The importance, challenges and prospects of taking work practices into account for healthcare quality improvement

Purpose – The purpose of this paper is to underline the importance of taking work practices into account for quality improvement (QI) purposes, highlight some of the challenges of doing so, and suggest strategies for future research and practice. Patient status at a glance, a Lean-inspired QI intervention designed to alleviate nurses of their knowledge mobilisation function, is deployed as an illustrative case. Design/methodology/approach – Ethnographic data and practice-based theories are utilised to describe nurses’ knowledge mobilisation work. The assumptions about knowledge sharing embedded in patient status at a glance white boards (PSAGWBs) are analysed drawing on actor network theory. Findings – There is a disparity between nurses’ knowledge mobilisation practices and the scripts that inform the design of PSAGWBs. PSAGWBs are designed to be intermediaries and to transport meaning without transformation. When nurses circulate knowledge for patient management purposes, they operate as mediators, translating diverse information sources and modifying meaning for different audiences. PSAGWBs are unlikely to relieve nurses of their knowledge mobilisation function and may actually add to the burdens of this work. Despite this nurses have readily embraced this QI intervention. Research limitations/implications – The study is limited by its focus on a single case and by the inferential (rather than the empirical) nature of its conclusions. Originality/value – This paper illustrates the importance of taking practice into account in healthcare QI, points to some of the challenges of doing so and highlights the potential of practice-based approaches in supporting progress in this field

"Just a typical teenager": The social ecology of "normal adolescence" - insights from diabetes care

In Western society “normal adolescence” is understood to be a biologically driven phase characterized by emotional turmoil and irrational behavior. Despite being discredited within academic literature this discourse persists both in formal theory and everyday use. Drawing on the case of diabetes care, I argue that the discourse of “normal adolescence” derives its power from its value as a vocabulary of motive through which to navigate the contradictions inherent in the social order at this stage of the life-course. While helping us to comprehend sociologically the ecological niche in which “normal adolescence” is sustained, this analysis raises questions about the persistence of this discourse for social action

Complexity and Change in the United Kingdom's System of Mental Health Care

In the context of wider efforts to improve efficiency and the user-centeredness of health and social care provision, public policy in the United Kingdom (UK) demonstrates an explicit appeal to ‘whole systems’ management. This otherwise laudable attempt to develop services may, however, reveal an underestimation by policymakers of how complex systems of work can evolve in unpredictable ways. In this paper we utilize sociological theories of the division of labour to underpin a wide-ranging case study of the historical evolution and current characteristics of the ecology of mental health care in the UK. Beginning with an analysis of the development of a system in which psychiatry emerged as the lead profession, and progressing to a review of the challenges faced by psychiatric knowledge and practice, we highlight the interrelated and dynamic features of this system of work. Our paper closes with an examination of contemporary ‘modernization’, which we argue has the potential for triggering widespread system disturbance

Giving a fig about roles: Policy, context and work in community mental health care

Across the UK, mental health professionals are strongly objecting to threats to their roles. Against this background we use ethnographic data from a study of roles and responsibilities in community care, undertaken across two contrasting sites in Wales, to demonstrate how work is sensitive to local organizational features and to show how gaps can grow between the public claims professions make about their contributions and the actual roles which their members fulfil in the workplace. We reveal how, in one of our two research sites, immediate contextual features shaped the work of nurses and social workers towards the fulfilment of expanded packages of activity. We then show how subsequent policy (including ‘new ways of working’), combined with new pressures arising from the economic downturn, carry the potential to accelerate the wider creation of workplaces of this type. We examine some implications of these processes for nurses and others, and for the system of mental health care as a whole, and conclude with a call for closer attention to be paid to the potential, wider, impact of current developments

Complex caring trajectories in community mental health: contingencies, divisions of labor and care coordination

The concept of ‘trajectory’ refers to the unfolding of individual service users’ health and illness experiences, the organization of health and social care work surrounding them and the impact this work has on people involved. Using qualitative data from a study completed in two sites in Wales we first reveal the complex character of trajectories encountered in the community mental health field. We show how these can be shaped by features peculiar to mental ill-health per se, and by features with organizational origins. We then use our data to lay bare true divisions of labor. Mental health professionals featured prominently in our study. We also reveal relatively invisible contributions made by professionals on the periphery, support workers, unpaid lay carers and service users. In examining the significance of our findings we identify particular lessons for mental health practitioners, managers and policymakers sharing concerns for the coordination of care

A tale of two studies: research governance issues arising from two ethnographic investigations into the organisation of health and social care

In a number of countries throughout the world attention is being paid to the ways in which health and social care research is undertaken and regulated. In the United Kingdom, new research governance frameworks are intended to promote improvement in research quality. This paper draws on our experiences of seeking research ethics committee approval for two investigations with the same research design, in order to address four governance issues: consistency within and between ethics committees; the assessment of vulnerable individuals regarding their suitability to participate in studies; the relationship between ethics and access; and ethics committee understanding of qualitative research

Leadership and management for infection prevention and control: what do we have and what do we need?

Leadership is widely considered to be vital for infection prevention and control (IPC).1 Its purpose is to maintain progress in the reduction of risks of healthcare-associated infections, especially those caused by antimicrobial-resistant organisms, and to achieve continuous quality improvement.2 However, given its importance, there is little rigorous research on effective leadership for IPC. While there is indirect evidence that IPC experts and clinicians working at the frontline of patient care can assume leadership, almost nothing has been written about IPC leadership at senior level. This situation is all the more surprising given international interest in the senior managerial model of IPC adopted throughout the National Health Service (NHS) in England, and claims that ‘top down’ intervention for IPC is effective.1 and 2 The terms ‘management’ and ‘leadership’ are often used interchangeably in relation to the organization and delivery of health care. Greater conceptual clarity could prompt consideration of what is needed for IPC

Taking data seriously: the value of actor-network theory in rethinking patient experience data

Hospitals are awash with patient experience data, much of it collected with the ostensible purpose of improving the quality of patient care. However, there has been comparatively little consideration of the nature and capacities of data itself. Using insights from actor-network theory, we propose that paying attention to patient experience data as having agency in particular hospital interactions allows us to better trace how and in what circumstances data lead (or fail to lead) to quality improvement

Evidence into practice: evaluating a child-centred intervention for diabetes medicine management The EPIC Project

BACKGROUND: There is a lack of high quality, child-centred and effective health information to support development of self-care practices and expertise in children with acute and long-term conditions. In type 1 diabetes, clinical guidelines indicate that high-quality, child-centred information underpins achievement of optimal glycaemic control with the aim of minimising acute readmissions and reducing the risk of complications in later life. This paper describes the development of a range of child-centred diabetes information resources and outlines the study design and protocol for a randomized controlled trial to evaluate the information resources in routine practice. The aim of the diabetes information intervention is to improve children and young people's quality of life by increasing self-efficacy in managing their type 1 diabetes. METHODS/DESIGN: We used published evidence, undertook qualitative research and consulted with children, young people and key stakeholders to design and produce a range of child-centred, age-appropriate children's diabetes diaries, carbohydrate recording sheets, and assembled child-centred, age-appropriate diabetes information packs containing published information in a folder that can be personalized by children and young people with pens and stickers. Resources have been designed for children/young people 6-10; 11-15; and 16-18 years.To evaluate the information resources, we designed a pragmatic randomized controlled trial to assess the effectiveness, cost effectiveness, and implementation in routine practice of individually tailored, age-appropriate diabetes diaries and information packs for children and young people age 6-18 years, compared with currently available standard practice.Children and young people will be stratified by gender, length of time since diagnosis ( 2 years) and age (6-10; 11-15; and 16-18 years). The following data will be collected at baseline, 3 and 6 months: PedsQL (generic, diabetes and parent versions), and EQ-5 D (parent and child); NHS resource use and process data (questionnaire and interview). Baseline and subsequent HbA1c measurements, blood glucose meter use, readings and insulin dose will be taken from routine test results and hand-held records when attending routine 3-4 monthly clinic visits.The primary outcome measure is diabetes self-efficacy and quality-of-life (Diabetes PedsQL). Secondary outcomes include: HbA1c, generic quality of life, routinely collected NHS/child-held data, costs, service use, acceptability and utility. TRIAL REGISTRATION: ISRCTN17551624