Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review

Background: The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement. Methods: We used a scoping review methodology drawing on Arksey and O’Malley’s methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 – April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills. Results: We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking. Conclusions: We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers

Study protocol: DEcisions in health Care to Introduce or Diffuse innovations using Evidence (DECIDE)

BACKGROUND: A range of evidence informs healthcare decision-making, from formal research findings to 'soft intelligence' or local data, as well as practical experience or tacit knowledge. However, cultural and organisational factors often prevent the translation of such evidence into practice. Using a multi-level framework, this project will analyse how interactions between the evidence available and processes at the micro (individual/group) and meso (organisational/system) levels influence decisions to introduce or diffuse innovations in acute and primary care within the National Health Service in the UK. METHODS/DESIGN: This study will use a mixed methods design, combining qualitative and quantitative methods, and involves four interdependent work streams: (1) rapid evidence synthesis of relevant literature with stakeholder feedback; (2) in-depth case studies of 'real-world' decision-making in acute and primary care; (3) a national survey and discrete choice experiment; and (4) development of guidance for decision-makers and evaluators to support the use of evidence in decision-making. DISCUSSION: This study will enhance the understanding of decision-makers' use of diverse forms of evidence. The findings will provide insights into how and why some evidence does inform decisions to introduce healthcare innovations, and why barriers persist in other cases. It will also quantify decision-makers' preferences, including the 'tipping point' of evidence needed to shift stakeholders' views. Practical guidance will be shared with healthcare decision-makers and evaluators on uses of evidence to enable the introduction and diffusion of innovation

The role of organizational and professional cultures in medication safety: a scoping review of the literature

Purpose: This scoping review explores what is known about the role of organizational and professional cultures in medication safety. The aim is to increase our understanding of ‘cultures’ within medication safety and provide an evidence base to shape governance arrangements. / Data sources: Databases searched are ASSIA, CINAHL, EMBASE, HMIC, IPA, MEDLINE, PsycINFO and SCOPUS. / Study selection: Inclusion criteria were original research and grey literature articles written in English and reporting the role of culture in medication safety on either organizational or professional levels, with a focus on nursing, medical and pharmacy professions. Articles were excluded if they did not conceptualize what was meant by ‘culture’ or its impact was not discussed. / Data extraction: Data were extracted for the following characteristics: author(s), title, location, methods, medication safety focus, professional group and role of culture in medication safety. / Results of data synthesis: A total of 1272 citations were reviewed, of which, 42 full-text articles were included in the synthesis. Four key themes were identified which influenced medication safety: professional identity, fear of litigation and punishment, hierarchy and pressure to conform to established culture. At times, the term ‘culture’ was used in a non-specific and arbitrary way, for example, as a metaphor for improving medication safety, but with little focus on what this meant in practice. / Conclusions: Organizational and professional cultures influence aspects of medication safety. Understanding the role these cultures play can help shape both local governance arrangements and the development of interventions which take into account the impact of these aspects of culture

One to one specialling and sitters in acute care hospitals: a scoping review

Background One to one specialling is a type of care which is provided to ensure the safety of patients who may be suffering from cognitive impairment, exhibit challenging behaviour, or may be at risk of falls or of causing harm to themselves or others. Care such as this, often referred to as ‘specialling’ or ‘sitting’ is common practice in most hospitals around the world, but there is a lack of evidence regarding its cost effectiveness and the quality of care provided. Aim The aim of this scoping review was to explore the breadth and scope of literature on one to one specialling, sitters and similar types of care in acute secondary care settings, in order to identify the challenges and concerns relating to the quality of care (process and outcomes) and cost effectiveness emerging from the literature, and determine the implications of this for policy, practice and future research. Design This review was based on scoping review methodology following a five stage scoping review process. A keyword search was conducted in the following databases: MEDLINE, Scopus, CINAHL Plus, Web of Science, ProQuest Social Science, and ProQuest Nursing and Allied Health. The time limit placed on the search was January 2000 to April 2016. Inclusion and exclusion criteria were applied. The Mixed Methods Appraisal Tool was used to assess the quality of primary research articles. Findings Forty-four articles were included in the review. We found a lack of clarity in the terms used to describe one to one specialling and variability in what this type of care entails, who provides the care and the needs of patients requiring this type of care. High costs of specialling are often seen as a concern, but there was a lack of economic evaluations considering the full cost of specialling and balancing these against the benefits. Some of the articles proposed alternatives to one to one specialling or the use of sitters, but only some of these were evaluated. Conclusion There is wide variation in what specialling and one to one care entails, which can in turn lead to the provision of poor quality care. A reduction in this variation and improved quality care might be achieved through the development of guidelines, training and standardized decision-making tools. Further research on the impact of one to one specialling on patient outcomes and cost would be beneficial, as well as robust evaluations of the alternatives to specialling

Effects of the Novel NMDA Receptor Antagonist Gacyclidine on Recovery From Medial Frontal Cortex Contusion Injury in Rats

Gacyclidine, a novel, noncompetitive NMDA receptor antagonist, was injected (i.v.) into rats at three different doses to determine if the drug could promote behavioral recovery and reduce the behavioral and anatomical impairments that occur after bilateral contusions of the medial frontal cortex (MFC). In the Morris water maze,contused rats treated with gacyciidine at a dosage of 0.1 mg/kg performed better than their vehicle-treated conspecifics. Rats given gacyclidine at either 0,3 or 0.03 mg/kg performed better than brain-injured controls, but not as well as those treated with 0.1 mg/kg. Counts of surviving neurons in the nucleus basalis magnoceilularis (NBM) and the medial dorsal nucleus (MDN) of the thalamus were used to determine whether gacyclidine treatment attenuated secondary cell death. In both the NBM and the MDN, the counts revealed fewer surviving neurons in untreated contused rats than in gacyclidine-treated rats. Increases in the size and number of microglia and astrocytes were observed in the striatum of gacyclidinetreated contused brains. Although most consequences of MFC contusions were attenuated, we still observed increases in ventricle dilation and thinning of the cortex. In fact, the ventricles of rats treated with 0.1 mg/kg of gacyclidine were larger than those of their vehicle treated counterparts, although we observed no behavioral impairment

Evidence use as sociomaterial practice? A qualitative study of decision-making on introducing service innovations in health care

A policy aspiration is that evidence should inform decision-making on introducing health service innovations. Internationally, innovation adoption has historically been slow and patchy. Three innovations in the English and Scottish National Health Service were analysed qualitatively: stroke service reconfiguration; revised national guidance on cancer referral; and ‘virtual’ glaucoma outpatient clinics. The authors identify three sociomaterial mechanisms through which evidence and context shape each other in decision-making: connecting, ordering, resisting. Shared preferences for research evidence enabled the medical profession to exert influence on decision-making, while other professions used alternative evidence. Implications for promoting inclusive public management around service innovations are discussed

Investigating the use of patient involvement and patient experience in quality improvement in Norway: rhetoric or reality?

Background Patient involvement in health care decision making is part of a wider trend towards a more bottom-up approach to service planning and provision, and patient experience is increasingly conceptualized as a core dimension of health care quality. The aim of this multi-level study is two-fold: 1) to describe and analyze how governmental organizations expect acute hospitals to incorporate patient involvement and patient experiences into their quality improvement (QI) efforts and 2) to analyze how patient involvement and patient experiences are used by hospitals to try to improve the quality of care they provide. Methods This multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews and non-participant observation of key meetings and shadowing of staff at the meso and micro levels in two purposively sampled Norwegian hospitals. Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011–2012). Results Governmental documents and regulations at the macro level demonstrated wide-ranging expectations for the integration of patient involvement and patient experiences in QI work in hospitals. The expectations span from systematic collection of patients’ and family members’ experiences for the purpose of improving service quality through establishing patient-oriented arenas for ongoing collaboration with staff to the support of individual involvement in decision making. However, the extent of involvement of patients and application of patient experiences in QI work was limited at both hospitals. Even though patient involvement was gaining prominence at the meso level − and to a lesser extent at the micro level − relevant tools for measuring and using patient experiences in QI work were lacking, and available measures of patient experience were not being used meaningfully or systematically. Conclusions The relative lack of expertise in Norwegian hospitals of adapting and implementing tools and methods for improving patient involvement and patient experiences at the meso and micro levels mark a need for health care policymakers and hospital leaders to learn from experiences of other industries and countries that have successfully integrated user experiences into QI work. Hospital managers need to design and implement wider strategies to help their staff members recognize and value the contribution that patient involvement and patient experiences can make to the improvement of healthcare quality