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?‘ 

Posted in CPD, Critical realism, Ethics, implementation science, PhD, Research | Tagged , , ,

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 , , , , , , , , , ,

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 , , , , , , ,

How do speech and language therapists go about doing their work, and why do they do it that way?

Although my PhD is in the field of implementation, I have a somewhat uneasy relationship with the word.

According to, its etymology can be traced back to Late Latin, meaning ‘a filling up’ in the sense of completion, satisfaction or fulfilment. I like this because, for me, ‘implementation’ is about people doing something because it matters to them and because they are curious to see if it makes a difference. I am uncomfortable with an alternative definition that focuses on compliance, carrying out orders and doing what you have to do in order to get what you want.

Speech and language therapists have many demands on their time and energy, and you don’t have to be among them very long to know that their main motivation is helping their clients. Implementation scientists want to support therapists to integrate research findings into this process, also with the aim of doing the best for clients. But, as sociologist Ray Pawson argues so eloquently (e.g. 2013), implementation is not a passive, one-way process. Rather, it is a cumulative, dynamic chain that depends on the active reasoning and reactions of all involved at different stages in different contexts. It is therefore important that implementation scientists ask how therapists already go about doing their work, why they do it that way, and what the consequences may be.

Within speech and language therapy research, implementation papers that I like include Walden and Bryan (2011), Muttiah et al. (2011), James (2011) and Crais et al. (2006). This is firstly because their research designs recognise the social, interactive and reciprocal aspects of implementation, but secondly because I think they give real clues about how we can improve efforts to support practice change. I am looking forward to exploring this theory further.

Posted in Books, journals and articles, CPD, implementation science, Research, Service delivery, Speech and Language Therapy | Tagged , ,

Manualised interventions – can they help us change practice?

“The profession of speech therapy in Great Britain has never taken kindly to the construction of stereotyped programmes of treatment. It perceives therapy to be a creative process in which procedures are used with considerable selectivity.”

This introduction to Jennifer Warner, Betty Byers-Brown and Elspeth McCartney’s 1984 book ‘Speech therapy: a clinical companion’ makes me smile because I instinctively identify with it. Perhaps that is why it has taken me some time to come round to the idea that a manualised intervention is not the same thing as a stereotyped programme.

Health services researchers encourage practitioners to use published interventions which are accompanied by a manual and based on the findings of peer-reviewed research. If this research has been done well, and the theory behind the intervention is clear, it is easy to see the advantages. A manual has to include detailed information and instructions that help therapists and families think about important questions such as: who is it for? why can we expect it to work? how should we use it? what is the point of each component? how much can we adapt it? how can we record progress? how often does it have to be done to be effective?

The  ‘What Works‘ database of interventions for children with speech, language and communication needs shows that relatively few are manualised. Moreover, the reports from the Better Communication Research Programme suggest a vagueness and lack of consistency in describing what we actually do with clients and why. Research efforts are therefore focused on better description of interventions. In my own unit, for example, Alex Pollock is doing some really interesting systematic review work by breaking reported interventions down into component parts and finding that we can usefully compare apples with pears (pp.1-17).

When we are discussing a potential practice change with colleagues, thinking about the principles of manualisation may actually help us to be more creative and selective. The TIDieR checklist and guide was published recently in an effort to improve the description of interventions in research reports. I’d be interested to know if it’s also useful in a practice context (see table 1).

Posted in CPD, implementation science, Research, Resources, Speech and Language Therapy | Tagged , , , , ,

Smoothing the way for practice change

Journal Clubs are becoming popular as a way for teams to look together at research evidence and decide if practice needs to change as a result. But do we give enough thought to what happens next? Introducing and getting familiar with using a new practice / intervention (or adapting or stopping use of an existing one) takes a lot of work. Paying more attention to implementation might benefit our clients if it leads to us changing our practice more quickly and effectively.

Mulling over an idea before you do anything about it, both on your own and together with other people, is part of making it happen. One of the most useful frameworks I have found for thinking through implementation is Normalisation Process Theory. Unfortunately, while the theory itself is very practical, the wording is too complicated to make this immediately obvious. So, with some trepidation but in the spirit of speech and language therapy, here is my first attempt at an accessible version. (Although I have adapted it from table 1 in Mair et al., 2012, I take full responsibility for any misinterpretation of the original theory!) You will need to amend the questions depending on the ‘thing’ you are discussing, whether you are intending to implement or de-implement it, and to take account of the opinions of all the groups who need to be involved (e.g. clients, user representatives, other professionals).

Normalisation Process Theory is organised into 4 sections, each of which has 4 sub-sections. I have phrased all of these as questions for discussion, and it would be pointless to treat it as a tick-box list. Although there will always be overlap, each sub-section offers a slightly different perspective. This may highlight tensions between members of your team, or between your team and other groups of people, and help you decide where to focus your efforts.

Section 1: Does the new practice make sense?

a) How is the new practice different from what we are doing already?

b) What difference can we expect it to make?

c) What would each of us need to do to get it to happen?

d) What makes the new practice important?

Section 2: Do we want to make the change?

a) Does everyone agree it is a good idea to do this?

b) Are we able and willing to persist with it?

c) Do any of us want to take a lead in showing how it can be done?

d) Do we think it’s right for us to be doing this?

Section 3: How will we go about it? 

a) Will this change have an impact on our roles or responsibilities, and what training will be needed?

b) Will we have any support from our organisation to make the change happen?

c) Could the new practice make our job easier in any way?

d) Are we confident that the new practice will work?

Section 4: How will we know it’s been worth doing?

a) How will we collect information about any adaptations we make?

b) How will we find out what other people (e.g. clients) think of the new practice?

c) How will we collect and use information about how the new practice has affected us and our work environment?

d) How will we measure benefits or problems resulting from the new practice?

Posted in CPD, implementation science, Professional standards, Research, Resources, Service delivery, Speech and Language Therapy | Tagged , , ,

Questions of efficacy, effectiveness and implementation

When doing research in an applied field such as speech and language therapy, different sorts of questions are needed depending on what you are trying to understand. As with all attempts at categorisation, the following question types have fuzzy and overlapping boundaries. However, in general, when investigating a particular intervention or practice:

Efficacy questions ask:
Can it work? For whom? How? Why?

Effectiveness questions ask:
Does it actually work? For whom? In what contexts? How? Why?

Implementation questions ask:
Does it get done? By whom? In what contexts? How? Why?

It becomes more complicated to explain what we are doing when we ask efficacy, effectiveness and / or implementation questions about a strategy designed to encourage implementation of an intervention or practice! Nonetheless, attention to implementation is vital.

This will not come as a surprise to speech and language therapists. They have long had to ask all these questions of themselves, their clients and other professionals to try to understand whether and how their intervention strategy may be making a difference. Communication impairment impacts on every aspect of life, and all  strategies (whether they are direct or indirect) depend on work being done.

Posted in CPD, Ethics, implementation science, Research, Service delivery | Tagged , , ,