Background: There is growing interest in realist synthesis as an alternative systematic review me... more Background: There is growing interest in realist synthesis as an alternative systematic review method. This approach offers the potential to expand the knowledge base in policy-relevant areas-for example, by explaining the success, failure or mixed fortunes of complex interventions. No previous publication standards exist for reporting realist syntheses. This standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The project's aim is to produce preliminary publication standards for realist systematic reviews. Methods: We (a) collated and summarized existing literature on the principles of good practice in realist syntheses; (b) considered the extent to which these principles had been followed by published syntheses, thereby identifying how rigor may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, realist research, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing realist syntheses and the open-access RAMESES online discussion list so as to capture problems and questions as they arose; and (e) synthesized expert input, evidence syntheses and real-time problem analysis into a definitive set of standards. Results: We identified 35 published realist syntheses, provided real-time support to 9 ongoing syntheses and captured questions raised in the RAMESES discussion list. Through analysis and discussion within the project team, we summarized the published literature and common questions and challenges into briefing materials for the Delphi panel, comprising 37 members. Within three rounds this panel had reached consensus on 19 key publication standards, with an overall response rate of 91%. Conclusion: This project used multiple sources to develop and draw together evidence and expertise in realist synthesis. For each item we have included an explanation for why it is important and guidance on how it might be reported. Realist synthesis is a relatively new method for evidence synthesis and as experience and methodological developments occur, we anticipate that these standards will evolve to reflect further methodological developments. We hope that these standards will act as a resource that will contribute to improving the reporting of realist syntheses. To encourage dissemination of the RAMESES publication standards, this article is co-published in the Journal of Advanced Nursing and is freely accessible on Wiley Online Library (http://www.wileyonlinelibrary.com/journal/jan). Please see related article
Background: Meta-narrative review is one of an emerging menu of new approaches to qualitative and... more Background: Meta-narrative review is one of an emerging menu of new approaches to qualitative and mixed-method systematic review. A meta-narrative review seeks to illuminate a heterogeneous topic area by highlighting the contrasting and complementary ways in which researchers have studied the same or a similar topic. No previous publication standards exist for the reporting of meta-narrative reviews. This publication standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The project's aim is to produce preliminary publication standards for meta-narrative reviews. Methods: We (a) collated and summarized existing literature on the principles of good practice in meta-narrative reviews; (b) considered the extent to which these principles had been followed by published reviews, thereby identifying how rigor may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, meta-narrative reviews, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing meta-narrative reviews and the open-access RAMESES online discussion list so as to capture problems and questions as they arose; and (e) synthesized expert input, evidence review and real-time problem analysis into a definitive set of standards.
Purpose – The questions addressed by this review are: first, what are the guiding principles unde... more Purpose – The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues. Design/methodology/approach – The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts. Findings – Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. Practical implications – The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application. Originality/value – This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.
Background: In 2004, Gabbay and le May showed that clinicians generally base their decisions on m... more Background: In 2004, Gabbay and le May showed that clinicians generally base their decisions on mindlines— internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines. We considered how the concept of mindlines has been taken forward since.
social participation and integration is important for mental and physical wellbeing. However, for... more social participation and integration is important for mental and physical wellbeing. However, for many older people, declining health, reduced mobility, and separation from family members and friends can make it difficult to maintain an active social life. A large number of technological interventions have been developed to prevent social isolation and alleviate loneliness. Information and communication technologies (ICTs) have the potential to maintain social inclusion by supporting social interaction. However, these are generally designed for younger users, and may not always meet the needs and wishes of older people with regard to social connection. This chapter focuses on the development of ICTs to help older people remain socially connected. Our starting point is that the design of such interventions must be grounded in an understanding of how older people manage their social relationships and deal with loneliness to ensure that any technologies developed are easy to use and fit for purpose. In turn, this can only be achieved if older people are involved in the design process. 'Co-design' refers to a range of methods and tools to enable users to engage fully in the design process and so assist IT professionals and other stake-holders to understand users' everyday practices, needs and experiences (Hartswood et al. 2008). The first section looks at the range of interventions to prevent and alleviate loneliness in older adults. The second section focuses on the involvement of older people in the design of ICTs to support social connection. The final section explores the deployment of technology prototypes in real social contexts and calls for providers of technologies and services for older people to pay more attention to 'co-deployment', supporting users in exploring, learning and adapting technologies and services 'in-use'.
social participation and integration is important for mental and physical wellbeing. However, for... more social participation and integration is important for mental and physical wellbeing. However, for many older people, declining health, reduced mobility, and separation from family members and friends can make it difficult to maintain an active social life. A large number of technological interventions have been developed to prevent social isolation and alleviate loneliness. Information and communication technologies (ICTs) have the potential to maintain social inclusion by supporting social interaction. However, these are generally designed for younger users, and may not always meet the needs and wishes of older people with regard to social connection. This chapter focuses on the development of ICTs to help older people remain socially connected. Our starting point is that the design of such interventions must be grounded in an understanding of how older people manage their social relationships and deal with loneliness to ensure that any technologies developed are easy to use and fit for purpose. In turn, this can only be achieved if older people are involved in the design process. 'Co-design' refers to a range of methods and tools to enable users to engage fully in the design process and so assist IT professionals and other stake-holders to understand users' everyday practices, needs and experiences (Hartswood et al. 2008). The first section looks at the range of interventions to prevent and alleviate loneliness in older adults. The second section focuses on the involvement of older people in the design of ICTs to support social connection. The final section explores the deployment of technology prototypes in real social contexts and calls for providers of technologies and services for older people to pay more attention to 'co-deployment', supporting users in exploring, learning and adapting technologies and services 'in-use'.
Background: The low uptake of telecare and telehealth services by older people may be explained b... more Background: The low uptake of telecare and telehealth services by older people may be explained by the limited involvement of users in the design. If the ambition of 'care closer to home' is to be realised, then industry, health and social care providers must evolve ways to work with older people to co-produce useful and useable solutions. Method: We conducted 10 co-design workshops with users of telehealth and telecare, their carers, service providers and technology suppliers. Using vignettes developed from in-depth ethnographic case studies, we explored participants' perspectives on the design features of technologies and services to enable and facilitate the co-production of new care solutions. Workshop discussions were audio recorded, transcribed and analysed thematically.
Background: The low uptake of telecare and telehealth services by older people may be explained b... more Background: The low uptake of telecare and telehealth services by older people may be explained by the limited involvement of users in the design. If the ambition of 'care closer to home' is to be realised, then industry, health and social care providers must evolve ways to work with older people to co-produce useful and useable solutions. Method: We conducted 10 co-design workshops with users of telehealth and telecare, their carers, service providers and technology suppliers. Using vignettes developed from in-depth ethnographic case studies, we explored participants' perspectives on the design features of technologies and services to enable and facilitate the co-production of new care solutions. Workshop discussions were audio recorded, transcribed and analysed thematically.
Background: There is growing interest in assisted living technologies to support independence at ... more Background: There is growing interest in assisted living technologies to support independence at home. Such technologies should ideally be designed ‘in the wild’ i.e. taking account of how real people live in real homes and communities. The ATHENE (Assistive Technologies for Healthy Living in Elders: Needs Assessment by Ethnography) project seeks to illuminate the living needs of older people and facilitate the co-production with older people of technologies and services. This paper describes the development of a cultural probe tool produced as part of the ATHENE project and how it was used to support home visit interviews with elders with a range of ethnic and social backgrounds, family circumstances, health conditions and assisted living needs. Method: Thirty one people aged 60 to 98 were visited in their homes on three occasions. Following an initial interview, participants were given a set of cultural probe materials, including a digital camera and the ‘Home and Life Scrapbook’ to complete in their own time for one week. Activities within the Home and Life Scrapbook included maps (indicating their relationships to people, places and objects), lists (e.g. likes, dislikes, things they were concerned about, things they were comfortable with), wishes (things they wanted to change or improve), body outline (indicating symptoms or impairments), home plan (room layouts of their homes to indicate spaces and objects used) and a diary. After one week, the researcher and participant reviewed any digital photos taken and the content of the Home and Life Scrapbook as part of the home visit interview. Findings: The cultural probe facilitated collection of visual, narrative and material data by older people, and appeared to generate high levels of engagement from some participants. However, others used the probe minimally or not at all for various reasons including limited literacy, physical problems (e.g. holding a pen), lack of time or energy, limited emotional or psychological resources, life events, and acute illness. Discussions between researchers and participants about the materials collected (and sometimes about what had prevented them completing the tasks) helped elicit further information relevant to assisted living technology design. The probe materials were particularly helpful when having conversations with non-English speaking participants through an interpreter. Conclusions: Cultural probe methods can help build a rich picture of the lives and experiences of older people to facilitate the co-production of assisted living technologies. But their application may be constrained by the participant’s physical, mental and emotional capacity. They are most effective when used as a tool to facilitate communication and development of a deeper understanding of older people’s needs.
Mega-sporting event regeneration, as a specific approach to urban renewal, uses impending host-ci... more Mega-sporting event regeneration, as a specific approach to urban renewal, uses impending host-city status as a catalyst for revitalisation and has the potential to improve health both through addressing deprivation and by promoting increased sport and physical activity among the host-city's population. This qualitative study explored how hosting of the London 2012 Games impacted upon the way East London residents perceived and experienced the social determinants of health in their local neigh- bourhood. We conducted narrative family interviews, go-along interviews and video focus group workshops with 66 Newham residents, aged 12–55 years, immediately after the Games. A narrative analytic approach examined accounts of health and wellbeing experiences in terms of neighbourhood change and the spectacle of the Games. Participants of this qualitative study generally welcomed the respite and the unexpected chance to live in a cleaner, safer and more unified environment. However, this positivity was underscored by an acute awareness that this was a very temporary situation and one that was intended to support the event rather than residents.
Background: The quality of information recorded about patient care is considered key to improving... more Background: The quality of information recorded about patient care is considered key to improving the overall quality, safety and efficiency of patient care. Assigning codes to patients' records is an important aspect of this documentation. Current interest in large datasets in which individual patient data are collated (e.g. proposed NHS care.data project) pays little attention to the details of how 'data' get onto the record. This paper explores the work of summarising and coding records, focusing on 'back office' practices, identifying contributors and barriers to quality of care. Methods: Ethnographic observation (187 hours) of clinical, management and administrative staff in two UK general practices with contrasting organisational characteristics. This involved observation of working practices, including shadowing, recording detailed field notes, naturalistic interviews and analysis of key documents relating to summarising and coding. Ethnographic analysis drew on key sensitizing concepts to build a 'thick description' of coding practices, drawing these together in a narrative synthesis. Results: Coding and summarising electronic patient records is complex work. It depends crucially on nuanced judgements made by administrators who combine their understanding of: clinical diagnostics; classification systems; how healthcare is organised; particular working practices of individual colleagues; current health policy. Working with imperfect classification systems, diagnostic uncertainty and a range of local practical constraints, they manage a moral tension between their idealised aspiration of a 'gold standard' record and a pragmatic recognition that this is rarely achievable in practice. Adopting a range of practical workarounds, administrators position themselves as both formally accountable to their employers (general practitioners), and informally accountability to individual patients, in a coding process which is shaped not only by the 'facts' of the case, but by ongoing working relationships which are co-constructed alongside the patient's summary. Conclusion: Data coding is usually conceptualised as either a technical task, or as mundane, routine work, and usually remains invisible. This study offers a characterisation of coding as a socially complex site of moral work through which new lines of accountability are enacted in the workplace, and casts new light on the meaning of coded data as conceptualised in the 'quality of care' discourse.
Objective: To investigate how electronic templates shape, enable and constrain consultations abou... more Objective: To investigate how electronic templates shape, enable and constrain consultations about chronic diseases. Design: Ethnographic case study, combining field notes, video-recording, screen capture with a microanalysis of talk, body language and data entry— an approach called linguistic ethnography. Setting: Two general practices in England. Participants and methods: Ethnographic observation of administrative areas and 36 nurse-led consultations was done. Twenty-four consultations were directly observed and 12 consultations were video-recorded alongside computer screen capture. Consultations were transcribed using conversation analysis conventions, with notes on body language and the electronic record. The analysis involved repeated rounds of viewing video, annotating field notes, transcription and microanalysis to identify themes. The data was interpreted using discourse analysis, with attention to the sociotechnical theory. Results: Consultations centred explicitly or implicitly on evidence-based protocols inscribed in templates. Templates did not simply identify tasks for completion, but contributed to defining what chronic diseases were, how care was being delivered and what it meant to be a patient or professional in this context. Patients’ stories morphed into data bytes; the particular became generalised; the complex was made discrete, simple and manageable; and uncertainty became categorised and contained. Many consultations resembled bureaucratic encounters, primarily oriented to completing data fields. We identified a tension, sharpened by the template, between different framings of the patient—as ‘individual’ or as ‘one of a population’. Some clinicians overcame this tension, responding creatively to prompts within a dialogue constructed around the patient’s narrative. Conclusions: Despite their widespread implementation, little previous research has examined how templates are actually used in practice. Templates do not simply document the tasks of chronic disease management but profoundly change the nature of this work. Designed to assure standards of ‘quality’ care they contribute to bureaucratisation of care and may marginalise aspects of quality care which lie beyond their focus. Creative work is required to avoid privileging ‘institution-centred’ care over patient-centred care.
Objective To describe, explore, and compare organisational routines for repeat prescribing in gen... more Objective To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality. Design Ethnographic case study. Setting Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing. Participants 395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally. Main outcome measures Potential threats to patient safety and characteristics of good practice. Methods Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies. Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as " exceptions " by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. Conclusion Receptionists and administrative staff make important " hidden " contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety.
Abstract
One of the most pervasive changes in general practice is the introduction of the electro... more Abstract One of the most pervasive changes in general practice is the introduction of the electronic patient record (EPR). The EPR supports both immediate clinical and anticipatory care (e.g. management of risk factors). Incorporating the EPR into social interaction is a complex task which is achieved discursively, clinician and patient responding to interactional contingencies as the consultation unfolds. Clinicians are presented with a ‘dilemma of attention’ as they seek to deal with the immediacy (‘here and now’) of the interpersonal interaction and the institutional demands (‘there and then’) of the EPR. We present data analysis which illuminates the EPR as an important presence in the clinic consul- tation context, one which places material and textual demands. Developing previous work on the triadic (three party) consultation, our novel multi-modal analysis of the EPR-in-use suggests there is value in considering the EPR as a collection of silent but conse- quential voices. Micro-analytic attention to the way in which these different voices are managed, combined with understandings drawn from ethnographic observation of the primary care context, reveals the EPR as exhibiting a previously under-explored kind of ‘agency’ within the consultation.
Abstract
Background: Effective strategies are needed to provide screening and treatment for hepa... more Abstract Background: Effective strategies are needed to provide screening and treatment for hepatitis B and C to immigrant groups in the UK at high risk of chronic infection. This study aimed to build an understanding of the knowledge, beliefs and attitudes towards these conditions and their management in a range of high-risk minority ethnic communities and health professionals, in order to inform the design of a screening and treatment programme in primary care. Methods: Qualitative data collection consisted of three sequential phases- (i) semi-structured interviews with key informants (n = 17), (ii) focus groups with people from Chinese, Pakistani, Roma, Somali, and French- and English- speaking African communities (n = 95), and (iii) semi-structured interviews with general practitioners (n = 6). Datasets from each phase were analysed using the Framework method. Results: Key informants and general practitioners perceived that there was limited knowledge and understanding about hepatitis B and C within high-risk immigrant communities, and that chronic viral hepatitis did not typically feature in community discourses about serious illness. Many focus group participants were confused about the differences between types of viral hepatitis, held misconceptions regarding transmission, and were unaware of the asymptomatic nature of chronic infection. Most welcomed the idea of a screening programme, but key informants and focus group participants also identified numerous practical barriers to engagement with primary care-based screening and treatment; including language and communication difficulties, limited time (due to long working hours), and (for some) low levels of trust and confidence in general practice-based care. General practitioners expressed concerns about the workload implications and sustainability of screening and treating immigrant patients for chronic viral hepatitis in primary care. Conclusions: Strategies to reduce the burden of chronic viral hepatitis in immigrant communities will need to consider how levels of understanding about hepatitis B and C within these communities, and barriers to accessing healthcare, may affect capacity to engage with screening and treatment. Services may need to work with community groups and language support services to provide information and wider encouragement for screening. Primary care services will need ongoing consultation regarding their support needs to deliver hepatitis screening and treatment programmes.
Purpose: To identify and explore factors that influence adoption, implementation and continued us... more Purpose: To identify and explore factors that influence adoption, implementation and continued use of telecare technologies. Method: As part of the Assistive Technologies for Healthy Living in Elders: Needs Assessment by Ethnography (ATHENE) project, 16 semi-structured interviews were conducted with key participants from organisations involved in developing and providing telecare technologies and services. Data were analysed thematically, using a conceptual model of diffusion of innovations. Results: Participants identified numerous interacting factors that facilitated or hindered adoption and use. As predicted by the model, these related variously to the technology, individual adopters, the process of social influence, the innovativeness and readiness of organisations, implementation and routinisation processes following initial adoption, and the nature and strength of linkages between these elements. Key issues included (i) the complexity and uniqueness of the ''user system'', (ii) the ongoing work needed to support telecare use beyond initial adoption, and (iii) the relatively weak links that typically exist between users of telecare technologies and the organisations who design and distribute them. Conclusions: Telecare is not merely a technology but a complex innovation requiring input from, and coordination between, people and organisations. To promote adoption and use, these contextual factors must be specified, understood and addressed. ä Implications for Rehabilitation Telecare should not be thought of as a ''plug and play'' technology but as a complex innovation requiring input from, and coordination between, people and organisations. To promote adoption and use of telecare, a number of contextual factors must be specified, understood and addressed. End users and other stakeholders should be linked at the earliest stages of design and development. Such co-production should aim to identify how technologies might better fit with users' material surroundings, social networks and desired lifestyles, rather than being technology-driven and focused on proof of concept or usability.
Background: There is growing interest in realist synthesis as an alternative systematic review me... more Background: There is growing interest in realist synthesis as an alternative systematic review method. This approach offers the potential to expand the knowledge base in policy-relevant areas-for example, by explaining the success, failure or mixed fortunes of complex interventions. No previous publication standards exist for reporting realist syntheses. This standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The project's aim is to produce preliminary publication standards for realist systematic reviews. Methods: We (a) collated and summarized existing literature on the principles of good practice in realist syntheses; (b) considered the extent to which these principles had been followed by published syntheses, thereby identifying how rigor may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, realist research, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing realist syntheses and the open-access RAMESES online discussion list so as to capture problems and questions as they arose; and (e) synthesized expert input, evidence syntheses and real-time problem analysis into a definitive set of standards. Results: We identified 35 published realist syntheses, provided real-time support to 9 ongoing syntheses and captured questions raised in the RAMESES discussion list. Through analysis and discussion within the project team, we summarized the published literature and common questions and challenges into briefing materials for the Delphi panel, comprising 37 members. Within three rounds this panel had reached consensus on 19 key publication standards, with an overall response rate of 91%. Conclusion: This project used multiple sources to develop and draw together evidence and expertise in realist synthesis. For each item we have included an explanation for why it is important and guidance on how it might be reported. Realist synthesis is a relatively new method for evidence synthesis and as experience and methodological developments occur, we anticipate that these standards will evolve to reflect further methodological developments. We hope that these standards will act as a resource that will contribute to improving the reporting of realist syntheses. To encourage dissemination of the RAMESES publication standards, this article is co-published in the Journal of Advanced Nursing and is freely accessible on Wiley Online Library (http://www.wileyonlinelibrary.com/journal/jan). Please see related article
Background: Meta-narrative review is one of an emerging menu of new approaches to qualitative and... more Background: Meta-narrative review is one of an emerging menu of new approaches to qualitative and mixed-method systematic review. A meta-narrative review seeks to illuminate a heterogeneous topic area by highlighting the contrasting and complementary ways in which researchers have studied the same or a similar topic. No previous publication standards exist for the reporting of meta-narrative reviews. This publication standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The project's aim is to produce preliminary publication standards for meta-narrative reviews. Methods: We (a) collated and summarized existing literature on the principles of good practice in meta-narrative reviews; (b) considered the extent to which these principles had been followed by published reviews, thereby identifying how rigor may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, meta-narrative reviews, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing meta-narrative reviews and the open-access RAMESES online discussion list so as to capture problems and questions as they arose; and (e) synthesized expert input, evidence review and real-time problem analysis into a definitive set of standards.
Purpose – The questions addressed by this review are: first, what are the guiding principles unde... more Purpose – The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues. Design/methodology/approach – The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts. Findings – Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. Practical implications – The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application. Originality/value – This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.
Background: In 2004, Gabbay and le May showed that clinicians generally base their decisions on m... more Background: In 2004, Gabbay and le May showed that clinicians generally base their decisions on mindlines— internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines. We considered how the concept of mindlines has been taken forward since.
social participation and integration is important for mental and physical wellbeing. However, for... more social participation and integration is important for mental and physical wellbeing. However, for many older people, declining health, reduced mobility, and separation from family members and friends can make it difficult to maintain an active social life. A large number of technological interventions have been developed to prevent social isolation and alleviate loneliness. Information and communication technologies (ICTs) have the potential to maintain social inclusion by supporting social interaction. However, these are generally designed for younger users, and may not always meet the needs and wishes of older people with regard to social connection. This chapter focuses on the development of ICTs to help older people remain socially connected. Our starting point is that the design of such interventions must be grounded in an understanding of how older people manage their social relationships and deal with loneliness to ensure that any technologies developed are easy to use and fit for purpose. In turn, this can only be achieved if older people are involved in the design process. 'Co-design' refers to a range of methods and tools to enable users to engage fully in the design process and so assist IT professionals and other stake-holders to understand users' everyday practices, needs and experiences (Hartswood et al. 2008). The first section looks at the range of interventions to prevent and alleviate loneliness in older adults. The second section focuses on the involvement of older people in the design of ICTs to support social connection. The final section explores the deployment of technology prototypes in real social contexts and calls for providers of technologies and services for older people to pay more attention to 'co-deployment', supporting users in exploring, learning and adapting technologies and services 'in-use'.
social participation and integration is important for mental and physical wellbeing. However, for... more social participation and integration is important for mental and physical wellbeing. However, for many older people, declining health, reduced mobility, and separation from family members and friends can make it difficult to maintain an active social life. A large number of technological interventions have been developed to prevent social isolation and alleviate loneliness. Information and communication technologies (ICTs) have the potential to maintain social inclusion by supporting social interaction. However, these are generally designed for younger users, and may not always meet the needs and wishes of older people with regard to social connection. This chapter focuses on the development of ICTs to help older people remain socially connected. Our starting point is that the design of such interventions must be grounded in an understanding of how older people manage their social relationships and deal with loneliness to ensure that any technologies developed are easy to use and fit for purpose. In turn, this can only be achieved if older people are involved in the design process. 'Co-design' refers to a range of methods and tools to enable users to engage fully in the design process and so assist IT professionals and other stake-holders to understand users' everyday practices, needs and experiences (Hartswood et al. 2008). The first section looks at the range of interventions to prevent and alleviate loneliness in older adults. The second section focuses on the involvement of older people in the design of ICTs to support social connection. The final section explores the deployment of technology prototypes in real social contexts and calls for providers of technologies and services for older people to pay more attention to 'co-deployment', supporting users in exploring, learning and adapting technologies and services 'in-use'.
Background: The low uptake of telecare and telehealth services by older people may be explained b... more Background: The low uptake of telecare and telehealth services by older people may be explained by the limited involvement of users in the design. If the ambition of 'care closer to home' is to be realised, then industry, health and social care providers must evolve ways to work with older people to co-produce useful and useable solutions. Method: We conducted 10 co-design workshops with users of telehealth and telecare, their carers, service providers and technology suppliers. Using vignettes developed from in-depth ethnographic case studies, we explored participants' perspectives on the design features of technologies and services to enable and facilitate the co-production of new care solutions. Workshop discussions were audio recorded, transcribed and analysed thematically.
Background: The low uptake of telecare and telehealth services by older people may be explained b... more Background: The low uptake of telecare and telehealth services by older people may be explained by the limited involvement of users in the design. If the ambition of 'care closer to home' is to be realised, then industry, health and social care providers must evolve ways to work with older people to co-produce useful and useable solutions. Method: We conducted 10 co-design workshops with users of telehealth and telecare, their carers, service providers and technology suppliers. Using vignettes developed from in-depth ethnographic case studies, we explored participants' perspectives on the design features of technologies and services to enable and facilitate the co-production of new care solutions. Workshop discussions were audio recorded, transcribed and analysed thematically.
Background: There is growing interest in assisted living technologies to support independence at ... more Background: There is growing interest in assisted living technologies to support independence at home. Such technologies should ideally be designed ‘in the wild’ i.e. taking account of how real people live in real homes and communities. The ATHENE (Assistive Technologies for Healthy Living in Elders: Needs Assessment by Ethnography) project seeks to illuminate the living needs of older people and facilitate the co-production with older people of technologies and services. This paper describes the development of a cultural probe tool produced as part of the ATHENE project and how it was used to support home visit interviews with elders with a range of ethnic and social backgrounds, family circumstances, health conditions and assisted living needs. Method: Thirty one people aged 60 to 98 were visited in their homes on three occasions. Following an initial interview, participants were given a set of cultural probe materials, including a digital camera and the ‘Home and Life Scrapbook’ to complete in their own time for one week. Activities within the Home and Life Scrapbook included maps (indicating their relationships to people, places and objects), lists (e.g. likes, dislikes, things they were concerned about, things they were comfortable with), wishes (things they wanted to change or improve), body outline (indicating symptoms or impairments), home plan (room layouts of their homes to indicate spaces and objects used) and a diary. After one week, the researcher and participant reviewed any digital photos taken and the content of the Home and Life Scrapbook as part of the home visit interview. Findings: The cultural probe facilitated collection of visual, narrative and material data by older people, and appeared to generate high levels of engagement from some participants. However, others used the probe minimally or not at all for various reasons including limited literacy, physical problems (e.g. holding a pen), lack of time or energy, limited emotional or psychological resources, life events, and acute illness. Discussions between researchers and participants about the materials collected (and sometimes about what had prevented them completing the tasks) helped elicit further information relevant to assisted living technology design. The probe materials were particularly helpful when having conversations with non-English speaking participants through an interpreter. Conclusions: Cultural probe methods can help build a rich picture of the lives and experiences of older people to facilitate the co-production of assisted living technologies. But their application may be constrained by the participant’s physical, mental and emotional capacity. They are most effective when used as a tool to facilitate communication and development of a deeper understanding of older people’s needs.
Mega-sporting event regeneration, as a specific approach to urban renewal, uses impending host-ci... more Mega-sporting event regeneration, as a specific approach to urban renewal, uses impending host-city status as a catalyst for revitalisation and has the potential to improve health both through addressing deprivation and by promoting increased sport and physical activity among the host-city's population. This qualitative study explored how hosting of the London 2012 Games impacted upon the way East London residents perceived and experienced the social determinants of health in their local neigh- bourhood. We conducted narrative family interviews, go-along interviews and video focus group workshops with 66 Newham residents, aged 12–55 years, immediately after the Games. A narrative analytic approach examined accounts of health and wellbeing experiences in terms of neighbourhood change and the spectacle of the Games. Participants of this qualitative study generally welcomed the respite and the unexpected chance to live in a cleaner, safer and more unified environment. However, this positivity was underscored by an acute awareness that this was a very temporary situation and one that was intended to support the event rather than residents.
Background: The quality of information recorded about patient care is considered key to improving... more Background: The quality of information recorded about patient care is considered key to improving the overall quality, safety and efficiency of patient care. Assigning codes to patients' records is an important aspect of this documentation. Current interest in large datasets in which individual patient data are collated (e.g. proposed NHS care.data project) pays little attention to the details of how 'data' get onto the record. This paper explores the work of summarising and coding records, focusing on 'back office' practices, identifying contributors and barriers to quality of care. Methods: Ethnographic observation (187 hours) of clinical, management and administrative staff in two UK general practices with contrasting organisational characteristics. This involved observation of working practices, including shadowing, recording detailed field notes, naturalistic interviews and analysis of key documents relating to summarising and coding. Ethnographic analysis drew on key sensitizing concepts to build a 'thick description' of coding practices, drawing these together in a narrative synthesis. Results: Coding and summarising electronic patient records is complex work. It depends crucially on nuanced judgements made by administrators who combine their understanding of: clinical diagnostics; classification systems; how healthcare is organised; particular working practices of individual colleagues; current health policy. Working with imperfect classification systems, diagnostic uncertainty and a range of local practical constraints, they manage a moral tension between their idealised aspiration of a 'gold standard' record and a pragmatic recognition that this is rarely achievable in practice. Adopting a range of practical workarounds, administrators position themselves as both formally accountable to their employers (general practitioners), and informally accountability to individual patients, in a coding process which is shaped not only by the 'facts' of the case, but by ongoing working relationships which are co-constructed alongside the patient's summary. Conclusion: Data coding is usually conceptualised as either a technical task, or as mundane, routine work, and usually remains invisible. This study offers a characterisation of coding as a socially complex site of moral work through which new lines of accountability are enacted in the workplace, and casts new light on the meaning of coded data as conceptualised in the 'quality of care' discourse.
Objective: To investigate how electronic templates shape, enable and constrain consultations abou... more Objective: To investigate how electronic templates shape, enable and constrain consultations about chronic diseases. Design: Ethnographic case study, combining field notes, video-recording, screen capture with a microanalysis of talk, body language and data entry— an approach called linguistic ethnography. Setting: Two general practices in England. Participants and methods: Ethnographic observation of administrative areas and 36 nurse-led consultations was done. Twenty-four consultations were directly observed and 12 consultations were video-recorded alongside computer screen capture. Consultations were transcribed using conversation analysis conventions, with notes on body language and the electronic record. The analysis involved repeated rounds of viewing video, annotating field notes, transcription and microanalysis to identify themes. The data was interpreted using discourse analysis, with attention to the sociotechnical theory. Results: Consultations centred explicitly or implicitly on evidence-based protocols inscribed in templates. Templates did not simply identify tasks for completion, but contributed to defining what chronic diseases were, how care was being delivered and what it meant to be a patient or professional in this context. Patients’ stories morphed into data bytes; the particular became generalised; the complex was made discrete, simple and manageable; and uncertainty became categorised and contained. Many consultations resembled bureaucratic encounters, primarily oriented to completing data fields. We identified a tension, sharpened by the template, between different framings of the patient—as ‘individual’ or as ‘one of a population’. Some clinicians overcame this tension, responding creatively to prompts within a dialogue constructed around the patient’s narrative. Conclusions: Despite their widespread implementation, little previous research has examined how templates are actually used in practice. Templates do not simply document the tasks of chronic disease management but profoundly change the nature of this work. Designed to assure standards of ‘quality’ care they contribute to bureaucratisation of care and may marginalise aspects of quality care which lie beyond their focus. Creative work is required to avoid privileging ‘institution-centred’ care over patient-centred care.
Objective To describe, explore, and compare organisational routines for repeat prescribing in gen... more Objective To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality. Design Ethnographic case study. Setting Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing. Participants 395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally. Main outcome measures Potential threats to patient safety and characteristics of good practice. Methods Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies. Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as " exceptions " by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. Conclusion Receptionists and administrative staff make important " hidden " contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety.
Abstract
One of the most pervasive changes in general practice is the introduction of the electro... more Abstract One of the most pervasive changes in general practice is the introduction of the electronic patient record (EPR). The EPR supports both immediate clinical and anticipatory care (e.g. management of risk factors). Incorporating the EPR into social interaction is a complex task which is achieved discursively, clinician and patient responding to interactional contingencies as the consultation unfolds. Clinicians are presented with a ‘dilemma of attention’ as they seek to deal with the immediacy (‘here and now’) of the interpersonal interaction and the institutional demands (‘there and then’) of the EPR. We present data analysis which illuminates the EPR as an important presence in the clinic consul- tation context, one which places material and textual demands. Developing previous work on the triadic (three party) consultation, our novel multi-modal analysis of the EPR-in-use suggests there is value in considering the EPR as a collection of silent but conse- quential voices. Micro-analytic attention to the way in which these different voices are managed, combined with understandings drawn from ethnographic observation of the primary care context, reveals the EPR as exhibiting a previously under-explored kind of ‘agency’ within the consultation.
Abstract
Background: Effective strategies are needed to provide screening and treatment for hepa... more Abstract Background: Effective strategies are needed to provide screening and treatment for hepatitis B and C to immigrant groups in the UK at high risk of chronic infection. This study aimed to build an understanding of the knowledge, beliefs and attitudes towards these conditions and their management in a range of high-risk minority ethnic communities and health professionals, in order to inform the design of a screening and treatment programme in primary care. Methods: Qualitative data collection consisted of three sequential phases- (i) semi-structured interviews with key informants (n = 17), (ii) focus groups with people from Chinese, Pakistani, Roma, Somali, and French- and English- speaking African communities (n = 95), and (iii) semi-structured interviews with general practitioners (n = 6). Datasets from each phase were analysed using the Framework method. Results: Key informants and general practitioners perceived that there was limited knowledge and understanding about hepatitis B and C within high-risk immigrant communities, and that chronic viral hepatitis did not typically feature in community discourses about serious illness. Many focus group participants were confused about the differences between types of viral hepatitis, held misconceptions regarding transmission, and were unaware of the asymptomatic nature of chronic infection. Most welcomed the idea of a screening programme, but key informants and focus group participants also identified numerous practical barriers to engagement with primary care-based screening and treatment; including language and communication difficulties, limited time (due to long working hours), and (for some) low levels of trust and confidence in general practice-based care. General practitioners expressed concerns about the workload implications and sustainability of screening and treating immigrant patients for chronic viral hepatitis in primary care. Conclusions: Strategies to reduce the burden of chronic viral hepatitis in immigrant communities will need to consider how levels of understanding about hepatitis B and C within these communities, and barriers to accessing healthcare, may affect capacity to engage with screening and treatment. Services may need to work with community groups and language support services to provide information and wider encouragement for screening. Primary care services will need ongoing consultation regarding their support needs to deliver hepatitis screening and treatment programmes.
Purpose: To identify and explore factors that influence adoption, implementation and continued us... more Purpose: To identify and explore factors that influence adoption, implementation and continued use of telecare technologies. Method: As part of the Assistive Technologies for Healthy Living in Elders: Needs Assessment by Ethnography (ATHENE) project, 16 semi-structured interviews were conducted with key participants from organisations involved in developing and providing telecare technologies and services. Data were analysed thematically, using a conceptual model of diffusion of innovations. Results: Participants identified numerous interacting factors that facilitated or hindered adoption and use. As predicted by the model, these related variously to the technology, individual adopters, the process of social influence, the innovativeness and readiness of organisations, implementation and routinisation processes following initial adoption, and the nature and strength of linkages between these elements. Key issues included (i) the complexity and uniqueness of the ''user system'', (ii) the ongoing work needed to support telecare use beyond initial adoption, and (iii) the relatively weak links that typically exist between users of telecare technologies and the organisations who design and distribute them. Conclusions: Telecare is not merely a technology but a complex innovation requiring input from, and coordination between, people and organisations. To promote adoption and use, these contextual factors must be specified, understood and addressed. ä Implications for Rehabilitation Telecare should not be thought of as a ''plug and play'' technology but as a complex innovation requiring input from, and coordination between, people and organisations. To promote adoption and use of telecare, a number of contextual factors must be specified, understood and addressed. End users and other stakeholders should be linked at the earliest stages of design and development. Such co-production should aim to identify how technologies might better fit with users' material surroundings, social networks and desired lifestyles, rather than being technology-driven and focused on proof of concept or usability.
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Papers by Trish Greenhalgh
Findings – Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. Practical implications – The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application.
Originality/value – This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.
Method: Thirty one people aged 60 to 98 were visited in their homes on three occasions. Following an initial interview, participants were given a set of cultural probe materials, including a digital camera and the ‘Home and Life Scrapbook’ to complete in their own time for one week. Activities within the Home and Life Scrapbook included maps (indicating their relationships to people, places and objects), lists (e.g. likes, dislikes, things they were concerned about, things they were comfortable with), wishes (things they wanted to change or improve), body outline (indicating symptoms or impairments), home plan (room layouts of their homes to indicate spaces and objects used) and a diary. After one week, the researcher and participant reviewed any digital photos taken and the content of the Home and Life Scrapbook as part of the home visit interview.
Findings: The cultural probe facilitated collection of visual, narrative and material data by older people, and appeared to generate high levels of engagement from some participants. However, others used the probe minimally or not at all for various reasons including limited literacy, physical problems (e.g. holding a pen), lack of time or energy, limited emotional or psychological resources, life events, and acute illness. Discussions between researchers and participants about the materials collected (and sometimes about what had prevented them completing the tasks) helped elicit further information relevant to assisted living technology design. The probe materials were particularly helpful when having conversations with non-English speaking participants through an interpreter.
Conclusions: Cultural probe methods can help build a rich picture of the lives and experiences of older people to facilitate the co-production of assisted living technologies. But their application may be constrained by the participant’s physical, mental and emotional capacity. They are most effective when used as a tool to facilitate communication and development of a deeper understanding of older people’s needs.
Design: Ethnographic case study, combining field notes, video-recording, screen capture with a microanalysis of talk, body language and data entry— an approach called linguistic ethnography.
Setting: Two general practices in England. Participants and methods: Ethnographic
observation of administrative areas and 36 nurse-led consultations was done. Twenty-four consultations were directly observed and 12 consultations were video-recorded alongside computer screen capture. Consultations were transcribed using conversation analysis conventions, with notes on body language and the electronic record. The analysis involved repeated rounds of viewing video, annotating field notes, transcription and microanalysis to identify themes. The data was interpreted using discourse analysis, with attention to the sociotechnical theory.
Results: Consultations centred explicitly or implicitly on evidence-based protocols inscribed in templates. Templates did not simply identify tasks for completion, but contributed to defining what chronic diseases were, how care was being delivered and what it meant to be a patient or professional in this context. Patients’ stories morphed into data bytes; the particular became generalised; the complex was made discrete, simple and manageable; and uncertainty became categorised and contained. Many consultations resembled bureaucratic encounters, primarily oriented to completing data fields. We identified a tension, sharpened by the template, between different framings of the patient—as ‘individual’ or as ‘one of a population’. Some clinicians overcame this tension, responding creatively to prompts within a dialogue constructed around the patient’s narrative. Conclusions: Despite their widespread implementation, little previous research has examined how templates are actually used in practice. Templates do not simply document the tasks of chronic disease management but profoundly change the nature of this work. Designed to assure standards of ‘quality’ care they contribute to bureaucratisation of care and may marginalise aspects of quality care which lie beyond their focus. Creative work is required to avoid privileging ‘institution-centred’ care over patient-centred care.
One of the most pervasive changes in general practice is the introduction of the electronic patient record (EPR). The EPR supports both immediate clinical and anticipatory care (e.g. management of risk factors). Incorporating the EPR into social interaction is a complex task which is achieved discursively, clinician and patient responding to interactional contingencies as the consultation unfolds. Clinicians are presented with a ‘dilemma of attention’ as they seek to deal with the immediacy (‘here and now’) of the interpersonal interaction and the institutional demands (‘there and then’) of the EPR.
We present data analysis which illuminates the EPR as an important presence in the clinic consul- tation context, one which places material and textual demands. Developing previous work on the triadic (three party) consultation, our novel multi-modal analysis of the EPR-in-use suggests there is value in considering the EPR as a collection of silent but conse- quential voices. Micro-analytic attention to the way in which these different voices are managed, combined with understandings drawn from ethnographic observation of the primary care context, reveals the EPR as exhibiting a previously under-explored kind of ‘agency’ within the consultation.
Background: Effective strategies are needed to provide screening and treatment for hepatitis B and C to immigrant groups in the UK at high risk of chronic infection. This study aimed to build an understanding of the knowledge, beliefs and attitudes towards these conditions and their management in a range of high-risk minority ethnic communities and health professionals, in order to inform the design of a screening and treatment programme in primary care.
Methods: Qualitative data collection consisted of three sequential phases- (i) semi-structured interviews with key informants (n = 17), (ii) focus groups with people from Chinese, Pakistani, Roma, Somali, and French- and English- speaking African communities (n = 95), and (iii) semi-structured interviews with general practitioners (n = 6). Datasets from each phase were analysed using the Framework method.
Results: Key informants and general practitioners perceived that there was limited knowledge and understanding about hepatitis B and C within high-risk immigrant communities, and that chronic viral hepatitis did not typically feature in community discourses about serious illness. Many focus group participants were confused about the differences between types of viral hepatitis, held misconceptions regarding transmission, and were unaware of the asymptomatic nature of chronic infection. Most welcomed the idea of a screening programme, but key informants and focus group participants also identified numerous practical barriers to engagement with primary care-based screening and treatment; including language and communication difficulties, limited time (due to long working hours), and (for some) low levels of trust and confidence in general practice-based care. General practitioners expressed concerns about the workload implications and sustainability of screening and treating immigrant patients for chronic viral hepatitis in primary care.
Conclusions: Strategies to reduce the burden of chronic viral hepatitis in immigrant communities will need to consider how levels of understanding about hepatitis B and C within these communities, and barriers to accessing healthcare, may affect capacity to engage with screening and treatment. Services may need to work with community groups and language support services to provide information and wider encouragement for screening. Primary care services will need ongoing consultation regarding their support needs to deliver hepatitis screening and treatment programmes.
Findings – Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. Practical implications – The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application.
Originality/value – This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.
Method: Thirty one people aged 60 to 98 were visited in their homes on three occasions. Following an initial interview, participants were given a set of cultural probe materials, including a digital camera and the ‘Home and Life Scrapbook’ to complete in their own time for one week. Activities within the Home and Life Scrapbook included maps (indicating their relationships to people, places and objects), lists (e.g. likes, dislikes, things they were concerned about, things they were comfortable with), wishes (things they wanted to change or improve), body outline (indicating symptoms or impairments), home plan (room layouts of their homes to indicate spaces and objects used) and a diary. After one week, the researcher and participant reviewed any digital photos taken and the content of the Home and Life Scrapbook as part of the home visit interview.
Findings: The cultural probe facilitated collection of visual, narrative and material data by older people, and appeared to generate high levels of engagement from some participants. However, others used the probe minimally or not at all for various reasons including limited literacy, physical problems (e.g. holding a pen), lack of time or energy, limited emotional or psychological resources, life events, and acute illness. Discussions between researchers and participants about the materials collected (and sometimes about what had prevented them completing the tasks) helped elicit further information relevant to assisted living technology design. The probe materials were particularly helpful when having conversations with non-English speaking participants through an interpreter.
Conclusions: Cultural probe methods can help build a rich picture of the lives and experiences of older people to facilitate the co-production of assisted living technologies. But their application may be constrained by the participant’s physical, mental and emotional capacity. They are most effective when used as a tool to facilitate communication and development of a deeper understanding of older people’s needs.
Design: Ethnographic case study, combining field notes, video-recording, screen capture with a microanalysis of talk, body language and data entry— an approach called linguistic ethnography.
Setting: Two general practices in England. Participants and methods: Ethnographic
observation of administrative areas and 36 nurse-led consultations was done. Twenty-four consultations were directly observed and 12 consultations were video-recorded alongside computer screen capture. Consultations were transcribed using conversation analysis conventions, with notes on body language and the electronic record. The analysis involved repeated rounds of viewing video, annotating field notes, transcription and microanalysis to identify themes. The data was interpreted using discourse analysis, with attention to the sociotechnical theory.
Results: Consultations centred explicitly or implicitly on evidence-based protocols inscribed in templates. Templates did not simply identify tasks for completion, but contributed to defining what chronic diseases were, how care was being delivered and what it meant to be a patient or professional in this context. Patients’ stories morphed into data bytes; the particular became generalised; the complex was made discrete, simple and manageable; and uncertainty became categorised and contained. Many consultations resembled bureaucratic encounters, primarily oriented to completing data fields. We identified a tension, sharpened by the template, between different framings of the patient—as ‘individual’ or as ‘one of a population’. Some clinicians overcame this tension, responding creatively to prompts within a dialogue constructed around the patient’s narrative. Conclusions: Despite their widespread implementation, little previous research has examined how templates are actually used in practice. Templates do not simply document the tasks of chronic disease management but profoundly change the nature of this work. Designed to assure standards of ‘quality’ care they contribute to bureaucratisation of care and may marginalise aspects of quality care which lie beyond their focus. Creative work is required to avoid privileging ‘institution-centred’ care over patient-centred care.
One of the most pervasive changes in general practice is the introduction of the electronic patient record (EPR). The EPR supports both immediate clinical and anticipatory care (e.g. management of risk factors). Incorporating the EPR into social interaction is a complex task which is achieved discursively, clinician and patient responding to interactional contingencies as the consultation unfolds. Clinicians are presented with a ‘dilemma of attention’ as they seek to deal with the immediacy (‘here and now’) of the interpersonal interaction and the institutional demands (‘there and then’) of the EPR.
We present data analysis which illuminates the EPR as an important presence in the clinic consul- tation context, one which places material and textual demands. Developing previous work on the triadic (three party) consultation, our novel multi-modal analysis of the EPR-in-use suggests there is value in considering the EPR as a collection of silent but conse- quential voices. Micro-analytic attention to the way in which these different voices are managed, combined with understandings drawn from ethnographic observation of the primary care context, reveals the EPR as exhibiting a previously under-explored kind of ‘agency’ within the consultation.
Background: Effective strategies are needed to provide screening and treatment for hepatitis B and C to immigrant groups in the UK at high risk of chronic infection. This study aimed to build an understanding of the knowledge, beliefs and attitudes towards these conditions and their management in a range of high-risk minority ethnic communities and health professionals, in order to inform the design of a screening and treatment programme in primary care.
Methods: Qualitative data collection consisted of three sequential phases- (i) semi-structured interviews with key informants (n = 17), (ii) focus groups with people from Chinese, Pakistani, Roma, Somali, and French- and English- speaking African communities (n = 95), and (iii) semi-structured interviews with general practitioners (n = 6). Datasets from each phase were analysed using the Framework method.
Results: Key informants and general practitioners perceived that there was limited knowledge and understanding about hepatitis B and C within high-risk immigrant communities, and that chronic viral hepatitis did not typically feature in community discourses about serious illness. Many focus group participants were confused about the differences between types of viral hepatitis, held misconceptions regarding transmission, and were unaware of the asymptomatic nature of chronic infection. Most welcomed the idea of a screening programme, but key informants and focus group participants also identified numerous practical barriers to engagement with primary care-based screening and treatment; including language and communication difficulties, limited time (due to long working hours), and (for some) low levels of trust and confidence in general practice-based care. General practitioners expressed concerns about the workload implications and sustainability of screening and treating immigrant patients for chronic viral hepatitis in primary care.
Conclusions: Strategies to reduce the burden of chronic viral hepatitis in immigrant communities will need to consider how levels of understanding about hepatitis B and C within these communities, and barriers to accessing healthcare, may affect capacity to engage with screening and treatment. Services may need to work with community groups and language support services to provide information and wider encouragement for screening. Primary care services will need ongoing consultation regarding their support needs to deliver hepatitis screening and treatment programmes.