Repairing disrupted care processes as sources of stability, learning and change in a Finnish hospital: An activity-theoretical study.

INTRODUCTION: In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care; 50% of these are preventable. The aim of this study was to deepen our understanding of disruptions of care processes and how the repairing of disruptions can be sources of stability, learning and change in complex health care settings. METHODS: The organisational interactions associated with disruptions in the standard care processes of 15 surgical patients were followed in a public sector hospital in Finland. The patients and medical professionals were interviewed in situ during the observation of the care processes. An activity-theoretically informed methodological framework was used to identify and analyse disruptions and the associated repair efforts and repair solutions. RESULTS: Disruptions were frequent and found in all 15 care processes. These related to (1) the patient's worsening physiological state, (2) the equipment used in surgical care, (3) the information flow, (4) delays in the care process and (5) the unclear division of labour within the team. The actors carried out three types of repair efforts (technical, cognitive-emotional and extended collaborative) to overcome the disrupted processes, which usually led to repair solutions that restored stability. DISCUSSION: The different repair efforts required different kinds of collaboration and learning. Extended collaborative repair was most demanding, providing challenges and opportunities for practice change and expansive learning.

Organizational arrangements as a key to enhancing innovativeness and efficiency - analysis of a restructuring hospital in Finland.

BACKGROUND: Challenged to innovate and improve efficiency both at the policy level and in everyday work, many health care organizations are undergoing radical change. However, in many earlier studies, the significance of individuals' perceptions of their organization and its innovativeness and efficiency during restructuring is not well acknowledged. Our study examines how various organizational arrangements; performance-, hierarchy-, tradition-, and leader-focused types, as well as collaborative and fragmented ones, connect to reaching innovativeness and efficiency in health care during restructuring. METHOD: We built on previous organization and management research, innovation studies, and on research focusing in health care restructuring, and conducted an exploratory quantitative case study in a public sector hospital in Finland. Data comprising 447 responses from 19 professional groups across the hospital was analyzed using hierarchical regression analysis. RESULTS: Our results demonstrate that multiple, co-existing organizational arrangements can promote innovation and efficiency. The perceptions of the organizational members of the nature of their organization need to be generally positive and reflect future-orientation to show positive connections with efficiency and innovativeness; fragmentation in the members' perceptions of the character of their organization and their inability to go beyond established organizational traditions pose risks of inefficiency and stagnation rather than fruitful exploration. Our study further shows, somewhat surprisingly, that while collaborative organizational arrangements are positively related to increases in perceived efficiency, the same does not apply to innovativeness. CONCLUSIONS: Our study addresses understudied, yet inherently important aspects in providing high-quality health care: the relationships between different organizational arrangements and exploitation and exploration-related outcomes. In particular, examination of individuals' perceptions (that may have even more weight for the subsequent developments than the actual situation) adds insight to the existing knowledge that has addressed more objective factors. Implications on how to support high levels of performance are drawn for management of professional and pluralistic organizations undergoing restructuring. Our findings also generate information that is useful for policy making concerned with public sector health care.

Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings.

Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might 'tip the balance' towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

Getting palliative medications right across the contexts of homes, hospitals and hospices: protocol to synthesise scoping review and ethnographic methods in an activity theory analysis.

INTRODUCTION: Prescribing and medication use in palliative care is a multistep process. It requires systems coordination and is enacted through activities of patients, informal carers and professionals. This study compares practice to idealised descriptions of what should happen; identifying when, how and why process disturbances impact on quality and safety. Our objectives are to:Document an intended model (phase 1, scoping review).Refine the model with study of practice (phase 2, ethnography).Use the model to pinpoint 'hot' (viewed as problematic by participants) and 'cold' spots (observed as problematic by researchers) within or when patients move across three contexts-hospice, hospital and community (home).Create learning recommendations for quality and safety targeted at underlying themes and contributing factors. METHODS AND ANALYSIS: The review will scope Ovid Medline, CINAHL and Embase, Google Scholar and Images-no date limits, English language only. The Population (palliative), Concept (medication use), Context (home, hospice, hospital) framework defines inclusion/exclusion criteria. Data will be extracted to create a model illustrating how processes ideally occur, incorporating multiple steps of typical episodes of prescribing and medication use for symptom control. Direct observations, informal conversations around acts of prescribing and medication use, and semistructured interviews will be conducted with a purposive sample of patients, carers and professionals. Drawing on activity theory, we will synthesise analysis of both phases. The analysis will identify when, how and why activities affect patient safety and experience. Generating a rich multivoiced understanding of the process will help identify meaningful targets for improvement. ETHICS AND DISSEMINATION: Ethical approval granted by the Camden & Kings Cross NHS Regional Ethics Committee (21/LO/0459). A patient and public involvement (PPI) coinvestigator, a multiprofessional steering group and a PPI engagement group are working with the research team. Dissemination of findings is planned through peer-reviewed publications and a stakeholder (policymakers, commissioners, clinicians, researchers, public) report/dissemination event.

Organizational dynamics of interprofessional practice in the Norwegian prison system.

Reoffending rates may be reduced through efforts to rehabilitate prisoners. A more nuanced understanding is needed of how front-line prison and health care services collaborate during the rehabilitation process. We report an investigation of the organizational dynamics of interprofessional practice among prison, mental health, and welfare services in two Norwegian prison case studies. First, a high security (closed) prison where a coordination network was implemented among prison management, front-line staff, and external service personnel to enhance the prisoners' life management skills. Second, an (open) transitional residence, where interprofessional practice was facilitated by front-line prison staff to increase prisoners' ability to reintegrate into society through their socialization and access to external services. The study demonstrates the demands on prisoners as they move from passive service receivers to active service users/organizer, and how interprofessional practice and models of service integration support them in this process.

Making the invisible visible: a place for utilizing activity theory within in situ simulation to drive healthcare organizational development?

BACKGROUND: The healthcare needs of our societies are continual changing and evolving. In order to meet these needs, healthcare provision has to be dynamic and reactive to provide the highest standards of safe care. Therefore, there is a continual need to generate new evidence and implement it within healthcare contexts. In recent times, in situ simulation has proven to have been an important educational modality to accelerate individuals' and teams' skills and adaptability to deliver care in local contexts. However, due to the increasing complexity of healthcare, including in community settings, an expanded theoretical informed view of in situ simulation is needed as a form of education that can drive organizational as well as individual learning. MAIN BODY: Cultural-historical activity theory (CHAT) provides us with analytical tools to recognize and analyse complex health care systems. Making visible the key elements of an in situ simulation process and their interconnections, CHAT facilitates development of a system-level view of needs of change. CONCLUSION: In this paper, we theorize how CHAT could help guide in situ simulation processes-to generate greater insights beyond the specific simulation context and bring about meaningful transformation of an organizational activity.

How to assess the quality of qualitative research.

As a clinician interested in qualitative research, you are likely to have pondered whether a particular study is trustworthy. How do you know whether qualitative research findings are valid and can be applied in your setting? The quality standards you would look for in quantitative research do not apply. Furthermore, qualitative research is conducted within a number of paradigms, or ways of understanding the nature of reality and knowledge, each associated with different ways of defining, understanding and reporting quality. This 'How to …' article aims to support health care practitioners, educators and researchers to recognise some of the essential characteristics or 'markers' of high-quality qualitative research. We hope that this article will support those reflecting on the quality of their own research, those justifying research design to funders and those reviewing qualitative research for journals or for inclusion in reviews.

How to do longitudinal qualitative research.

In health professions education, we are often interested in researching change over time, for example the development of professional identity or the adoption of new practices. Taking a longitudinal qualitative approach to such research can provide valuable insights. In this article, we present some longitudinal qualitative methods to support researchers interested in getting started with this type of research. We discuss what longitudinal qualitative approaches offer, consider the challenges and suggest how to go about it. We also highlight some specific ethical considerations that may arise in longitudinal studies.

How to do mixed-methods research.

As a clinician, you will often combine patients' narratives with test results in order to obtain a coherent picture and then decide on a way forward. As an educator, you are also likely to combine different information from your learners to arrive at the best feedback, judgement or supervision plan. This is what researchers do when undertaking mixed-methods research: qualitative and quantitative data are typically brought together to provide different insights than could be achieved with a single type of data and analysis. Mixed-methods research has much to offer the clinical teacher but may involve more complex study designs than other types of research. Therefore, this article aims to highlight the different designs of mixed-methods research, and the opportunities and challenges that it provides, in order to support researchers who may be undertaking their first mixed-methods research study.

How to be reflexive when conducting qualitative research.

Reflexivity can be a complex concept to grasp when entering the world of qualitative research. In this article, we aim to encourage new qualitative researchers to become reflexive as they develop their critical research skills, differentiating between the familiar concept of reflection and reflective practice and that of reflexivity. Although reflection is, to all intents and purposes, a goal-oriented action with the aim of improving practice, reflexivity is a continual process of engaging with and articulating the place of the researcher and the context of the research. It also involves challenging and articulating social and cultural influences and dynamics that affect this context. As a hallmark of high-quality qualitative research, reflexivity is not only an individual process but one that needs to be considered a collective process within a research team, and communicated throughout the research process. In keeping with our previous articles in this series, we have illustrated the theoretical concept of reflexivity using practical examples of published research.

How to use qualitative research to change practice.

The 'How to …' series focuses on how to do qualitative research. But how can qualitative research enhance patient care? This paper aims to support health care practitioners, educators and researchers who are interested in bridging the gap between research and practice (both clinical and educational), to guide improvements that can ultimately benefit patients. We present action research and The Change Laboratory method as two approaches that typically involve qualitative research and have potential to change practice, blending scientific inquiry with social action. These approaches establish close research-practice partnerships and help answer tricky 'why' and 'how' questions that may unlock deep insights to enhance learning and patient care. … how can qualitative research enhance patient care?

Trainee doctors' experiences of common problems in the antibiotic prescribing process: an activity theory analysis of narrative data from UK hospitals.

INTRODUCTION: Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas. OBJECTIVES: Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur? METHODS: We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process. RESULTS: Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating. CONCLUSIONS: Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.

How to get started with theory in education.

This paper, on using theory in health professions education research, is the second in a series that aims to support novice researchers within clinical education, particularly those undertaking their first qualitative study. Diving into the world of education theory can be challenging and uncomfortable for clinician-educators. Nonetheless, theory is an essential ingredient in high-quality research, shaping everything from research questions to study design, analysis and, ultimately, the interpretation of findings. We hope that this paper, introducing different levels of theory and examples of how to use theory, will shed light on how theory can be used in research, and that it will help you in getting to grips with using theory in your own work. It will help you in getting to grips with using theory in your own work.

From the abstract to the concrete - Implementation of an innovative tool in home care.

Background The implementation of innovations in practice is a critical factor for change and development processes in health and home care. We therefore analyze how an innovative tool - a mobility agreement to maintain physical mobility of home care clients - was implemented in Finnish home care. Methods Our study involves ethnographic research of 13 home care visits, two years after the mobility agreement was implemented. We analyze the emergence of contradictions, the motives of the actors and the use of artifacts supporting or inhibiting the implementation. Two in-depth cases illustrate the implementation of the mobility agreement in home care visits. Findings Our findings show that, first, to achieve practice change and development, the innovation implementation requires the overcoming of contradictions in the implementation process. Second, it calls for the emergence of a shared motive between the actors to transform the abstract concept of an innovation into a concrete practice. Third, artifacts, customary to the clients are important in supporting the implementation process. Fourth, the implementation brings about a modification of the innovation and the adopting social system. Conclusions Innovation implementation should be seen as a transformation process of an abstract concept into a concrete practice, enabled by the actors involved. Concept design and implementation should be closely linked. In health/home care innovation management, the implementation of innovations needs to be understood as a complex collective learning process. Results can be far reaching - in our case leading to change of home care workers' professional understanding and elderly clients' mobility habits.

Clients' initiatives and caregivers' responses in the organizational dynamics of care delivery.

Our aim with this article is to develop a typology for the analysis of client-caregiver encounters in health care. We first observed client-caregiver interactions in the homes of home care clients and during the care processes of surgical patients. We then conducted a data-driven analysis to identify the clients' initiatives and the degree of engagement in the responses they received. The clients shaped their care by commenting on, questioning, ensuring, and enriching their care. The responses from the caregivers consisted of neutral acceptance, disregard, and shared expansive development of the clients' initiatives. The typology developed from these will be a tool to widen our understanding of the complex interactions in care delivery and of the different conceptualizations of care that actors hold. In future studies this typology will help in the analysis of the organizational dynamics of health care delivery.