General practices as emergent research organizations: a qualitative study into organizational development

BACKGROUND: An increasing proportion of research in primary care is locally undertaken in designated research practices. Capacity building to support high quality research at these grass roots is urgently needed and is a government priority. There is little previously published research on the process by which GP practices develop as research organizations or on their specific support needs at organizational level. METHODS: Using in-depth qualitative interviews with 28 key informants in 11 research practices across the UK, we explored their historical accounts of the development of research activity. We analysed the data with reference to contemporary theories of organizational development. RESULTS: Participants identified a number of key events and processes, which allowed us to produce a five-phase model of practice development in relation to research activity (creative energy, concrete planning, transformation/differentiation, consolidation and collaboration). Movement between these phases was not linear or continuous, but showed emergent and adaptive properties in which specific triggers and set-backs were often critical. CONCLUSION: This developmental model challenges previous categorical taxonomies of research practices. It forms a theory-driven framework for providing appropriate support at the grass roots of primary care research, based on the practice's phase of development and the nature of external triggers and potential setbacks. Our findings have important implications for the strategic development of practice-based research in the UK, and could serve as a model for the wider international community.     

Sampling in qualitative research: a proposal for procedures to detect theoretical saturation

A qualitative study's methodological transparency is considered a key factor for achieving its reliability and should be guaranteed by the researchers. Closing the sampling process by saturation is a common approach, but it is rarely made explicit in research reports. Qualitative researchers also commonly experience technical difficulties in objectively identifying saturation. This article proposes a method to organize sample closing by saturation, with a sequence of eight procedural steps for treating and analyzing data collected through open or semi-structured interviews or focus groups. The article aims to help researchers objectively explain how and when saturation occurred and to allow their readers to know how this process occurred.     

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background  

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.     

Perceived barriers to the development of modern public health in Bulgaria: a qualitative study

Objectives  

This qualitative investigation documents Bulgarian perspectives on public health following its accession to the European Union (EU) and explores perceived obstacles to the modernization of public health sciences to more effectively address the country’s high rates of premature avoidable mortality.     

Head masters' perception of school-based hostility in Alicante, Spain: a qualitative study

BACKGROUND: There is growing social concern about school violence but little is known about how this situation is experienced in the schools. The objective of this study was to know the perception that School's head masters have of the school-based hostility, on their causes, how they value current preventive strategies, and their recommendations to develop future preventive interventions. METHODS: We conducted an exploratory study with 14 semistructured interviews of School's head masters. Interviews were conducted at the Schools between May and June 2003 in 1 independent school, 9 state comprehensive schools, and 4 other comprehensive schools within the city of Alicante. RESULTS: The perception of the head masters is that the prevalence of violence is low, more verbal than physical and within gender. They identify lack of punctuality, absenteeism and lack of interest as forms of hostility. As causes they identified age, family problems, school environment, society, media (TV and video-games) and poor language skills. Preventive methods in use were, on one hand, extra-lessons and transversal contents foreseen in the Education Law and common to all schools, and, on the other hand, ideological and pedagogical contents which were specific of some centres. Recommendations focused in demands for increased economic support and skilled human resources. CONCLUSIONS: School-based violence is not perceived as an alarming school issue, nor by its magnitude neither by the immediate causes and students' characteristics to which it is associated. A heavier emphasis is placed on external and environmental causes perceived as much more difficult to confront.     

Adoption of the AHCPR Clinical Practice Guideline for Smoking Cessation: a survey of California's HMOs

OBJECTIVE: Our objective was to assess the degree to which health maintenance organizations (HMOs) and Medicaid managed care (MMC) plans in California have adopted the 1996 AHCPR Clinical Practice Guideline for Smoking Cessation. (AHCPR [U.S. Agency for Health Care Policy and Research] was renamed AHRQ [Agency for Healthcare Research and Quality] in 1999.) METHODS: A fax survey of 13 licensed HMOs and 21 MMC plans operating in California in 1999 with up to 10 follow-up contacts by telephone, mail, fax, and/or electronic mail. RESULTS: Awareness of the AHCPR guideline is widespread, and all HMOs in California in 1999 offered coverage for at least one treatment for smoking cessation. We found that 77% of the HMOs in California were aware of the AHCPR guideline, but less than half had used it to design benefits or distribute treatment guidelines to medical care providers in their networks. While only 23% of California HMOs covered the nicotine patch or gum, 69% covered at least one form of the pharmacotherapy and one type of counseling to treat tobacco dependence. In addition, a majority of the HMOs and MMC plans inform their members about coverage for smoking cessation treatments and inform providers about their role in helping smokers to quit. CONCLUSION: Considerable progress has been made in increasing access to effective smoking cessation treatments in California's managed care organizations over the last 10 years. Future efforts and research must concentrate on: (1) adopting the 2000 Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence, (2) increasing purchaser demand for coverage of tobacco dependence treatments, (3) increasing health plan documentation and monitoring of member smoking status, and (4) increasing provider provision of effective tobacco dependence treatments.     

Quality improvement strategies for organizational change: a multiphase observational study to increase insight into nonparticipating organizations

Background

The scope of implementation research is often restricted to the analysis of organizations that participate voluntarily in implementation interventions. The recruitment of participants for a quality improvement collaborative increases awareness of the specific innovation. The objective of this multiphase observational study was to identify differences between organizations that participated in a large-scale implementation project aiming to improve perioperative care, functional recovery, and length of hospital stay after gynecologic surgery and organizations that did not participate. A secondary objective was to explore how perioperative practice changed among nonparticipants.

Methods

Of the seven gynecology departments of nonparticipating Dutch hospitals, five agreed to participate in a retrospective analysis. Baseline data of participating hospitals’ (N?=?19) characteristics, time to functional recovery, and length of hospital stay were compared. Outcome measures for the subsequent pre-post awareness study in the five nonparticipating hospitals were: (1) overall adherence to predefined evidence-based perioperative elements; and (2) change in functional recovery and length of hospital stay. Multivariable regression models, adjusted for baseline characteristics, were used for analysis.

Results

In retrospect, nonparticipating and participating hospitals did not differ in baseline characteristics, functional recovery, and length of hospital stay. In three of the five nonparticipating hospitals, adherence to the selected evidence-based perioperative elements increased significantly after awareness of the trial (overall mean difference 9.7%, 95% CI 6.9 to 12.5%, p?<? 0.001). Linear regression models revealed no statistically significant or clinically relevant differences in time to functional recovery (mean difference???0.2?days, 95% CI -0.7 to 0.2, p?=?0.319) or length of hospital stay (mean difference???0.4?days, 95% CI -1.3 to 0.5, p?=?0.419) in the nonparticipating hospitals. None of these hospitals managed to reduce time to functional recovery or length of hospital stay significantly.

Conclusions

No differences in perioperative outcomes between the nonparticipating and participating hospitals were identified at baseline. Despite the statistically significant improvement in overall evidence-based perioperative care, the awareness raised by recruitment activities alone was not enough to reduce time to functional recovery and length of hospital stay in nonparticipating hospitals. Insight into the trends of nonparticipants is valuable to existing implementation effectiveness research.

     

Recovering from a heart attack: a qualitative study into lay experiences and the struggle to make lifestyle changes

BACKGROUND: The adoption of healthy living advice by people with heart disease is known to be poor even in targeted interventions. Reasons for this can range from confusion about the seriousness of the condition to ineffectiveness in the form of advice and how it is conveyed. However, the social setting can be an important influence on lifestyle change. OBJECTIVES: To identify views and experiences of people recovering from myocardial infarction, specifically barriers to, and facilitators of, following advice about lifestyle change and maintenance. METHODS: Focus groups and interviews were undertaken with men and women discharged from hospital two/three years previously. A total of 53 people (35 men and 18 women) took part, recruited via a coronary care unit and patients' GPs. RESULTS: A major finding was participants' desires for long-term monitoring and support. While reported sources, form and content of coronary heart disease advice varied, most participants agreed that long-term follow up or back-up would be helpful, although what this should include and how it should be undertaken was not the same for all participants. This would fulfil needs such as: help in following lifestyle advice; sharing with people with similar experiences; regular contact with medical/health professionals (for confirmation of good heath and to ask questions); providing reassurance to other members of the patients' families. CONCLUSIONS: A long-term programme is needed incorporating mutual support and sharing with regular (not necessarily frequent) input from practitioners of information, advice and reassurance, as a support strategy for lifestyle change.     

Gaining insight into the health effects of soy but a long way still to go: commentary on the fourth International Symposium on the Role of Soy in Preventing and Treating Chronic Disease

Research into the health effects of soyfoods and soybean constituents has increased at a phenomenal pace over the past decade. This research includes a wide range of areas, such as cancer, coronary heart disease, osteoporosis, cognitive function, menopausal symptoms and renal function. Importantly, there are an increasing number of clinical studies being conducted in this field, which was quite evident from the findings presented at the Fourth International Symposium on the Role of Soy in Preventing and Treating Chronic Disease, November 4-7, 2001, in San Diego, California. There is no doubt that progress in understanding the health effects of soy is being made, but much of the data are frustratingly inconsistent. For example, there were conflicting results presented at the symposium on the role of isoflavones in bone health. Similarly, presentations painted an unclear picture of the role of isoflavones in cholesterol reduction. The relatively short duration and small sample size of many of the human studies in this field likely contribute to the inconsistent results. Although there are some controversies regarding the safety of soy for certain subsets of the population, special sessions at the symposium on breast cancer and cognitive function did much to alleviate concerns that soy could have detrimental effects in these areas. Furthermore, published data and new research presented at this meeting suggest that the consumption of even 10 g (typical of Asian intake) of isoflavone-rich soy protein per day may be associated with health benefits. If this modest amount of soy protein were to be incorporated in the American diet, it would represent only approximately 15% of total U. S. protein intake.     

Different timetables for change: understanding processes in reorganizations--a qualitative study in a psychiatric sector in Sweden

PURPOSE: It is well-known that a decrease in economic resources in health care results in increased workload, stress and pressure on personnel. The main aim of this study was to explore and understand how personnel in health care were influenced by multiple obligations in the context of a changing surrounding. DESIGN/METHODOLOGY/APPROACH: Personnel within psychiatry were interviewed in an open-ended, interactive mode. The transcribed interviews were analysed using grounded theory as the method of study. FINDINGS: These professionals working within a turbulent work situation experienced a struggle between external demands and internal obligations of an ethical or ideological character. For many of them earlier psychological contracts were broken, earlier organizational culture was overthrown and their professional authority was threatened. They were required to change or abandon well-established professional identities. Fundamental changes such as the transition of theoretical framework or revision of internal obligations have quite a different timetable from a technical change of method or organizational structure. PRACTICAL IMPLICATIONS: The findings of two timetables for change should be addressed when considering reorganizations. If these findings are applied to personnel in health care, seeing them also as patients in the system may be avoided. ORIGINALITY/VALUE: The different timetables for external change and internal reorganization, with support from findings in in-depth interviews, have not been described until now.     

Multidisciplinary cancer care in Spain,or when the function creates the organ: qualitative interview study

Background  

The Spanish National Health System recognised multidisciplinary care as a health priority in 2006, when a national strategy for promoting quality in cancer care was first published. This institutional effort is being implemented on a co-operative basis within the context of Spain's decentralised health care system, so a high degree of variability is to be expected. This study was aimed to explore the views of professionals working with multidisciplinary cancer teams and identify which barriers to effective team work should be considered to ensure implementation of health policy.     

Land mines in the field: a modest proposal for improving the craft of qualitative health research

In this commentary, the authors encourage a renewed enthusiasm for attention to quality criteria in qualitative health research by poking fun at what they understand to be patterns and themes emerging from data collected in their respective extensive "fieldwork" experiences within the genre. Conceptualizing some of the particularly problematic interpretive turns as land mines in the field (or, alternatively, missteps in the dance, cracks in the pottery, wrong turns in the journey, weeds in the garden, or dropped stitches in the quilt), they challenge researchers' collective relationship to both factual and metaphoric empirical claims. With a warning to those unaccustomed to self-deprecating humor, the authors challenge all to pay serious heed to what does and does not constitute rigorous, high-quality, empirical science within the qualitative tradition.     

Factors affecting language development in West African children: a pilot study using a qualitative methodology

Data on referral patterns to pre-school facilities for speech- and language-delayed children suggest that West African children are over represented relative to other ethnic/language groups. This study was set up as a pilot to explore some of the issues which distinguish this group of children and their families. A qualitative methodology was adopted to access the views of a small group of parents (nine) and professionals with direct experience of these services (three). Between them the parents had a total of 11 children who had received speech and language therapy services. Extensive in-depth interviews were transcribed and coded. The families are predominantly well educated with high expectations for their children. Their beliefs about child development in general and language development often differed from those of the professionals interviewed. For example, parents saw little direct link between very early language stimulation and subsequent school performance. West African parents also perceived that they had different (higher) expectations of behaviour than other families. It was generally accepted by all parties that the West African community experiences a high degree of stress resulting from a combination of interacting factors, namely pressures relating to employment, to immigration status, to matters financial and to expectations from family back in their own country. It is unclear exactly how these impact on the development of the child but there is an awareness that there may be a negative effect of such stress and that children's speech and language development may be one aspect of development that is affected. As a result of this pilot study a number of mechanisms relating to the relationship between environment factors and language development are proposed and suggestions are made regarding service provision for this community.