local facilitators conducted staff discovery interviews. Thereafter, the process followed the usual EBCD pattern: the film was shown to local patients in a workshop meeting, and staff had a separate meeting to discuss the results of their feedback. Staff and patients then came together in a further workshop to view the film, agree priorities for improvement and set up co-design working groups to take these priorities forward.

Results

The accelerated approach proved readily acceptable to staff and patients; using films of national rather than local narratives did not adversely affect local NHS staff engagement, and may in some cases have made the process less threatening or challenging. Local patients felt that the national films generally reflected important themes, although a minority felt that they were more negative than their own personal experience. However, they served their purpose as a ‘trigger’ to discussion, and the resulting 48 co-design activities across the four pathways were similar in nature to those in EBCD but achieved at reduced cost. AEBCD was nearly half the cost of EBCD. However, where a trigger film already exists, pathways can be implemented for as little as 40% of the cost of traditional EBCD. It was not necessary to do additional work locally to supplement the national interviews. The intervention carried a ‘cost’ in terms of heavy workload and intensive activity for the local facilitators, but also brought benefits in terms of staff development/capacity-building. Furthermore, as in previous EBCDs, the approach was subsequently adopted in other clinical pathways in the trusts.

Conclusions

Accelerated experience-based co-design delivered an accelerated version of EBCD, generating a comparable set of improvement activities. The national film acted as an effective trigger to the co-design process. Based on the results of the evaluation, AEBCD offers a rigorous and effective patient-centred quality improvement approach. We aim to develop further trigger films from the archived material as resources permit, and to investigate different ways of conducting the analysis (e.g. involving patients in doing the analysis).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Evidence-based practice: reflections from five European case studies

Background Evidence-based practice (EBP) is now the accepted orthodoxy in clinical practice and developed from evidence-based medicine. EBP is based on a specific type of evidence that is derived from studies based on randomised controlled trials (RCT). This type of evidence is suited to acute medical care and is more problematic for other clinicians such as nurses and therapists, particularly when they are situated within community or primary care settings. Setting Five stroke care services in England (2), Sweden (2) and Poland (1). Aims To reflect on the evidence gained from these case studies to shed light on various aspects of EBP. This paper focuses on three key issues: (1) the importance of context for evidence, (2) the nature of knowledge, and (3) professional hierarchies. Methods Five qualitative case studies into stroke care were carried out in England, Sweden and Poland. One hundred and twenty semi-structured interviews were carried out with a range of healthcare staff who provided specialised and non-specialised stroke care in acute, community and primary care between October 2010 and September 2011. Medical doctors, nurses and different therapists were included in the samples in all five case studies. For this paper, we reflect on some aspects of this work to illuminate the different interprofessional perspectives relating to EBP in stroke care. Results The lack of RCT-based evidence in the community and primary care sectors can lead to the clinicians working in these sectors being perceived as having a lower status. Clinicians use both tacit and encoded knowledge to guide their practice and there existed both intraand interprofessional tensions in these two types of knowledge. The professional hierarchy of stroke teams varies with national context and the role of the non-specialists is less valued in stroke care.

Engagement in research: an innovative three-stage review of the benefits for health-care performance

Background

There is a widely held assumption that research engagement improves health-care performance at various levels, but little direct empirical evidence.

Objectives

To conduct a theoretically and empirically grounded synthesis to map and explore plausible mechanisms through which research engagement might improve health services performance. A review of the effects on patients of their health-care practitioner's or institution's participation in clinical trials was published after submission of the proposal for this review. It identified only 13 relevant papers and, overall, suggested that the evidence that research engagement improves health-care performance was less strong than some thought. We aimed to meet the need for a wider review.

Methods

An hourglass review was developed, consisting of three stages: (1) a planning and mapping stage; (2) a focused review concentrating on the core question of whether or not research engagement improves health care; and (3) a wider (but less systematic) review of papers identified during the two earlier stages. Studies were included inthe focused review if the concept of ‘engagementinresearch’ was an input and some measure of ‘performance’ an output. The search strategy covered the period 1990 to March 2012. MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and other relevant databases were searched. A total of 10,239 papers were identified through the database searches, and 159 from other sources. A further relevance and quality check on 473 papers was undertaken, and identified 33 papers for inclusion in the review. A standard meta-analysis was not possible on the heterogeneous mix of papers in the focused review. Therefore an explanatory matrix was developed to help characterise the circumstances in which research engagement might improve health-care performance and the mechanisms that might be at work, identifying two main dimensions along which to categorise the studies:the degree of intentionalityandthe scope of the impact.

Results

Of the 33 papers in the focused review, 28 were positive (of which six were positive/mixed) in relation to the question of whether or not research engagement improves health-care performance. Five papers were negative (of which two were negative/mixed). Seven out of 28 positive papers reported some improvement in health outcomes. For the rest, the improved care took the form of improved processes of care. Nine positive papers were at a clinician level and 19 at an institutional level. The wider review demonstrated, for example, how collaborative and action research can encourage some progress along the pathway from research engagement towards improved health-care performance. There is also evidence that organisations in which the research function is fully integrated into the organisational structure out-perform other organisations that pay less formal heed to research and its outputs. The focused and wider reviews identified the diversity in the mechanisms through which research engagement might improve health care: there are many circumstances and mechanisms at work, more than one mechanism is often operative, and the evidence available for each one is limited.

Limitations

To address the complexities of this evidence synthesis of research we needed to spend significant time mapping the literature, and narrowed the research question to make it feasible. We excluded many potentially relevant papers (though we partially addressed this by conducting a wider additional synthesis). Studies assessing the impact made on clinician behaviour by small, locally conducted pieces of research could be difficult to interpret without full knowledge of the context.

Conclusions

Drawing on the focused and wider reviews, it is suggested that when clinicians and health-care organisations engage in research there is the likelihood of a positive impact on health-care performance. Organisations that have deliberately integrated the research function into organisational structures demonstrate how research engagement can, among other factors, contribute to improved health-care performance. Further explorations are required of research networks and schemes to promote the engagement of clinicians and managers in research. Detailed observational research focusing on research engagement within organisations would build up an understanding of mechanisms.

Study registration

PROSPERO: CRD42012001990.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The importance of normative integration in stroke services: Case study evidence from Sweden and England

Summary

Objectives:

A number of evidence-based interventions are now available for stroke patients. Good-quality stroke care involves a range of health professionals located across ambulance, hospital, community and primary care services. This study examined the perspectives of health-care workers involved in stroke care in Sweden and England on the integration challenges stroke care presents.

Methods:

Four qualitative case studies were carried out in Sweden and England, including 95 semistructured interviews with clinicians and managers associated with four different hospitals providing specialized stroke services.

Findings:

High levels of organizational, functional, service and clinical integration among clinicians that deliver emergency and acute stroke care were identified. This is frequently lacking among professionals delivering postacute care. These findings are linked to the prevalence or lack of normative and systemic integration in each respective stage of care.

Conclusions:

Emphasis on the need to treat stroke as an emergency condition in both countries has created a context in which normative and systemic integration often occurs among clinicians that deliver emergency and acute stroke care, aiding the development of organizational, functional, service and clinical integration across the case study sites. In contrast, integration between hospital and community (rehabilitation and general practice) care is frequently less successful.

Why do parents enroll their children in research: a narrative synthesis

OBJECTIVE

Recent legislation mandating the inclusion of children in clinical trials has resulted in an increase in the number of children participating in research. We reviewed the literature regarding the reasons parents chose to accept or decline an invitation to enroll their children in clinical research.

METHODS

We searched for qualitative studies, written in the English language that considered the experiences of parents who had been invited to enrol their children in research. SCOPUS and Web of Knowledge electronic databases and reference lists of retrieved articles and review papers were searched. Retrieved articles were synthesised using the narrative synthesis method.

RESULTS

16 qualitative studies exploring the experiences of parents living in five countries whose children had a range of health conditions of varying severity were included. The health status of the child appeared to influence parents' reasons for participation. Parents whose children had life threatening conditions often considered they had no choice but to participate and many welcomed the innovation offered through research participation. Such parents also viewed the risks of research less negatively than those whose children were healthy or in the stable stage of a chronic condition. This raises questions regarding the voluntariness of informed consent by such parents.

CONCLUSIONS

A tailored approach is needed when discussing research participation with parents of eligible children. While parents of healthy children may be more open to discussions of altruism, those whose children have life threatening illnesses should be given adequate information about the alternatives to, and risks of, research participation.