Advancing complexity science in healthcare research : the logic of logic models

BACKGROUND: Logic models are commonly used in evaluations to represent the causal processes through which interventions produce outcomes, yet significant debate is currently taking place over whether they can describe complex interventions which adapt to context. This paper assesses the logic models used in healthcare research from a complexity perspective. A typology of existing logic models is proposed, as well as a formal methodology for deriving more flexible and dynamic logic models. ANALYSIS: Various logic model types were tested as part of an evaluation of a complex Patient Experience Toolkit (PET) intervention, developed and implemented through action research across six hospital wards/departments in the English NHS. Three dominant types of logic model were identified, each with certain strengths but ultimately unable to accurately capture the dynamics of PET. Hence, a fourth logic model type was developed to express how success hinges on the adaption of PET to its delivery settings. Aspects of the Promoting Action on Research Implementation in Health Services (PARIHS) model were incorporated into a traditional logic model structure to create a dynamic "type 4" logic model that can accommodate complex interventions taking on a different form in different settings. CONCLUSION: Logic models can be used to model complex interventions that adapt to context but more flexible and dynamic models are required. An implication of this is that how logic models are used in healthcare research may have to change. Using logic models to forge consensus among stakeholders and/or provide precise guidance across different settings will be inappropriate in the case of complex interventions that adapt to context. Instead, logic models for complex interventions may be targeted at facilitators to enable them to prospectively assess the settings they will be working in and to develop context-sensitive facilitation strategies. Researchers should be clear as to why they are using a logic model and experiment with different models to ensure they have the correct type

Telling a story or reporting the facts? Interpretation and description in the qualitative analysis of applied health research data : A documentary analysis of peer review reports

Interpretative analysis of qualitative data has been likened to a form of creative storytelling. However, analysis of qualitative health research data is often subject to concerns derived from quantitative empiricism such as replicability, bias and impartiality. In applied health research, it seems that qualitative portrayals have become dominated by descriptive reporting at the expense of interpretative accounts. I conducted a documentary analysis based on 32 peer reviewer reports (received 2014–2019) in connection with four interpretative qualitative health research manuscripts. Peer reviewers were mostly positive towards the manuscripts and the findings of the studies seemed to resonate with them. Yet, interpretive analysis was viewed negatively leading to a lack of trust in the findings. Three broad issues seemed to trouble reviewers. First, line by line coding of all data was thought to be paramount in order to assure replicability. Second, it was asserted that verbatim quotations from participants must be included in the findings section otherwise the findings could be considered erroneous. Third, data should be subjected to a comparative analysis based on similarities and differences, rather than an interpretive approach, as this was thought to be more systematic. I offer a reflexive account of my positionality and understandings of interpretative creativity. The art of storytelling through qualitative data seems to have been derided within applied health research, with a push towards reportage of basic facts. Peer reviewers are evaluating creative analyses against a quantitative paradigm. This methodological conservatism is encouraging an oversimplification of the complexity resident in many qualitative datasets

An exploration of loss and identity among people living with Long COVID

Identity loss and (re)construction forms a central debate in sociology of chronic illness. People living with chronic/persistent health conditions are often faced with both a ‘broken’ body and a disrupted self-narrative. The loss of the coherence of ongoing life and identity also lies at the heart of the lived experiences of people living with Long COVID (LC). Drawing upon a qualitative study of 80 people with self-identified LC symptoms in the UK, this paper unveils an insightful picture of how our participants lost and also sought to restore their identity as a multi-dimensional, narratively constructed and embodied entity. We found that, as a complex and still largely underexplored health condition, LC could lead to the compounded loss of not only the physical self but also a profound sense of meaning and self-worth. As reported by our participants, identity loss around LC may arise from ongoing bodily disruptions to daily routines and the lack of support and understanding to legitimise their suffering. They often experienced LC as suppressing and existential loss of meaning and being. Their dynamic responses to LC also highlighted how their longing for a narratively coherent self profoundly shaped the ongoing construction of their identity

Understanding and supporting the long-term effects of COVID-19: A report from the Qualitative Long COVID Research Network in the United Kingdom

This report provides a timely summary about fast-evolving qualitative inquiries into Long COVID (LC) in the UK. Based on a survey conducted within a national qualitative LC (QLC) research network comprising 14 teams from across the UK, we aim to explore how the novel public health challenge of LC is being examined and supported across various care settings and how it is experienced among different demographic groups. Evident in the survey findings is the diverse research foci, participant sampling and methodological approaches in response to the complex and pervasive challenges presented by LC. Whilst the multifaceted impacts, diversified lived experiences and health inequalities of LC have been increasingly illuminated by the studies included in our survey, we have also identified a range of knowledge gaps for future research to address, for example carer and healthcare professionals’ experiences, regional disparity in LC responses and international comparison. Ultimately, on behalf of our research network, we aim to enhance QLC research by pooling our findings and expertise to produce further collaborative research outputs on this topic

‘I am just a shadow of who I used to be’—Exploring existential loss of identity among people living with chronic conditions of Long COVID

Identity loss and (re)construction forms a central debate in sociology of chronic illness. Living with chronic/persistent health conditions may raise questions about how disruptions can touch upon and further threaten the very roots of existence, by which people reflexively perceive a coherent and stable sense of ‘being-in-the-world’. Whilst medical sociologists have shown interest in ‘existential loss’ in chronic illness, this question remains largely underexplored. Adopting a qualitative study on Long COVID (LC) as an example, this article illuminates existential identity loss as a deeply painful experience of losing body as a fundamental medium to retain continuity and consistency of one’s narratively constructed identity. Interviews with 80 LC sufferers in the UK revealed that living with persistent and often uncertain symptoms and disruptions can cause the loss of biographical resources and resilience, making it difficult to reflexively understand their own being within the world. Their dynamic responses to LC also highlighted how sufferers’ longing for a narratively coherent self can profoundly shape the ongoing construction of their identity in chronic health conditions. These insights into the complicated and often hard-to-express existential pain of identity loss can also nurture more holistic understandings of and support for LC and chronic illness more broadly

Does team reflexivity impact teamwork and communication in interprofessional hospital-based healthcare teams? : A systematic review and narrative synthesis

BACKGROUND: Teamwork and communication are recognised as key contributors to safe and high-quality patient care. Interventions targeting process and relational aspects of care may therefore provide patient safety solutions that reflect the complex nature of healthcare. Team reflexivity is one such approach with the potential to support improvements in communication and teamwork, where reflexivity is defined as the ability to pay critical attention to individual and team practices with reference to social and contextual information. OBJECTIVE: To systematically review articles that describe the use of team reflexivity in interprofessional hospital-based healthcare teams. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six electronic databases were searched to identify literature investigating the use of team reflexivity in interprofessional hospital-based healthcare teams.The review includes articles investigating the use of team reflexivity to improve teamwork and communication in any naturally occurring hospital-based healthcare teams. Articles' eligibility was validated by two second reviewers (5%). RESULTS: Fifteen empirical articles were included in the review. Simulation training and video-reflexive ethnography (VRE) were the most commonly used forms of team reflexivity. Included articles focused on the use of reflexive interventions to improve teamwork and communication within interprofessional healthcare teams. Communication during interprofessional teamworking was the most prominent focus of improvement methods. The nature of this review only allows assessment of team reflexivity as an activity embedded within specific methods. Poorly defined methodological information relating to reflexivity in the reviewed studies made it difficult to draw conclusive evidence about the impact of reflexivity alone. CONCLUSION: The reviewed literature suggests that VRE is well placed to provide more locally appropriate solutions to contributory patient safety factors, ranging from individual and social learning to improvements in practices and systems. TRIAL REGISTRATION NUMBER: CRD42017055602

What are the sources of patient experience feedback in the UK prison setting, and what do patients and healthcare staff think about giving and receiving feedback in prison? A qualitative study

Background: The collection of patient experience feedback (PEF) has seen a marked global increase in the past decade. Research about PEF has concentrated mainly on hospital settings albeit a recent interest in primary care. There has been minimal research about PEF in the prison healthcare setting. The aim of this study was to explore the role of prison PEF, the different forms it might take and the perceptions of healthcare staff and people in prison. Methods: Qualitative face to face interview study involving 24 participants across two prisons (male and female) in the North of England, involving 12 healthcare staff and 12 patients. Framework analysis was undertaken. Results: PEF sources were variable, from informal and verbal through to formal and written. The willingness of people in prison to give PEF related to whether they felt sufficiently comfortable to raise concerns, with some feeling too frightened and having apprehension about anonymity. It was viewed as disheartening to give PEF but not be informed of any outcome. Healthcare staff opinions about PEF were divergent but they found PEF unhelpful when it was about prison regime issues rather than healthcare. Suggestions for improving the PEF process were put forward and included accessibility, anonymity and digitalisation. Conclusions: This is the first study to report findings about prison PEF. There are broad similarities between our findings and research examining hospital-based PEF. Prison healthcare services seem to be listening to patients but the ways in which PEF is collected, considered and used could be improved. Experience Framework This article is associated with the Policy & Measurement lens of The Beryl Institute Experience Framework. (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens

“Feedback is indeed a dainty dish to set before the Trust”: Comparing how online patient feedback is responded to and used across three hospital Trusts in England

Patients are increasingly reporting about their healthcare experiences in an unsolicited manner online. This emerging resource may offer valuable opportunities for organisational learning. Our study aimed to compare how online patient feedback was responded to and used for improvement in three hospital Trusts. Ethnographic data were collected across three hospital Trusts in England, recruited according to the way they responded to online patient feedback. Findings from three case studies were brought together using a reflexive thematic analysis approach, via a multi-case analysis. Three key themes were highlighted. Firstly, the organisational rationale for engaging with patient feedback influenced levels of compassion felt for feedback providers, and in turn, the extent feedback was valued and learned from. Secondly, multidisciplinary collaboration between patient experience teams and the wider organisation helped to disseminate ownership felt for feedback and overcome ‘contextual blindness’. Thirdly, the risk of patient feedback falling into an ‘abyss’ was reduced when staff prioritised learning over and above collecting and reporting data, and when managers disseminated a passion for improvement. Overall, online feedback was considered a courageous step into the unknown. However, these barriers could be culturally overcome. Our multi-case analysis demonstrates that there is still a way to go for some organisations to culturally embrace online patient feedback as a valued means to improve. However, we present five key suggestions to inform policy and practice and support the use and usefulness of online patient feedback for organisational learning. Experience Framework This article is associated with the Policy & Measurement lens of The Beryl Institute Experience Framework (https://theberylinstitute.org/experience-framework/). Access other PXJ articles related to this lens. Access other resources related to this lens

Growing up during a public health crisis: a qualitative study of Born in Bradford early adolescents during Covid-19

Background Whilst children and young people have not often been at forefront of the immediate Covid-19 pandemic health response there has been concern about the indirect consequences of Covid-19 on children’s physical and mental health and what the effect of the pandemic will be throughout their lifetimes. Early adolescence is a time of transition and reorientation. This study considers the impact of the first UK Covid-19 lockdown on early adolescents. Methods The study topic was identified through a consultation process which aimed to provide appropriate evidence to local decision makers in Bradford, UK and plan for future interventions. A group of children and their parents from the longitudinal Born in Bradford (BiB) cohort study were randomly selected and then purposively sampled by ethnicity, age, sex and deprivation. The BiB cohort is made up of 13,776 children and their families and were recruited at Bradford Royal Infirmary between 2007 and 2011. 41 interviews (with 20 families: 20 parents and 21 children) were carried out between August and September 2020. Interview data was analysed using reflexive thematic analysis. Results The transitional age of the children interviewed had an important influence on their experience Covid-19 and the first UK lockdown. Their age combined with lockdown and school closures meant that they missed out on key learning and social opportunities at a crucial time in their lives. Covid-19 and lockdown also disrupted their daily mental wellbeing and led to increased anxiety, lethargy and low moods, during a period of personal change and social transition. Conclusion For children at the start of their adolescence undergoing change and formation, the experiences and feelings Covid-19 has set in motion will likely have an impact on their mental and cognitive functioning as they develop further. It is important to acknowledge these early adolescent experiences and continue to monitor and provide targeted support to this group of young people