1,721,131 research outputs found
Implementing, embedding, and integrating practices: an outline of normalization process theory
No full textUnderstanding the processes by which practices become routinely embedded in everyday life is a long-standing concern of sociology and the other social sciences. It has important applied relevance in understanding and evaluating the implementation of material practices across a range of settings.This article sets out a theory of normalization processes that proposes a working model of implementation, embedding and integration in conditions marked by complexity and emergence. The theory focuses on the work of embedding and of sustaining practices within interaction chains, and helps in understanding why some processes seem to lead to a practice becoming normalized while others do not
Telecare: perspectives on the changing role of patients and citizens
No full textWe conducted a qualitative study in the UK to examine perspectives about telemedicine, telecare and e-health for the changing roles of patients and citizens. We believe there are important differences between these applications, but for simplicity, the term 'telecare' is used broadly here to include all three. In-depth, semistructured interviews were conducted between September 2002 and May 2004. Participants were 38 key informants from the UK, known to have involvement or interest in telecare: policy-makers, clinicians, technologists, health service managers, researchers and patient advocates. Interviews were conducted either in person or over the telephone, and were audio-recorded with participants' consent. The most frequently cited priorities for patients included accessibility to services, locations of care and quality of care, with some respondents emphasizing the importance of choice for the patient (in terms of appointments and ways of accessing services). However, telecare has implications for patients that go beyond issues of access. A major problem is that 'priorities' are assumed rather than based on an empirical understanding; moreover, for individual patients, preferences for particular forms of service delivery are likely to represent trade-offs between multiple priorities. The findings of the present study confirm that concepts of the patient's rights and responsibilities are changing with the increasing use of new technologies to deliver health care. <br/
Implementation, context and complexity
Full text linkBackground: Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice.Discussion: We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems.Conclusion: Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of ‘real world’ contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants’ discretion over resource mobilisation and actors’ contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.<br/
Towards a wireless patient: chronic illness, scarce care and technological innovation in the United Kingdom
No full text‘Modernization’ is a key health policy objective in the UK. It extends across a range of public service delivery and organizational contexts, and also means there are radical changes in perspective on professional behaviour and practice. New information and communications technologies have been seen as one of the key mechanisms by which these changes can be engendered. In particular, massive investment in information technologies promises the rapid distribution and deployment of patient-centred information across internal organizational boundaries. While the National Health Service (NHS) sits on the edge of a £6billion investment in electronic patient records, other technologies find their status as innovative vehicles for professional behaviour change and service delivery in question. In this paper, we consider the ways that telemedicine and telehealthcare systems have been constructed first as a field of technological innovation, and more recently, as management solutions to problems around the distribution of health care. We use NHS responses to chronic illness as a medium for understanding these shifts. In particular, we draw attention to the shifting definitions of ‘innovation’ and to the ways that these shifts define a move away from notions of technological advance towards management control.<br/
Integrating service development with evaluation in telehealthcare: an ethnographic study
No full textObjectives: to identify issues that facilitate the successful integration of evaluation and development of telehealthcare services.Design: ethnographic study using various qualitative research techniques to obtain data from several sources, including in-depth semistructured interviews, project steering group meetings, and public telehealthcare meetings.Setting: seven telehealthcare evaluation projects (four randomised controlled trials and three pragmatic service evaluations) in the United Kingdom, studied over two years. Projects spanned a range of specialties—dermatology, psychiatry, respiratory medicine, cardiology, and oncology.Participants: clinicians, managers, technical experts, and researchers involved in the projects.Results and discussion: key problems in successfully integrating evaluation and service development in telehealthcare are, firstly, defining existing clinical practices (and anticipating changes) in ways that permit measurement; secondly, managing additional workload and conflicting responsibilities brought about by combining clinical and research responsibilities (including managing risk); and, thirdly, understanding various perspectives on effectiveness and the limitations of evaluation results beyond the context of the research study.Conclusions: combined implementation and evaluation of telehealthcare systems is complex, and is often underestimated. The distinction between quantitative outcomes and the workability of the system is important for producing evaluative knowledge that is of practical value. More pragmatic approaches to evaluation, that permit both quantitative and qualitative methods, are required to improve the quality of such research and its relevance for service provision in the NH
Which quality of life score is best for glaucoma patients and why?
Get PDFBackground: the glaucomas are generally asymptomatic diseases until they are very advanced. They affect 2% of the population over 40 years of age and therefore represent a significant public health issue. There have been a number of attempts to develop quality of life scales for the disease. This review discusses the pros and cons of these scales and suggests the best of the current ones for use in a clinical setting.Methods: Medline, Embase and Google Scholar were searched for relevant articles. No time period was defined and all types of article were included.Results: 11 Quality of Life scores were identified that have been used with glaucoma patients.Conclusion: there is no generally accepted 'best' Quality of Life instrument for use in glaucoma. Many of the scales are biased towards physical symptoms and do little to address the personal or social factors of the disease. Further work is needed to produce scales that address all these areas as well as being simple to administer in a clinical settin
Technogovernance: evidence, subjectivity, and the clinical encounter in primary care medicine
No full textTechnological solutions to problems of knowledge and practice in health care are routinely advocated. This paper explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-centred clinical practice in which patients’ heterogeneous experiences and narratives of ill-health are qualitatively engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but both impulses are embodied in new ‘technological’ solutions to the management of heterogeneity in the clinical encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up a new array of practices—technogovernance—in which the heterogeneous narratives of the patient-centred encounter can be resituated and guide
Process evaluation for complex interventions in primary care: understanding trials using the normalization process model
Full text linkBackground: the Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.Method: in this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.Results: application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.Conclusion: the model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare setting
Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review
Full text linkOBJECTIVE: To systematically review the literature on the implementation of e-health to identify: (i) barriers and facilitators to e-health implementation, and (ii) outstanding gaps in research on the subject.METHODS: MEDLINE, EMBASE, CINAHL, PSYCINFO and the Cochrane Library were searched for reviews published between 1 January 1995 and 17 March 2009. Studies had to be systematic reviews, narrative reviews, qualitative metasyntheses or meta-ethnographies of e-health implementation. Abstracts and papers were double screened and data were extracted on country of origin; e-health domain; publication date; aims and methods; databases searched; inclusion and exclusion criteria and number of papers included. Data were analysed qualitatively using normalization process theory as an explanatory coding framework.FINDINGS: Inclusion criteria were met by 37 papers; 20 had been published between 1995 and 2007 and 17 between 2008 and 2009. Methodological quality was poor: 19 papers did not specify the inclusion and exclusion criteria and 13 did not indicate the precise number of articles screened. The use of normalization process theory as a conceptual framework revealed that relatively little attention was paid to: (i) work directed at making sense of e-health systems, specifying their purposes and benefits, establishing their value to users and planning their implementation; (ii) factors promoting or inhibiting engagement and participation; (iii) effects on roles and responsibilities; (iv) risk management, and (v) ways in which implementation processes might be reconfigured by user-produced knowledge.CONCLUSION: The published literature focused on organizational issues, neglecting the wider social framework that must be considered when introducing new technologies.<br/
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