Practice change in speech and language therapy: from PhD thesis to Plain English

It’s embarrassing as a speech and language therapist to admit this: I find it difficult to communicate the findings of my PhD in a way that can be easily understood.

My thesis is open access, but access doesn’t make it accessible. I’ve therefore been working on a Plain English summary.

I’ve tried to take into account the “I don’t know what you’re talking about” feedback. This relates to broad fields including speech and language therapy, client groups, qualitative research, sociology, implementation science, and critical realism. Here’s the latest version.

How speech and language therapists have changed their practice: a summary of my PhD in 400 words

Why did I think this research was needed?

Speech and language therapists work with people who have communication difficulties. For each person they see in clinical practice, therapists try to use approaches that will make the biggest difference. This takes skill because there are a lot of approaches to choose from and different combinations suit different people. On top of this, when therapists want to use a new approach, they need to be able to change what they are used to doing. I wanted to find out what it really takes for therapists to change their usual clinical practice.

How did I go about it?

I asked speech and language therapists how and why they had changed their clinical practice with children with speech problems. I considered how this was the same and different across three NHS speech and language therapy services and therapists working privately. I paid attention to how long these practice changes had taken and who and what had been involved. I noticed why some new therapy approaches seemed easier for therapists to use than others.

What did I find out?

Therapists had changed their usual clinical practice in six main ways:

1. using new approaches
2. organising therapy more often for particular children for a set period of time
3. trying out new approaches with particular children
4. making therapy very personal
5. teaching parents to do the therapy
6. constantly adjusting therapy to improve or freshen it up

I identified patterns in what had happened to make these changes to usual clinical practice possible. I found that the service where therapists worked had a big influence.

What do I think is the key message?

Changing usual clinical practice is hard work and careful planning is needed.

Knowing or learning about a new approach is not enough. To use even one new approach (‘Intervention’) in clinical practice can take a lot of thinking, organising, adapting and imagination. For it to be possible, therapists might also have to change two other things. The first is how they decide who gets therapy and when they get it (‘Candidacy’). The second is how they organise their work (‘Caseload’). In addition, the service where the therapists are based (‘Service’) might have to support the extra work involved for a number of years.

Changing therapists’ usual clinical practice may be more successful if Intervention, Candidacy, Caseload and Service are all considered.

So am I getting there? What questions does this summary leave you with? And does it matter that there is no space to acknowledge any of the work the thesis was built on? I’d also be interested to hear other ways people have gone about tackling this communication gap.

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Making memories: equal pay and learning about oral history

This (10th November) is Equal Pay Day 2016, the point in the year when women in Britain effectively stop earning relative to men. I’ve just come across an abridged oral history from 2006 reflecting on the fifteen year equal value case for NHS speech and language therapists. It features Pam Enderby, whose landmark case was successful at the European Court of Justice. Appropriately for an oral history project she observed, “what’s fascinating is everyone’s got a slightly different memory.”

dsc_0002Calling up different experiences, images, emotions and stories from past life and making sense of them from the present is the business of oral history. I joined other PhD students from across Scotland at an excellent University of Strathclyde oral history training day last week. The methodology clearly has wide appeal as, while I’m researching practice change in speech and language therapy, I was joined by people from disciplines including music, anthropology, politics, history, literature and sociology.

We learned that oral history is usually used to explore areas of life that are not well documented, or where particular perspectives have been excluded. As memory is not well suited to reconstructing an accurate past, oral historians instead harness it as a powerful way of interpreting what events in the past have come to mean for the people who remember them. This may be more varied and diverse than we expect.

The way we record memories is partial, and depends on what else is going on at the time, or what captures our interest. We retrieve memories in different ways, often helped by visual and sensory cues, or going back to particular places. In oral history interviews, interviewees also decide what to remember and how to tell it. This is always influenced by how they relate to the person who is interviewing them, and what other events have happened around the time of the interview.

One of the most interesting discussions for me was how memory is dynamic. This means our memories continue to adapt or change depending on how the same event, idea or experience becomes talked about and remembered publicly or collectively. While this can give some people a framework for talking about their experiences, it may make recall difficult for those who struggle to make what they remember fit the popular imagination.

The excellent Where Methods Meet series of videos shows that research methods often have much in common, and much to offer each other, and that’s certainly the case for oral history. In addition to well-developed ideas on memory and the social nature of an interview, I learned from the training day that oral historians have particular expertise around the ethics and logistics of archiving data, as well as engaging communities through research.

In the equal pay oral history, Margaret Evesham has interesting memories on the contrast between therapists who had rich husbands and those who were single parents, and Pam recalls the injustice of a male clinical psychologist colleague earning considerably more with less of a research portfolio. Lesley Cogher remembers feeling guilty when she was awarded the settlement, until the Union solicitor said, “You can’t run a health service on the backs of underpaid women”. In a review of oral history in Scotland, Angela Bartie and Arthur McIvor noted a gap on the meaning of work in the professions, so I hope there will be more opportunities to explore speech and language therapy in this way.

Using oral history in social science research: a workshop for PhD students was organised by the Scottish Graduate School of Social Science. It was held on 4th November at the Scottish Oral History Centre, University of Strathclyde and led by Arthur McIvor, Erin Jessee and Alison Chand.

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Presenting research findings: Tales of the unexpected

A friend getting ready for her viva was given a great bit of advice: there will always be something unexpected which you can only prepare for by accepting it will happen. I was reminded of this following my first experience presenting early findings from my PhD.

I’m investigating what it really takes to change practice, so have asked speech and language therapists about their experiences of practice change. I’m a member of the profession, studying the profession, and I was preparing a lightning talk for research-active members of the profession at the Royal College of Speech & Language Therapists (RCSLT) Research Champions day. No pressure…

Throughout the design and implementation of my study I’ve thought carefully about potential ethical implications for the participants and for the profession. I have also been conscious that qualitative research is not yet as familiar to or valued in the profession as other methods. My purpose is to describe and explain how and why practice has come to be as it is. While it is up to potential users of the research to decide whether and how they act on it, I have a responsibility to present the study in a way that they understand the assumptions running through it.

With this in mind, I chose to act out three monologues to show how one aspect of practice has lived on and changed in different ways in different contexts. To help ensure this would work in the way I hoped, I had already tried it out with colleagues at NMAHP RU, at a realist writing retreat, and with my mum. At each stage I used their critical feedback to hone and improve the clarity of my message.

I was curious to find out how I would feel presenting it to members of my profession, and how they would hear it. The nine 7 minute talks were about diverse projects. It was a warm, supportive audience, a number of whom were live tweeting, sparking further exchanges beyond the event. I had expected to be nervous, but to enjoy it, and to get a clear sense of whether my study would resonate.

What I was not prepared for was how profoundly the experience would make me reflect again on the ethical and political dimensions of presenting findings, and on the significance of the relationship between what is being researched and the expectations, ideas and experience the audience (in the room and beyond) brings to that. There is a fine line between presenting research in a way that resonates and in a way that reinforces stereotypes. I hope I didn’t cross it, but will have to remain mindful.

The RCSLT Research Champions day was on Friday 1st July 2016 at City University, London. Research Champions are members of the profession who form a supportive and capacity-building network across the United Kingdom. 

Posted in Conferences, CPD, Ethics, implementation science, PhD, Qualitative research, Research, Speech and Language Therapy, Uncategorized | Comments Off on Presenting research findings: Tales of the unexpected

Meta-ethnography: interpretations of interpretations of George Noblit

George Noblit in Edinburgh (photo by Siti)This post is my take on a methodology seminar at Stirling University and a public lecture in Edinburgh where Professor George Noblit asked ‘How qualitative (or interpretive or critical) is qualitative synthesis, and what can we do about this?’

What are we talking about?

Primary qualitative research in its many forms can help us understand how and why people experience the world in different ways. Qualitative synthesis is an umbrella term for methods used to bring reports of primary qualitative studies together. The aim of qualitative synthesis is to say more about a phenomenon than each included study could do on its own. Meta-ethnography is one approach to qualitative synthesis that researchers can draw on when designing a study.

Meta-ethnography was pioneered by George Noblit and Dwight Hare as an alternative to aggregative approaches which summed studies but failed to show what could be learnt from them. In 1988 Noblit and Hare published the seminal “little blue book”, Meta-Ethnography: Synthesizing Qualitative Studies. While this remains the foundation text, the context in which meta-ethnography is being designed and conducted is today very different, with researchers (as people) interpreting the principles – and how to put them into practice for different purposes – in different ways.

What’s the purpose of meta-ethnography?

Given that I am attempting a meta-ethnography as part of my PhD, I was fascinated to hear what George makes of developments in the field. He is passionate about synthesis methodology, and refreshingly relaxed about what people do with meta-ethnography as long as they are clear how they are going about it. However, as researchers help to construct ideas about society, he would prefer they use it for interpretation (to reveal taken-for-granted assumptions) and critique (to reveal how these are structured by power and ideology). This includes noticing what in the included studies could enable people to choose to do something more about their situation.

What are the implications of current practice?

George sees meta-ethnography as a way to talk about what we understand, in order to understand how we understand. He challenges some assumptions that (along with computer technology) are driving the current practice of meta-ethnography, comparing it to the tail wagging the dog and forcing research into a political discourse. These include that meta-ethnography:

  • is about an identifiable social problem (when it can be more appropriate to examine assumptions of what we think is okay)
  • says something definitive for a practical activity (when we need to build in the possibility of not having conclusive results)
  • needs to include all studies of a phenomenon (when it is more appropriate to layer the synthesis through iterative readings and more and more specification at each stage while preserving complexity and context).

George believes that misunderstandings of Noblit and Hare’s intentions have influenced what as well as how people have chosen to synthesise. As a result, if he was re-writing the book now, he would make two other methodological aspects of meta-ethnography clearer.

The first misunderstanding is that synthesis is literally of the ‘findings’ of included studies. Authors of a paper construct the whole account, and report their results in a way that fits this account. As there is more in accounts than the words say, there are clues for a synthesiser in the introduction, methods and conclusions sections as well as in the findings / results. George wishes he had used the term ‘storylines’ to show how synthesis can reveal what is not apparent in the individual stories alone. While the authors’ choice of themes can be used to explicate storylines, theme-to-theme synthesis is overly reductionist. George says it may therefore be appropriate to re-theme an account, “mess with” the authors’ interpretations, consider the connotations of terminology, and find the unacknowledged counter-stories.

The second misunderstanding is that the synthesis is about what is said in the accounts without considering the contexts in which they were produced. George sees this as “a real failure of our book”, as it is essential to add context to a synthesis that isn’t in the individual studies, such as what could or could not be said, the influence of time, geography, and professional cultures, or relationships between the researchers and the studies. “Even speculative context is helpful”, and he finds a historical perspective good for unpicking assumptions.

How can we contribute more through meta-ethnography?

The combination of storylines and context enables synthesisers to think about connections, and through this to understand mechanisms, which George believes is an essential contribution of a meta-ethnography. Acknowledging that observing and contemplating takes “forever” and can be “pretty boring”, he emphasises the need to play, to find ways to pay attention to what we are learning at each stage, and to notice what we may take for granted (for example by using a dictionary to consider older and newer meanings of words).

George proposes thinking of knowledge as a verb rather than a noun. This perhaps fits with his preference for using “I” in academic writing, a field that is more known for its pursuit of an abstract, formal tone through the use of nominalisations and third person. He also believes that a meta-ethnography should offer a comment on a field of study – including how knowledge gets constructed – and set a research agenda. In view of this, George suggests making it more participatory and accessible, with every step open to experiment, comparison and critique so we can discover what differences make a difference.

Professor George Noblit was in Scotland from 20th-24th June 2016 to work with the the eMERGe project team, who are developing a guideline to help researchers improve the quality of their meta-ethnography reporting. The seminar for researchers at Stirling University was arranged by Emma France of the NMAHP Research Unit, and the public lecture at the Dovecot Studios, Edinburgh was hosted jointly by NMAHP RU and the Scottish Collaboration for Public Health Research & Policy (SCPHRP). A video of the seminar and a Q&A chat with SCPHRP’s Ruth Jepson will be available soon.

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How can we talk about photos in research and therapy?

Penny Tinkler presented an IIQM webinar this week, ‘Talking about photos: how does photo-elicitation work and how can we use it productively in research?’ She explained that photo-elicitation doesn’t always meet researchers’ expectations and so, in order to use it well, we need to have a better understanding of how it works. Although aimed at researchers, it struck me that this is also highly relevant to speech and language therapists who want to get the most out of using photos in therapy.

Penny’s presentation included:
• Talking with photos versus talk-alone
• Using personal photos versus ones that have been taken for the session
• The way that photos provide a shared point of reference for communication
• Photos as a complex sensory experience (chills down the spine; smells)
• The relationship between photos and time
• Why photos might encourage talk and silences
• How familiarity or obviousness of the photo can be a double-edged sword
• The whole picture versus noticing detail
• Presenting photos creatively to stimulate communication
• Photos for sense-making through memory, processing and composing an account

Penny’s slides are available via IIQM, and the recording of her presentation is due to be posted on YouTube. She has also written a book ‘Using Photographs in Social and Historical Research’. It was published by SAGE in 2013, and a free chapter ‘Photo-interviews: Listening to talk about photos’ is available here.

The International Institute for Qualitative Methodology (IIQM) webinar Masterclass series is a free resource for anyone who is serious about doing qualitative research well. All webinars are archived as slide presentations and on YouTube.

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The metaphor of ‘missing data’ in qualitative research

How does the metaphor of ‘missing data’ work for you in relation to qualitative research?

Graham Crow tested this idea out with 12 of us (all PhD students) this week at a National Centre for Research Methods course. We discussed missing data as missing people, missing words, missing documents, missing contextual information and missed opportunities, as well as the ethics of missing data.

I’m at the stage of struggling with the narrative outline of my PhD; what is its argument, its story? What struck me was how the notion of ‘missing data’ gives you a slightly different way of thinking through all aspects of your research design and practice. This means that, rather than having to break the circuit to focus on one aspect, you can keep the current flowing so it becomes easier to spot where there is resistance.

Questioning my PhD narrative for ‘missing data’ has helped me realise I need to add a connecting element, as well as how to design it. As is often the case, the power for my lightbulb moment was already coming in via a messy tangle of cables, but I needed something to flick the switch.

The NCRM course ‘Missing Data’ in qualitative research: problems and responses with Professor Graham Crow was on Tuesday 19th May 2015 at the University of Edinburgh.

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Qualitative health research in practice

York UniversityHaving spent many years editing ‘Speech & Language Therapy in Practice’ magazine, it’s not surprising that an event titled ‘Qualitative health research in practice’ had huge appeal. In placing the focus on exploring the many processes of doing qualitative research, organisers Cath Exley, Nina Hallowell and Tim Rapley created a friendly and stimulating space that enabled PhD students and early career researchers to bring uncertainties, challenges and realities into the open.

The real mark of a worthwhile event is not so much what it does on the day but how it continues to percolate. This will work in different ways for different participants. For this reason, my blogpost doesn’t offer a speaker-by-speaker account. Instead, I hope to show how the event is already helping me reflect on aspects of qualitative research practice that really matter.

1. How we frame ‘the problem’ really matters

Our framing of the problem for investigation informs our research choices, and thus builds assumptions into all aspects of study design. These assumptions affect everything from who we recruit and who we do not, to the data we generate, to how we choose to share our findings. Framing is a political act: it accepts or challenges the status quo, it is done and used for different purposes, and it can enable or prevent us hearing what may be central to a problem.

Framing ‘the problem’ can involve critiquing dominant assumptions, but challenging our own assumptions and recognising where, how and why they may be coming into play is integral to all good qualitative research. As clinician researcher David Hamilton said, we are filters of – not windows on – data, and we need to be honest about our sieve.

Exemplifying this kind of honesty, Siân Benyon-Jones explained how she made assumptions about procedures she would have to put in place to get her study through an NHS Research Ethics Committee. She got ethics approval but, because she hadn’t designed her research around the needs of the study, recruitment didn’t work until she problematised those assumptions and changed her approach.

2. Recognising that something else might exist really matters

All research is partial. Jo Wildman’s paper made me wonder how we can remain open to the possibility that we are missing something significant because of our study design. Jo is doing mixed methods work with the Newcastle Thousand Families Study cohort, which has been providing longitudinal data since 1947. She explained that how we see ‘healthy’ or ‘successful’ ageing has largely been limited by quantitative methods with a biomedical slant. While they provide an important chronicle of trends, associations and timings, they can’t recognise variation in what is meaningful. However, Jo’s in-depth qualitative interviews have captured narratives of successful ageing as ‘going and doing’, along with the previously unrecognised importance of social ties and relationships. This new knowledge has enabled the research team to adapt quantitative data collection accordingly.

The choices we make about the setting of our research also influence what we might be missing. As Diane Trusson has found, being outside a medical setting may mean participants construct their stories differently, so they are much more contextualised as part of their life. Rupal Patel also took her research into the community so it would be more inductive, and one consequence is that her data is full of complexity and contradictions. Rupal therefore drew our attention to one of the dilemmas facing qualitative researchers who have a remit to inform practice or policy: to what extent do we work against this complexity to find ‘an answer’, versus working with it to present the diversity of what exists?

3. Relationship work really matters

Qualitative research is about people in their social contexts. People are active agents, not passive blank slates. Roles are not fixed, and people and relationships are always changing. As Jenni Remnant reflected, this means that any kind of collaboration introduces politics and dynamics that you may not be able to prepare for beyond making and fostering relationships, being nice and honest, and offering cake.

A running theme was how relationship work with ‘gatekeepers’ and potential participants is crucial for study recruitment. This is not necessarily comfortable; it can involve “hanging out” at a clinic (Siân) or “lingering around” a temple (Rupal). As Siân says, recruitment needs onsite, in person work, and an information pack can’t do it.

Once a study is underway, relationship work might involve communicating critical data back to your colleagues in a way that represents the difficulties they face (David). It might also mean you compromising your own preferences to accommodate those of your participants, as Siân found when she discovered many preferred a telephone interview over face-to-face.

4. It really matters that concepts are rounded (and not hollowed) out

Qualitative research is full of concepts that have been proposed as holistic and are therefore unlikely to be definable in one way. Ashok Patnaik, for example, finds ‘culture’ has become “a vast, global, aggregative concept” that is applied in a “wildly” divergent way. He argued that it has become so “hollowed out” and conflated with other concepts that it is of no practical use. Ashok proposed dealing with such “quicksand” concepts by having narrower and tighter definitions with operational consistency, clear boundaries and uniqueness. I think this is one possible strategy, but I can’t go along with it as a rule of thumb for qualitative research – one of the strengths of language is its fluidity, and the way you choose to handle a concept and its boundaries depends on why you are using it in the first place and what you want it to be able to do.

On the other hand ‘rounding out’ concepts (Tim Rapley) is undoubtedly qualitative work. The emotional work of research was raised one way or another by all speakers. Tim observed that there is a tendency to use the concept as “a gloss” and we need to take it more seriously by rounding out what these emotions are.

Clinician researcher David Hamilton suggested a way to tackle this:
a) Describe one concept in baby steps
b) Show your working and explain your theory
c) This will expose big, gaping holes
d) These holes will lead you to ask ‘why?’ which directs your next steps.

In some qualitative research, ‘rounding out’ concepts is key to ‘theoretical saturation’. Questions were raised about the possibility of theoretical saturation, which may partly be a consequence of common misunderstandings, but may also reflect a deeper unease. This has been addressed from a realist perspective in a recent blog by Nick Emmel.

5. Transparency about process really matters

Being open about the what, why and how of our processes is essential to developing as applied qualitative health researchers with sociological imagination. As a clinician researcher, David Hamilton wants to play a bridging role, but is aware of the danger of ending up with the worst of both worlds. The work of sociologist Erving Goffman has clearly helped David notice the ethical and practical tensions of his dual role and how these play out in the front stage, backstage and subplots of his settings. Once we become aware of what might be going on, we can’t pretend it doesn’t exist.

Valuing and being transparent about process therefore takes courage, but may leave us better equipped to embrace the accidental (Diane), live with uncertainty and change (Jenni) or enter the unknown (Becca Patterson). Becca is in the first year of her PhD. Her presentation reminded me how much preparatory work is needed before you even know if you will get funded, and of the importance of creating your own support network early on.

Now in my second year, this conference was my first go at presenting an aspect of my PhD to an external audience. I spoke about why and how I have used a realist sampling strategy in the early stages of an intended meta-ethnography. This prompted discussion about there being no one ‘correct’ way of synthesising primary qualitative research reports, hence the research community should stop looking for one and concentrate instead on describing what we do and why. Preparing a presentation, delivering it, being questioned on it and getting informal feedback is nerve-racking. However, it is also a fantastic way of understanding what you are doing, who might be interested in it, and how it might make a contribution.

The British Sociological Association MedSoc Applied Qualitative Health Research Group event (#AQHR) was on 13th May 2015 at York University. Speakers were: Siân Benyon-Jones, University of York; Diane Trusson, University of Nottingham; Rupal Patel, University of Nottingham; Jenni Remnant, Newcastle University; Avril Nicoll, University of Stirling; Ashok Patnaik, University of Huddersfield; Jo Wildman, Newcastle University; Becca Patterson, Newcastle University; David Hamilton, Newcastle University.

Posted in Conferences, CPD, Critical realism, implementation science, PhD, Qualitative research, Research | Tagged , , , , | Comments Off on Qualitative health research in practice

Getting past assumptions about putting ideas into practice

What matters to us opens us to new ideas. As clinicians or researchers, we don’t make sense of an idea as a free-floating ‘thing’ but through how it relates to our practice. If we think it might help us make enough of a difference, we put effort into understanding the idea and bringing it to life. Doing this can involve a variety of intellectual, social and practical work. As this is a time-consuming but largely invisible process, sharing different experiences may help us to value and find ways of supporting it more effectively. My PhD therefore involves hearing about speech and language therapists’ experiences of putting ideas into practice.

One problem arises when we have a hunch that an idea is worth following up, but the gulf between what we know and what we think we need to know about it is overwhelmingly vast. In designing my PhD study, for example, I had a hunch that ideas from sociology could be really important, but there are only so many hours in a day and only so many books and papers I can read. To act on my hunch in a way that would help me make meaningful progress, I needed to float ideas from sociology without drowning in them. Eighteen months in, this is still percolating, but I have built a metaphorical bridge.

If we can start to ‘see’ any research study as a social scene, it becomes clear that the researcher is an integral part of what goes on in it. Visual metaphors are very good for making sense of different perspectives on a scene: ‘through the lens of’, ‘from my point of view’, ‘as I see it’. However, it can be hard to see past dominant assumptions about the world, especially if the researcher frames a study from that angle.

In trying to think about the social scene of my study more critically, I became aware that I was using an aural metaphor to apply the idea of ‘social ontology’. Social ontology is concerned with the nature of being, becoming, existence and reality in the social world. Ideas about agency, structure, culture, power, time, place, bodies and material, for example, all influence the design and conduct of research, whether we choose to hear them or not.

MixerIf social ontology is the background noise of a study, part of my ethical role as a researcher is to be aware that there is a certain amount I can do to try to ramp up or dampen down different dimensions. A bit like a sound engineer with a mixing desk, this means I need to be attuned to both the purpose of the mix and the possibility of what could be heard if things were different.

For more on social ontology, see the Centre for Social Ontology website and Mark Carrigan’s blog. Knowledge is indeed a social product, and I am particularly grateful to Margaret Archer and Mark Carrigan who hosted a PhD workshop at Warwick University in June 2014 called ‘What’s the point of social ontology?‘ 

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What can we do with applied qualitative health research?

Newcastle University

Newcastle University

The British Sociological Association has a new special interest group in applied qualitative health research. Yesterday I was in Newcastle for its inaugural symposium (on twitter as #AQHR).

Over 60 researchers had gathered to explore the question, ‘What can we do with applied qualitative health research?’ There was no shortage of answers.

1. We can do more with qualitative research to improve trials

Helen Eborall of the SAPPHIRE group called for more attention to qualitative development work on interventions before they are piloted. For a current trial, Helen’s team adapted a framework for ‘mhealth’, the name given to interventions supported by mobile devices. Phase 1 (conceptualisation) involved observation of ‘what happens on the ground’ combined with a focused literature review to inform the intervention objectives. Phase 2 (formative research) was carried out with focus groups comprising people involved in a previous trial. The phase 3 focus groups pre-tested the intervention in real-time to see how it might work or not. This meant that, rather than the final phase 4 revealing major problems with the intervention and its implementation, it was a genuine pilot used only for tweaking.

Helen emphasised that this process “really changed the eventual intervention”. For example, it demonstrated that, in order to work, the intervention had to be tailored according to a participant’s previous experience, motivation and confidence. This was then built into the design.

Process evaluations alongside randomised controlled trials are now common, but Laura Sheard and Claire Marsh showed why they are so important in ‘making sense’ of statistical data. The PRASE trial is investigating how action planning informed by patient feedback is used by nursing teams to improve patient safety on hospital wards. The process evaluation methods include observation and analysis of action planning meetings. This means explanatory non-verbal communication can be captured as well as what is said. Follow-up structured telephone interviews with lead nurses establish if intentions were implemented and what contextual information might be relevant. Fieldworker diaries add another dimension in terms of ward culture.

The process evaluation is highlighting many reasons why change is difficult, even with action planning, and why some changes are more likely to be implemented than others. Changing a culture is particularly difficult, and most nursing teams don’t feel they can challenge the status quo.

2. We can do more with qualitative research to drive improvement

One method which can leave “a legacy of cultural change” is experience-based co-design (developed by Paul Bate and Glenn Robert). However, as this participatory action research approach involves a process of discovery interviews and observation leading to the production of ‘trigger films’ for discussion, it is costly and time intensive. As an alternative, Louise Locock tested the use of national films from an archive. Patients and staff watched the films at a co-design workshop, and used their response to them to plan improvements together. As well as removing the bulk of the cost and development time, the national films were acceptable to both patients and staff. They may have reduced some of the social awkwardness that can arise around a personal story, and allowed each party to see the other as fallible, caring human beings.

Louise notes that, while the improvements that predominate are seemingly small, they can be “momentous” for those involved, for example the implications for communication, eating and overall dignity when a patient’s teeth travel with them to another ward. Louise suggests that, rather than leaving them feeling criticised, the process “reconnects healthcare professionals with the values they joined the NHS for in the first place”.

Experience-based co-design draws on narrative persuasion and transportation theory. Also making the case for the use of theory in qualitative research was Andrew Morden (MOSAICS). Andrew is interested in “getting inside practice dynamics”, and is investigating how resources and training can be developed, implemented and sustained in a way that works for patients and practitioners. He says Normalisation Process Theory, which I wrote about in a previous post, has helped explain and guide the research.

3. We can structure qualitative methods for different purposes

Ann Hutchinson also wanted to bring patients and practitioners together to understand how community management of people with long-term conditions could be improved. To do this, she used linked interviews. This means a patient (with or without a family member) is interviewed first. With their agreement, the researcher then interviews a healthcare professional who provides care to that patient.

Ann emphasised the linkage is not for ‘triangulation’ of findings, but to exploit the interaction of different perspectives to help explain and address a problem. Linked interviews take advantage of the particularisation of qualitative methods, and Ann found that emphasis on a specific patient seemed to enthuse the healthcare professionals.

When research concerns a social behaviour that is highly socially determined, qualitative methods are especially useful, and Jenny Dalrymple also wanted to focus on the particular, in this case how people’s ‘scripts’ about sexual health had changed over time. As I am planning to use episodic interviews in my PhD, I was reassured to hear from Jenny how they had worked in practice to take people back to how they felt and behaved at specific times in the past.

Depending on how they are convened, focus groups can be more like qualitative interviews, or more like participant observation. In either case, Sally Brown pointed out that interaction is the critically useful element of focus groups that often gets missed. She has found colour coding of participants’ contributions in the transcript gives a useful visual impression of power dynamics and comfort with communication in the group.

Sally has chosen to run focus groups in naturally occurring settings. This means that, rather than convening groups somewhat artificially in a neutral environment, the research is taken to places where families, friends or colleagues happen to be hanging out together. As a consequence, what is said and done, and the way it is said and done, may offer a more realistic picture and be more acceptable to participants. This is especially important to consider when our questions are around ‘social’ learning or decisions.

4. We need to value and support the work of qualitative research

The social learning aspect of the day was particularly obvious during discussions around ethics, self-care and reflexivity.

Sarah Chew and Pam Carter asked to what extent we are colluding in a deception, wasting resources and compromising ethical principles by agreeing to undertake Good Clinical Practice training. Although this is commonly required for any health service research, it was specifically developed as a safeguard for patients in trials of medicinal products and offers no protection to researchers or participants in ‘messier’ social projects.

Judy Richards also emphasised the need to move beyond the processes of qualitative research and recognise the decisions and responsibilities borne by researchers carrying out such emotionally exhausting work. Her presentation about recognising our vulnerability, reducing our isolation and finding supportive strategies provoked a lot of discussion when we divided into groups. I was reminded of two resources that have proved helpful to me. The first is a book aimed at caring professionals, ‘The Resilient Practitioner‘. The other relates to the difficulty of exiting interviews when people have been in distress, Deborah Hersh’s work on the emotional labour of discharging clients.

5. We can use qualitative research to go beyond the specific

On a day of sharing the practice and experience of qualitative research, it was appropriate that keynote speaker Carl May should urge us to participate in the “intellectual conviviality and collegiality” of communities of practice.

Moreover, as we looked to the future of qualitative research, it was also fitting that he should reflect on how we have arrived at this point. Returning to Newcastle University where he did much of the development work of Normalisation Process Theory, Carl took the opportunity to theorise his own research journey in different ways: the types of research questions he has asked, the relationships he has examined and the conceptual problems he has addressed. Although we now take interdisciplinarity for granted, Carl pointed out it was not always this way. That development may explain why methods have come to dominate our conversations, as they offer a shared vocabulary focused on a problem. We are also now “living in a golden age of middle-range theory” and need to take advantage of all that has to offer.

Through health research, we aim to identify, characterise and explain things that can be empirically demonstrated to matter. What looks like a small and isolated qualitative study is not when we move it beyond the specific. Using theory as a window, we can link empirical research with practice tools and policy objectives. Qualitative health research therefore offers “opportunities for reshaping and reinvigorating” the way that healthcare professionals, researchers and patients understand their world, and we should be ambitious in taking it forward.

Thank you to my funder ESRC for enabling me to attend this symposium, to the organisers including Cath Exley and Tim Rapley, and to all the speakers and participants for making it such a useful and friendly event.  

Posted in Aphasia, Books, journals and articles, Conferences, CPD, Ethics, implementation science, Research, Service delivery | Tagged , , , , , , , , , , | Comments Off on What can we do with applied qualitative health research?

Wired, tired or expired? A week of practice change @WeSpeechies

My week as ‘rotation curator’ of the @WeSpeechies handle on Twitter is coming to an end. The tweetchat on our topic ‘Making a change in your practice – what does it take #WeSpeechies?’ generated a particularly wide range of perspectives. This blog post is a chance for me to reflect and offer some references to follow up points raised.

1. How do we find out what supports practice change?

In a systematic review to understand why outcome measurement has failed to be used routinely by allied health professionals, Eddie Duncan and Jennifer Murray find that the barriers and facilitators relate to individual therapists, teams and organisations. Importantly, “many of these factors are bi-directional and can be viewed as either a barrier or facilitator depending on the emphasis given”. Although it is much more common to look for barriers, they suggest that putting the emphasis on facilitators may provide more useful insights.

2. Would research based in natural settings help?

Health services researcher Shaun Treweek is committed to a way of designing trials in which components are assembled to build in the likelihood of speedy and effective implementation. A successful recent example is Football Fans in Training, where professional football clubs provide the setting for weight management groups.

3. What can Journal Clubs contribute?

Lucylynn Lizarondo has had a number of articles on journal clubs for the allied health professions published. What makes this work really interesting is the way she uses the complementary skills of researchers and practitioners, and evaluates the difference the journal clubs have actually made to practice.

4. Do narrative approaches have a role in changing practice?

In a recent BMJ Quality & Safety article, Hilligoss and Moffatt-Bruce explain why narrative or ‘storied’ approaches are safer and more effective for communication-intensive practices such as patient handovers than structured checklists. Another example is Campion-Smith et al.’s use of story sharing as a way of encouraging more interprofessional learning to improve practice in palliative care.

5. What influences implementation?

Finally, if you are interested in all the elements of implementation, Laura Damschroder runs a Wiki of the Consolidated Framework for Implementation Research. Each item in the taxonomy is explained further when you click on it, and this might help you to think through where there are opportunities to encourage change in your own practice environment.

6. Are we wired for implementation?

Samuel Odom characterises implementation as “the tie that binds” evidence-based practices and positive outcomes. Somewhat tongue-in-cheek, he borrows a classification system from Wired© magazine to categorise historically our efforts to make sense of this process: Expired (practices based only on professional opinion; narrative reviews of the literature); Tired (meta-analysis; What Works Clearinghouse; quantitative reviews of studies and aggregation of results) and Wired (practice-based review of evidence; implementation science; enlightened professional development).

At the end of this week I confess to being Tired, but have thankfully not Expired. Meanwhile, @WeSpeechies founders Caroline Bowen and Bronwyn Helmsley remain relentlessly Wired. They lead by example in using social media to encourage international connection and exchange of ideas to benefit people with speech, language and communication needs. If you would like to take a turn as a rotation curator, do get in touch with them.

Posted in Books, journals and articles, CPD, implementation science, Research, Resources, Service delivery, Speech and Language Therapy | Tagged , , , , , , , | Comments Off on Wired, tired or expired? A week of practice change @WeSpeechies