Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitative study.

Stroke is a leading cause of disability. Early treatment of acute ischaemic stroke with rtPA reduces the risk of longer term dependency but carries an increased risk of causing immediate bleeding complications. To understand the challenges of knowledge translation and decision making about treatment with rtPA in hyperacute stroke and hence to inform development of appropriate decision support we interviewed patients, their family and health professionals. The emergency setting and the symptomatic effects of hyper-acute stroke shaped the form, content and manner of knowledge translation to support decision making. Decision making about rtPA in hyperacute stroke presented three conundrums for patients, family and clinicians. 1) How to allow time for reflection in a severely time-limited setting. 2) How to facilitate knowledge translation regarding important treatment risks and benefits when patient and family capacity is blunted by the effects and shock of stroke. 3) How to ensure patient and family views are taken into account when the situation produces reliance on the expertise of clinicians. Strategies adopted to meet these conundrums were fourfold: face to face communication; shaping decisions; incremental provision of information; and communication tailored to the individual patient. Relational forms of interaction were understood to engender trust and allay anxiety. Shaping decisions with patients was understood as an expression of confidence by clinicians that helped alleviate anxiety and offered hope and reassurance to patients and their family experiencing the shock of the stroke event. Neutral presentations of information and treatment options promoted uncertainty and contributed to anxiety. 'Drip feeding' information created moments for reflection: clinicians literally made time. Tailoring information to the particular patient and family situation allowed clinicians to account for social and emotional contexts. The principal responses to the challenges of decision making about rtPA in hyperacute stroke were relational decision support and situationally-sensitive knowledge translation.

'This place isn't worth the left boot of one of our boys': Geopolitics, militarism and memoirs of the Afghanistan war.

This paper argues for the continued significance of the text as a source and focus in critical geopolitical inquiry. It establishes the utility of the military memoir in explorations of popular contemporary geopolitical imaginaries, and considers the memoir as a vector of militarism. The paper examines the memoirs written by military personnel about service in Afghanistan with the British armed forces, specifically about deployments to Helmand province between 2006 and 2012. The paper explores how Afghanistan is scripted through these texts, focussing on the explanations for deployment articulated by their authors, on the representations they contain and promote about other combatants and about civilian non-combatants, and the constitution and expression of danger in the spaces and places of military action which these texts construct and convey. The paper then turns to consider how a reading of the military memoir with reference to the genre of testimonio might extend and inform our understanding and use of these texts as a source for exploring popular geopolitics and militarism.

Integrating telecare for chronic disease management in the community: what needs to be done?

BACKGROUND: Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community. METHODS: Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers. RESULTS: Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice. CONCLUSION: Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care.

The challenge of electronic health records (EHRs) design and implementation: responses of health workers to drawing a 'big and rich picture' of a future EHR programme using animated tools.

BACKGROUND AND AIM: To investigate the use of animation tools to aid visualisation of problems for discussion within focus groups, in the context of healthcare workers discussing electronic health records (EHRs). METHOD: Ten healthcare staff focus groups, held in a range of organisational contexts. Each focus group was in four stages: baseline discussion, animator presentation, post-animator discussion and questionnaire. Audio recordings of the focus groups were transcribed and coded and the emergent analytic themes analysed for issues relating to EHR design and implementation. The data allowed a comparison of baseline and post-animator discussion. RESULTS: The animator facilitated discussion about EHR issues and these were thematically coded as: Workload; Sharing Information; Access to Information; Record Content; Confidentiality; Patient Consent; and Implementation. CONCLUSION: We illustrate that use of the animator in focus groups is one means to raise understanding about a proposed EHR development. The animator provided a visual 'probe' to support a more proactive and discursive localised approach to end-user concerns, which could be part of an effective stakeholder engagement and communication strategy crucial in any EHR or health informatics implementation programme. The results of the focus groups were to raise salient issues and concerns, many of which anticipated those that have emerged in the current NHS Connecting for Health Care Records programme in England. Potentially, animator-type technologies may facilitate the user ownership which other forms of dissemination appear to be failing to achieve.

Implementation, change management and benefit realization: investigating the utility of ethnographically enriched process maps.

Following developments in the use of ethnographies in systems design, this article illustrates an investigation into using ethnography for healthcare system implementation, change management and benefits realization. The article illustrates the possibility of creating ethnographically enriched process maps. These are process maps that are created for specific implementation sites to facilitate the locally situated work of implementation, change management and benefits realization teams. The simple premise is that, to change and improve what you are doing, you need to know what you are currently doing. Reported are the pros and cons of a potential solution and, importantly, why it was not adopted. While not producing a definitive solution, this approach to looking at the problems, and using ethnographically enriched process maps, does suggest itself as an area for further development.

What constitutes evidence in hospital new drug decision making?

In National Health Service hospitals in the UK the introduction of new drugs is controlled by a local Drug and Therapeutics Committee (DTC), which is expected to apply the principles of evidence-based medicine (EBM). In the light of growing expenditure on drugs, there is interest in how the decisions are made that lead to the local acceptance or rejection of a new drug. In this study the DTCs of two general hospitals were observed, tape-recorded and analysed to determine what was considered as evidence and how it was used in decision making. Evidence, as constituted by DTC members, was issues that affected the decision-making process and included: clinical trial data, cost, pre-existing prescribing of the drug, pharmaceutical company activities, decisions of other DTCs, patient demand, clinician excitement, and personality of the applicant. Debate usually started with a discussion of the scientific evidence, then the cost would be considered. Often this evidence was either inadequate or insufficient enough for a locally implementable decision and further types of evidence would be brought in to try and estimate the likely impact of adopting the new drug. EBM, while used in decision making, was supplemented by local knowledge, although decisions were accounted for in the language of scientific rationality. Both abstract scientific rationality and the local rationality of practical healthcare provision were present in the decisions of the DTCs on the adoption, or otherwise, of new drugs into local formularies and healthcare. We suggest the coming together of local and abstract in local decision-making needs to be taken into account when formulating policy and providing decision support.