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1.  Using computer decision support systems in NHS emergency and urgent care: ethnographic study using normalisation process theory 
Background
Information and communication technologies (ICTs) are often proposed as ‘technological fixes’ for problems facing healthcare. They promise to deliver services more quickly and cheaply. Yet research on the implementation of ICTs reveals a litany of delays, compromises and failures. Case studies have established that these technologies are difficult to embed in everyday healthcare.
Methods
We undertook an ethnographic comparative analysis of a single computer decision support system in three different settings to understand the implementation and everyday use of this technology which is designed to deal with calls to emergency and urgent care services. We examined the deployment of this technology in an established 999 ambulance call-handling service, a new single point of access for urgent care and an established general practice out-of-hours service. We used Normalization Process Theory as a framework to enable systematic cross-case analysis.
Results
Our data comprise nearly 500 hours of observation, interviews with 64 call-handlers, and stakeholders and documents about the technology and settings. The technology has been implemented and is used distinctively in each setting reflecting important differences between work and contexts. Using Normalisation Process Theory we show how the work (collective action) of implementing the system and maintaining its routine use was enabled by a range of actors who established coherence for the technology, secured buy-in (cognitive participation) and engaged in on-going appraisal and adjustment (reflexive monitoring).
Conclusions
Huge effort was expended and continues to be required to implement and keep this technology in use. This innovation must be understood both as a computer technology and as a set of practices related to that technology, kept in place by a network of actors in particular contexts. While technologies can be ‘made to work’ in different settings, successful implementation has been achieved, and will only be maintained, through the efforts of those involved in the specific settings and if the wider context continues to support the coherence, cognitive participation, and reflective monitoring processes that surround this collective action. Implementation is more than simply putting technologies in place – it requires new resources and considerable effort, perhaps on an on-going basis.
doi:10.1186/1472-6963-13-111
PMCID: PMC3614561  PMID: 23522021
Computer technology; CDSS; Urgent care; Emergency care; Normalisation process theory
2.  Eliciting symptoms interpreted as normal by patients with early-stage lung cancer: could GP elicitation of normalised symptoms reduce delay in diagnosis? Cross-sectional interview study 
BMJ Open  2012;2(6):e001977.
Objectives
To investigate why symptoms indicative of early-stage lung cancer (LC) were not presented to general practitioners (GPs) and how early symptoms might be better elicited within primary care.
Design, setting and participants
A qualitative cross-sectional interview study about symptoms and help-seeking in 20 patients from three south England counties, awaiting resection of LC (suspected or histologically confirmed). Analysis drew on principles of discourse analysis and constant comparison to identify processes involved in interpretation and communication about symptoms, and explain non-presentation.
Results
Most participants experienced health changes possibly indicative of LC which had not been presented during GP consultations. Symptoms that were episodic, or potentially caused by ageing or lifestyle, were frequently not presented to GPs. In interviews, open questions about health changes/symptoms in general did not elicit these symptoms; they only emerged in response to closed questions detailing specific changes in health. Questions using disease-related labels, for example, pain or breathlessness, were less likely to elicit symptoms than questions that used non-disease terminology, such as aches, discomfort or ‘getting out of breath’. Most participants described themselves as feeling well and were reluctant to associate potentially explained, non-specific or episodic symptoms with LC, even after diagnosis.
Conclusions
Patients with early LC are unlikely to present symptoms possibly indicative of LC that they associate with normal processes, when attending primary care before diagnosis. Faced with patients at high LC risk, GPs will need to actively elicit potential LC symptoms not presented by the patient. Closed questions using non-disease terminology might better elicit normalised symptoms.
doi:10.1136/bmjopen-2012-001977
PMCID: PMC3533064  PMID: 23166137
Symptoms; Early cancer diagnosis; Terminology as topic; Help seeking; Lung cancer; Discourse Analysis
3.  Strengthening organizational performance through accreditation research-a framework for twelve interrelated studies: the ACCREDIT project study protocol 
BMC Research Notes  2011;4:390.
Background
Service accreditation is a structured process of recognising and promoting performance and adherence to standards. Typically, accreditation agencies either receive standards from an authorized body or develop new and upgrade existing standards through research and expert views. They then apply standards, criteria and performance indicators, testing their effects, and monitoring compliance with them. The accreditation process has been widely adopted. The international investments in accreditation are considerable. However, reliable evidence of its efficiency or effectiveness in achieving organizational improvements is sparse and the value of accreditation in cost-benefit terms has yet to be demonstrated. Although some evidence suggests that accreditation promotes the improvement and standardization of care, there have been calls to strengthen its research base.
In response, the ACCREDIT (Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork) project has been established to evaluate the effectiveness of Australian accreditation in achieving its goals. ACCREDIT is a partnership of key researchers, policymakers and agencies.
Findings
We present the framework for our studies in accreditation. Four specific aims of the ACCREDIT project, which will direct our findings, are to: (i) evaluate current accreditation processes; (ii) analyse the costs and benefits of accreditation; (iii) improve future accreditation via evidence; and (iv) develop and apply new standards of consumer involvement in accreditation. These will be addressed through 12 interrelated studies designed to examine specific issues identified as a high priority. Novel techniques, a mix of qualitative and quantitative methods, and randomized designs relevant for health-care research have been developed. These methods allow us to circumvent the fragmented and incommensurate findings that can be generated in small-scale, project-based studies. The overall approach for our research is a multi-level, multi-study design.
Discussion
The ACCREDIT project will examine the utility, reliability, relevance and cost effectiveness of differing forms of accreditation, focused on general practice, aged care and acute care settings in Australia. Empirically, there are potential research gains to be made by understanding accreditation and extending existing knowledge; theoretically, this design will facilitate a systems view of accreditation of benefit to the partnership, international research communities, and future accreditation designers.
"Accreditation of health-care organisations is a multimillion dollar industry which shapes care in many countries. Recent reviews of research show little evidence that accreditation increases safety or improves quality. It's time we knew about the cost and value of accreditation and about its future direction." [Professor John Øvretveit, Karolinska Institute, Sweden, 7 October 2009]
doi:10.1186/1756-0500-4-390
PMCID: PMC3199265  PMID: 21981910
4.  Normalisation process theory: a framework for developing, evaluating and implementing complex interventions 
BMC Medicine  2010;8:63.
Background
The past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation).
Discussion
In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential.
Summary
The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial.
doi:10.1186/1741-7015-8-63
PMCID: PMC2978112  PMID: 20961442
5.  Does distance matter? Geographical variation in GP out-of-hours service use: an observational study 
Background
GP cooperatives are typically based in emergency primary care centres, and patients are frequently required to travel to be seen. Geography is a key determinant of access, but little is known about the extent of geographical variation in the use of out-of-hours services.
Aim
To examine the effects of distance and rurality on rates of out-of-hours service use.
Design of study
Geographical analysis based on routinely collected data on telephone calls in June (n = 14 482) and December (n = 19 747), and area-level data.
Setting
Out-of-hours provider in Devon, England serving nearly 1 million patients.
Method
Straight-line distance measured patients' proximity to the primary care centre. At area level, rurality was measured by Office for National Statistics Rural and Urban Classification (2004) for output areas, and deprivation by The Index of Multiple Deprivation (2004).
Results
Call rates decreased with increasing distance: 172 (95% confidence interval [CI] = 170 to 175) for the first (nearest) distance quintile, 162 (95% CI = 159 to 165) for the second, and 159 (95% CI = 156 to 162) per thousand patients/year for the third quintile. Distance and deprivation predicted call rate. Rates were highest for urban areas and lowest for sparse villages and hamlets. The greatest urban/rural variation was in patients aged 0–4 years. Rates were higher in deprived areas, but the effect of deprivation was more evident in urban than rural areas.
Conclusion
There is geographical variation in out-of-hours service use. Patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas. Geographical barriers must be taken into account when planning and delivering services.
doi:10.3399/bjgp08X319431
PMCID: PMC2441507  PMID: 18611312
distance; general practice; geographic factors; health services accessibility; out-of-hours medical care; rural health
6.  Thou shalt versus thou shalt not: a meta-synthesis of GPs' attitudes to clinical practice guidelines 
Background
GPs' adherence to clinical practice guidelines is variable. Barriers to guideline implementation have been identified but qualitative studies have not been synthesised to explore what underpins these attitudes.
Aim
To explore and synthesise qualitative research on GPs' attitudes to and experiences with clinical practice guidelines.
Design of study
Systematic review and meta-synthesis of qualitative studies.
Method
PubMed, CINAHL, EMBASE, Social Science Citation Index, and Science Citation Index were used as data sources, and independent data extraction was carried out. Discrepancies were resolved by consensus. Initial thematic analysis was conducted, followed by interpretative synthesis.
Results
Seventeen studies met the inclusion criteria. Five were excluded following quality appraisal. Twelve papers were synthesised which reported research in the UK, US, Canada, and the Netherlands, and covered different clinical guideline topics. Six themes were identified: questioning the guidelines, GPs' experience, preserving the doctor–patient relationship, professional responsibility, practical issues, and guideline format. Comparative analysis and synthesis revealed that GPs' reasons for not following guidelines differed according to whether the guideline in question was prescriptive, in that it encouraged a certain type of behaviour or treatment, or proscriptive, in that it discouraged certain treatments or behaviours.
Conclusion
Previous analyses of guidelines have focused on professional attitudes and organisational barriers to adherence. This synthesis suggests that the purpose of the guideline, whether its aims are prescriptive or proscriptive, may influence if and how guidelines are received and implemented.
PMCID: PMC2084137  PMID: 18252073
attitudes of health personnel; general practice; guideline adherence; guidelines; meta-synthesis; qualitative research
7.  Informing Policy Making and Management in Healthcare: The Place for Synthesis 
Healthcare Policy  2006;1(2):43-48.
Research synthesis has an important role supporting the transfer of knowledge between researchers and healthcare decision-makers. But if our goal is to make knowledge more useable and context specific, then extending the scope of systematic reviews or producing syntheses with policy makers and managers may be insufficient. Dialogues, partnerships and reinterpretations of evidence in context will help us achieve this goal.
PMCID: PMC2585321  PMID: 19305652
8.  Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study 
BMJ : British Medical Journal  2003;327(7424):1132.
Objective To obtain the views of women on the impact of operative delivery in the second stage of labour.
Design Qualitative interview study.
Setting Two urban teaching hospitals in the United Kingdom.
Participants Purposive sample of 27 women who had undergone operative delivery in the second stage of labour between January 2000 and January 2002.
Key themes Preparation for birth, understandings of the indications for operative delivery, and explanation or debriefing after birth.
Results The women felt unprepared for operative delivery and thought that their birth plan or antenatal classes had not catered adequately for this event. They emphasised the importance of maintaining an open mind about the management of labour. They had difficulty understanding the need for operative delivery despite a review by medical and midwifery staff before discharge. Operative delivery had a noticeable impact on women's views about future pregnancy and delivery.
Conclusions Women consider postnatal debriefing and medical review important deficiencies in current care. Those who experienced operative delivery in the second stage of labour would welcome the opportunity to have a later review of their intrapartum care, physical recovery, and management of future pregnancies.
PMCID: PMC261808  PMID: 14615336
11.  Analysing qualitative data 
BMJ : British Medical Journal  2000;320(7227):114-116.
PMCID: PMC1117368  PMID: 10625273
12.  Assessing quality in qualitative research 
BMJ : British Medical Journal  2000;320(7226):50-52.
PMCID: PMC1117321  PMID: 10617534
14.  Capacity for care: meta-ethnography of acute care nurses' experiences of the nurse-patient relationship 
Journal of Advanced Nursing  2012;69(4):760-772.
Aims
To synthesize evidence and knowledge from published research about nurses' experiences of nurse-patient relationships with adult patients in general, acute inpatient hospital settings.
Background
While primary research on nurses' experiences has been reported, it has not been previously synthesized.
Design
Meta-ethnography.
Data sources
Published literature from Australia, Europe, and North America, written in English between January 1999–October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO.
Review methods
Qualitative studies describing nurses' experiences of the nurse-patient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method.
Results
Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses' capacity to build and sustain these relationships. The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients.
Conclusion
The findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses' capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients.
doi:10.1111/jan.12050
PMCID: PMC3617468  PMID: 23163719
caring; experiences; hospitals; literature review; meta-ethnography; nurses; professional-patient relations; qualitative research; systematic review

Results 1-14 (14)