Hot on the tail of news about our London meeting on November 18 to launch the NoMAD instrument to measure implementation using Normalization Process Theory, comes the publication of our overview of systematic reviews of professional behaviour change interventions in healthcare.
An important question is why there are so many negative trials of behaviour change interventions that link beliefs and attitudes with intentions. We often see that these intentions are not translated into behaviour change, or that if they are, behaviour changes are temporary. This seems to be true across a range of important translational problems – from operationalizing guidelines and care plans through to implementing telemedicine systems.
Mark Johnson and I looked at 67 systematic reviews of professional behaviour change interventions and coded them against the constructs of NPT. We showed that interventions that are successful are more likely to be include a greater spread of the activities defined by Normalization Process Theory. In particular, our overview suggests that collective action and reflexive monitoring components are crucial to successful behaviour change interventions.
Read our overview of systematic reviews of health professional behaviour change interventions here.
At last, a quantitative tool to investigate implementation processes using normalization process theory
Right now a group of us are working on a major review of studies that have used Normalization Process Theory as their sole analytic framework. We’ve identified about 90 empirical studies and systematic reviews that could be included. For a theoretical perspective that was only published in 2009, this is a surprisingly large number of studies and it’s very gratifying to see how good some of them are.
One thing that does stand out with the studies that are likely to go into the review is that they are mainly qualitative. There’s certainly a demand for a tool that can be used to measure aspects of implementation processes though. My friend Tracy Finch has led an ESRC funded study from Newcastle University here in the UK to develop just such a tool and we met to decide the final version last week. The NoMAD Questionnaire measures all 16 dimensions of NPT and we’re going to launch it at a meeting in London in November. We’ll also launch the new and improved NPT website and on-line toolkit. Would you like to join us?
The launch will be held at the King’s Fund (11-12 Cavendish Square, just off Oxford Street, nearest Underground is Oxford Circus) on 18 November from 10.00am to 4pm. Robbie Foy (Deputy Editor-in-Chief of Implementation Science and Professor of Primary Care at Leeds University) will be giving a keynote talk, and so will I.
Attendance – including morning coffee, lunch, and afternoon tea – is free, but you must reserve a place. You can do that by contacting Melissa Girling at Newcastle University at firstname.lastname@example.org
Find the King’s Fund here. Find out about Robbie Foy here . Find out about Tracy Finch here.
Depression - a psychiatrist's story
My friend Linda Gask is a distinguished psychiatrist who also suffers from a profound and sometimes very disabling depression. Linda is a great writer and has just published her autobiography - The Other Side of Silence: A Psychiatrist's Memoir of Depression - which is out now on Amazon. I was privileged to see a prepublication copy and I although I don't often do book reviews I thought I would say a few words about it here.
In her book, Linda Gask offers us three interwoven stories. The advertised story – and the main focus of the narrative – is about what it means to experience depression. Here, her story is a painful one because there is no medical answer to her depression. Neither pharmaceutical medicine nor psychotherapy can offer her a complete solution. Even so, this isn’t a book in which the author achieves some kind of self-validation through the lived experience of suffering. Dr Gask is serious about understanding depression and knowing the limits of human responses to it, and her second narrative is about this. It’s an account of what it means to experience depression in others, from the standpoint of someone who, through the course of the book, progresses from life as a schoolgirl to a very distinguished professor of psychiatry. This stream of narrative is an emotionally complex one, because it explores not only the limits of what psychiatry can achieve for the author, but also the limits of what she can achieve for her patients. The third narrative that runs through this book is one that explores the ways that complicated and difficult family relationships echo through the years, and how our achievements sometimes carry us far away from the little pattern of relationships into which we are born and mean that we must negotiate the sometimes very demanding expectations of the people that we grow up with. Each of these stories weaves into the other, as Linda Gask tells us about how she has learned to live with depression. I recommend this book to people who live with depression, but I also recommend it to students and practitioners in medicine, nursing, and psychotherapy: all will find an interesting story here, and both patients and professionals will find profitable lessons about the limits of medicine.
NPT & SSM
If you’re interested in NPT as a way in to the sociological understanding of technology and practice, two excellent recent papers in Social Science and Medicine offer really interesting analyses. In Survival of the Project: a case study of ICT innovation in health care Hege Andreassen, Lars Kjekshus and Aksel Tjora discuss the problem of routine embedding of new technologies in practice, using telemedicine systems as an exemplar. They show how not embedding a system in routine work eases both the practices of routine work and the process of innovation by holding the new socio-technical system at a distance. It thus hardly perturbs the already embedded and integrated practices at work. In Moving beyond local practice: Reconfiguring the adoption of a breast cancer diagnostic technology Greg Maniatopoulos, Rob Proctor and colleagues explore how technological innovations are adopted, through practices that operate at multiple levels of analysis. Once again, this is a case study, but it pushes beyond the particular and hints at the central role of politics in shaping the forms that sociotechnical change take.
Both papers are behind the Elsevier paywall. Andreassen et al's paper is here, and Maniatopoulos et al's paper is here.
My program of research with Alison Richardson on Complexity and Patient Experience in End of Life Care is gathering momentum. An important part of this program is work that seeks to improve communications and decision-making in challenging situations. A new paper with our Postdoctoral Fellow Susi Lund is published in PLoS ONE today. We used NPT to structure a systematic review of qualitative studies of the implementation of advance care plans in the care of people with terminal illnesses, and to develop an explanatory model of processes that increase or decrease clinicians confidence in the use of advance care plans. Click here to download the paper.
Our programme of work on developing and refining Normalization Process Theory is also growing, and 2015 promises to be an exciting year for this work. Cathy Pope and I will be leading an NPT workshop in Tromso, Norway, on 8 April (contact Hege.Andreassen@telemed.no if you’d like to attend). I’ll be giving a much shorter introduction to NPT for staff and students in the Faculty of Health Sciences at Southampton University at 3.30-5pm on 14 May, but there will be some spaces for visitors too. Let me know if you’d like to attend.
If you’re down under (or heading down under) and you’re planning to attend the big IIQM Qualitative Methods extravanganza in Melbourne – and I hope you are – I’m doing the opening plenary. Just for once I’m not talking about NPT, Burden of Treatment, or Minimally Disruptive Medicine. I'm also doing a workshop on ‘the basic mechanics of theory building’ which I hope students and early career researchers will find useful. There are still about seven places left at my workshop, and there are few places at other workshops too. Sally Thorne from UBC is doing a great workshop on data analysis in applied health research; and Alex Clark (Alberta) will be doing a really useful session on grant proposal writing. Check out the the workshop time table here.
Back in the summer I was lucky enough to spend some time with James Dunbar and his group at the fantastic Flinders University business centre in Melbourne. We were talking about the Diabetes Collaborative that they are working to support, and using NPT as a framework to think through an unusual problem. How do you deal with implementing events that are rare? We'll have a paper about this ready for publication next year, but in the meantime there's a lot of interest in analysing quality improvement processes using NPT. This is exciting, because QI work is so vital to improving patient experience and outcomes. Trudy van der Weijden's group in the Netherlands has just published a useful and interesting paper that applies NPT to a QI trial. Trudy is one of Europe's leading knowledge translation researchers, and she and I have just participated in a really interesting project - led by Glyn Elwyn, at Dartmouth College in the US - to develop a model for deliberative decision-making in the clinical consultation.
The North American Primary Care Group conference is happening in New York at the moment. The brilliant Victor Montori gave a keynote on Minimally Disruptive Medicine. By all accounts, this was one of the best keynote talks ever given by anyone, and he received a well deserved standing ovation from an international assembly of primary care researchers. If you've ever given a conference plenary, you'll understand what an impossible concept a standing ovation is, and what an extraordinary presentation it must have been. I really wish I had been there!
Frances Mair and I have an Editorial in this week's British Medical Journal that sets out some of the key problems around Burden of Treatment and multi-morbidity. That the BMJ should commission this editorial from us shows that the idea of Burden of Treatment is getting traction across the healthcare economy. And why shouldn't it? The bug issue here is patient and carer workload - something that we know much less about than we should. The editorial comes hot on the heels of an important meeting sponsored jointly by the National Institute of Health Research and the Royal College of General Practitioners that sought to develop a strong research agenda on multi-morbidity. The key message that I took away from that meeting was that there was a real risk of turning multi-morbidity into a kind of new disease in itself - in the way that we often now hear chronic illness and long-term conditions spoken about in a quite undifferentiated way. In fact, the big problems here are at a system level, and they're the problems that Frances and I discuss in our editorial. I was a plenary speaker at the RCGP NIHR Multimorbidity meeting and I've embedded my powerpoint presentation below.
I've just advertised an interesting vacancy for a post-doc Research Fellow to work with our NIHR funded programme of work on Complexity, Patient Experience and Organizational Behaviour. The Fellow will mainly work on two projects, the first is developing an implementation analysis in relation to a large clinical trial. We will have a plethora of interview data relating to how people understand and use an everyday health technology, how clinicians make decisions about its use, and about how the marketplace for the technology is organized. We're developing an interesting analytic framework that links micro approaches to the affordances of technologies to macro level analyses of market structuration. The second project is a large scale qualitative meta-synthesis that will look at patient careers through complex illness trajectories towards the end of life. Here the Fellow will support two clinical academic fellows as they develop the review, and work to support the development of a conceptual model of complex illness trajectories that could be the foundation for further research.This is really interesting stuff, and for a recent PhD interested in integrating theoretical development with real data about important problems this combination of projects - both of which ought to produce several publications - could easily be a goldmine. Check out the further particulars on the University of Southampton website and see if the post is the right one for you.
Action & Context
I've had a great summer: NPT workshops in Melbourne, Australia; Prato, Italy; E2P14 at the King's Fund in London, and in Newcastle in the UK have been really successful, and we've had the opportunity to talk through some of the really interesting complexities of implementation with healthcare providers - clinicians and managers - as well as researchers. In conversation, they have articulated three important needs: to have rigorous conceptual models of the adoption, implementation, and embedding of innovations that are (a) relatively comprehensive; (b) that are linked to actual experiences of the organization and delivery of healthcare; and (c) that can be operationalized through practical tools for understanding and ‘thinking through’ implementation processes. So this is an exciting prospect for the next stage of developing from NPT a useful set of policy and practice tools. We already have plans to revamp the NPT website and add the NPT questionnaires that Tracy Finch and colleagues are developing, but some new opportunities are coming on stream too. I'll keep you posted.
Some really interesting questions about the role of context have been coming up in discussions about applying NPT. Elizabeth Murray and colleagues have undertaken an important systematic review of implementation studies that points to the shaping effects of different aspects of implementation contexts. The big question is how to integrate 'action' and 'context' in studies. Mandy Stijnen and colleagues at Maastricht have done a really nice job in a recently published paper that describes a complex intervention to improve health-related quality of life and reduce disability among potentially frail community-dwelling older people in the Netherlands. Importantly, they show how NPT constructs were used to frame specific research questions. It's pretty cool, so check it out.
I'm really interested in the ways that we understand action in context - the fundamental social science question that I'm interested in is about how we understand the dynamics of human agency in conditions of constraint - and I'm contemplating hosting an expert seminar on this topic in 2015. If you'd be interested in attending or contributing to a meeting like that, please let me know, Use the comments box below.
NPT, ACPs & Italy
This week, I'm giving a keynote talk in Prato, Italy at a meeting being run by Monash University and Newcastle University on Electronic Health Records and Health Improvement. It should be a great meeting, and Trisha Greenhalgh is giving the other keynote, talking about her research on Electronic Health Records. My friend and collaborator Tracy Finch is chairing sessions and giving a paper. It all be great to see her again and hear what she's been up to. In my keynote, I'll be talking about Behaviour Change, Practice Implementation, and Organisational Context. To give what I'm saying a practice edge, I'll use NPT informed systematic reviews of implementation studies of practice guidelines and advance care plans as a vehicle for thinking about professional and patient behaviours in conditions of constraint.