Transforming Healthcare with Qualitative Research

Frances Rapport, Jeffrey Braithwaite

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000194333
• Edition: 1
• Topic: Sciences sociales
• Subtopic: Études du développement mondial

Drawing on the knowledge and experiences of world-renowned scientists and healthcare professionals, this important book brings together academic, medical and health systems accounts of the impact of applying qualitative research methods to transform healthcare behaviours, systems and services. It demonstrates the translation of tried-and-tested and new interventions into high-quality care delivery, improved patient pathways, and enhanced systems management. It melds social theory, health systems analysis and research methods to address real-life healthcare issues in a rich and realistic fashion.

The systems and services examined include those affecting patient care and patient and professional wellbeing, and the roles and responsibilities of people providing and receiving care. Some chapters delve deeply into the human psyche, examining the very private face of health and illness. Others concentrate on public health and how people's needs can be met through health promotion and new investments. From real-time case studies to narratives on illness to theories of change, there is something here for everybody. Transforming health systems needs ingenuity – and the drive of individuals, the staying power of systems and above all the involvement of patients.

Full of novel ideas and innovative solutions from around the world, all underpinned by qualitative methods and methodologies, this book is a key contribution for advanced students, practitioners and academics interested in health services research, research methods and the sociology of health and illness.

Part 1

Ideas

We begin the substantive chapters of the book with Part 1, Ideas, which sets the scene for what is to follow. It takes both a philosophical and theoretical approach to the search for dependable qualitative evidence underpinning medical and health services research.

We open with an examination in Chapter 2 where Nicky Britten supports the transformation and resilience of healthcare systems by combining evidence synthesis with real world patient experience. Then in Chapter 3, Nigel Rapport examines the relationship between consciousness and the individual embodiment of health and illness. Coming to Chapter 4, Arthur Frank discusses the symbiotic relationship between people and their health and illness stories. Completing a tetralogy of wisdom about patients and individuals, in Chapter 5, Andrew C Sparkes takes the reader on a journey to discover how useful narratives are, as a qualitative mechanistic tool, but also as a way of mapping people’s life pathways as they come to terms with life altering disease.

Building on this, but changing the pace somewhat, Frances Rapport and Jeffrey Braithwaite in Chapter 6 discuss what we call the third and fourth research paradigms. While others have written about the Third Research Paradigm in terms of corroborative data from mixed methods studies, the Fourth Research Paradigm is quite new. It concludes this section and paves the way for Part 2, Systems, by acting as a bridge between the two, and by framing the book in terms of the integral nature of theory to research to implementation, examining how rigorous planned qualitative studies drive research designs that in turn allow researchers to work alongside those at the forefront of healthcare delivery in the twenty-first century. Chapter 6 presents new approaches to data collection and analysis, particularly concentrating on ‘mobile methods’; where a wide array of data are collected ‘on the hoof’, and where researchers work side-by-side with research participants, in active and passive roles, examining not only what they are doing, but also who they perceive themselves to be, through observations and responses to others’ needs and experiences. By working alongside others on an equal footing, the fourth research paradigm encourages an assessment of what motivates actions and reactions from healthcare professionals, patients and others, while researchers are careful to work ‘with’, not ‘on’, research participants.

1 Introduction

Why this book?

Frances Rapport and Jeffrey Braithwaite

This book features an exciting collection of writings from world-renowned international academics working in the field of medicine and qualitative health research. The book has been purposefully crafted as highly interdisciplinary, with contributions from health services researchers, healthcare professionals, social scientists, anthropologists, psychologists and sociologists, to ensure wide-ranging perspectives on the topic of transforming healthcare using qualitative research methods. The authors’ expertise spans policy, healthcare systems, healthcare services, teamwork, delivery systems, individual healthcare practices and individual’s aspirations for good health and wellbeing. The systems and services that are examined affect not only patient care and patient and professional safety and wellbeing, but also the roles and responsibilities people take in relation to healthcare provision and receipt, including an individual’s sense of self-knowing and self-actualization.

The book delves into modern-day healthcare services, some of which are delivered according to epidemiological considerations of population need, health promotion or outcomes relevant to public health. Others are delivered according to developments in cutting-edge technologies such as the single, electronic healthcare record, and still others, according to personalized treatments and therapies, such as precision medicine. Some chapters delve deeply into the human psyche – investing in personhood, personal wellbeing and life-projects, and examining the very private face of health and illness. Through contemporary examples of people’s extraordinary ability to adapt and change to changing circumstances, individual resilience is examined, particularly in the face of a debilitating, chronic illness such as cancer or epilepsy. Some writers have taken a humanist approach to the presentation of theories and ideas, while others use realist theory, critical ethnography or narrative methodology to present the latest evidence.

Authors have not been afraid to ask some deep-seated questions about what healthcare professionals, patients and members of the public should expect of modern healthcare services and systems, in terms of service availability, access and clinical outcomes. By so doing, they have also raised theoretical awareness of flaws in the design of services, some of which extend to service implementation. These chapters examine how to develop systems that are flexible and adaptable to change, how to manage fractured patient care pathways, how to enhance shared-care and shared decision-making, how to contain patient and professional expectations, how to share information with family members and other healthcare professionals, and what amounts to an appropriate engagement, within and across different healthcare sectors. As a consequence, the book offers a unique contribution to the debate on whether current healthcare transformations are delivering on their promise to benefit patients, professionals, other stakeholders and society at large.

Chapters consider how, when systems function well, patients are at the receiving end of high-quality, safe and efficacious care. They also examine how, when things go wrong and systems fail to function effectively, relationships can break down, unsafe care practices can lead to medical errors, and people’s lives can be irrevocably affected. While some early chapters, particularly in Part 1, concentrate almost exclusively on how illness is ‘felt’ within the body, and how that precipitates the notion that we carry illness with us through our lives, others, particularly in Part 2, consider how illness stories are shared through novel narrative styles that effectively reach patients and the caring community.

The nature of this book is rich in variety, from chapters describing how to transform the healthcare system to enable people to work more safely and effectively, to those arguing that patients are individuals not disease-types. Some authors take the reader down the patient’s care pathway, others contend with how complex diseases and their co-morbidities are being managed. Whatever the case, it is evident from each chapter’s content and quality that the depth of the authors’ subject-knowledge, as well as their integrity to their craft, is of the highest calibre.

This is an ambitious project. As editors we have attempted to marry groups of writers’ narratives across disciplinary backgrounds, topic areas and methodological interests – writers employing different styles, agendas and objectives. At the same time, what holds this together as a body of work is its impressive originality and integrity, and the shared intention of all authors to develop transformative healthcare systems and services using qualitative methodologies in support of best care practices.

To keep the subject contemporary and fresh, all writers have explained the transformative healthcare challenges they are examining, the qualitative methodologies and methods they are using and the aspirations they hold dear. Many chapters include the views of healthcare professionals, patients, public members, significant others, policy developers and other stakeholders who ask searching questions about how sustainable our current healthcare system really is in the face of an ever-growing, ageing population, attempting to manage with stretched resources, and the pressures of inadequate time and space. Chapters range from those presenting data from empirical research to those offering information about a new theory or research paradigm. They are all searching for knowledge on transformation, be it in service delivery, human experience or a new paradigm shift. As a result, some chapters are highly individualistic, while others depend on shared, dialogical conversations between authors, with knowledge derived from the cross-fertilization of ideas including a precise of the current literature or position statements on a new policy drive.

The book has been designed in three parts: Part 1, Ideas; Part 2, Systems; and Part 3, Solutions. Part 1, Ideas, sets the scene for what is to follow. It takes both a philosophical and theoretical approach to the search for dependable qualitative evidence underpinning medical and health services research.

Part 2 is a departure from the theoretical and philosophical aspects of qualitative methodological development, taking some of the Ideas presented in Part 1 and examining their relationship to healthcare systems’ developments. In Part 2, Systems, the systems that surround the healthcare service are all examined through a qualitative lens. In Part 2, authors concentrate variously on macro, meso and micro levels of care, paying particular attention to aspects indicated in system delivery, while considering processes and mechanisms that allow care to be provided well; such as groups of professionals working together, and less well; for example, individual healthcare practitioners working in isolation.

In Part 3, Solutions, the book moves from ‘ideas about health and personhood’ in Part 1, and ‘notions for change’ in Part 2, to ‘positive change’. Part 3 examines new frameworks for change management and the management of uncertainty. Together, Parts 1 to 3 offer a unique and highly creative reflection on the current values and credibility of qualitative methods within medicine, health services research and health systems research. Methods are examined for their versatility and rigour, while writers are bold in predicting where new methodologies might take us in our search for sustainable, high-quality, safe systems of care that serve personal preferences and needs. Seen holistically, chapters celebrate the perspicacity and drive of individuals: those who are sick and those who are well, those who care for others and those who are cared-for, those who write policy and those who implement policy, those who research and those being researched. Together they provide a clear vision for the future of qualitative research methods in this field, while examining what is being researched and what needs to be researched more. Together they reveal the qualitative tools at our disposal and those that can only be imagined, to drive research forward towards implementable interventions, proclaiming a chance to improve healthcare systems worldwide, in ways that are both transactional and realistic, for the good of society.

2 Qualitative evidence synthesis and conceptual development

Nicky Britten

Introduction

Research in healthcare often addresses practical problems about best treatments for specific health problems or the best ways of providing healthcare to particular groups of people. Since the 1990s healthcare research has been in thrall to evidence-based medicine and its associated hierarchy of evidence. Randomized controlled trials are considered the best method for establishing the efficacy of drugs and other treatments. In this context, qualitative research is considered to be inferior due to its inability to provide precise quantitative estimates, its small sample sizes, its supposed lack of generalizability and its ‘anecdotal’ nature. However, healthcare research has to achieve much more than identify best treatments. Even solutions to practical problems require underpinning mechanisms or theoretical explanations. In this chapter, I aim to show how the synthesis of qualitative evidence can provide conceptual insights which have the potential to improve and transform the quality of healthcare.

Background and problem

Although qualitative research has a rich and distinguished history in the social sciences, qualitative researchers have struggled to get their work taken seriously in medical research. Reviewers of papers sent to medical journals in the 1990s criticized qualitative research as being ‘anecdotal’ due to their small sample sizes. This began to change with the publication of a series of papers about different aspects of qualitative research in the British Medical Journal in 1995. These were later republished as an edited book which is now going into its fourth edition, suggesting a sustained appetite for an introductory text aimed at medical researchers (Pope and Mays 2006). Over time, qualitative research has become more acceptable as evidenced by growing numbers of qualitative papers in many medical journals. But 20 years after the original series, the British Medical Journal stated that qualitative research papers were an extremely low priority, claiming that qualitative papers were less highly cited than quantitative papers. This was despite the fact that of the 20 most influential papers published in the British Medical Journal over the previous 20 years, the top three qualitative papers were more highly cited than the top three randomized controlled trials (RCTs) (Greenhalgh et al. 2016). In advocating the value of qualitative research, it would be misguided to overlook the shortcomings of some published papers, or to avoid talking about how the quality of qualitative research could be improved. The development of methods of qualitative evidence synthesis (QES) was driven in part by the need to address some of the shortcomings of primary qualitative research. These problems included the publication of many small-scale studies in limited populations coupled with the lack of citation of similar or relevant previous research, which impeded the building of a cumulative knowledge base. Many of these primary studies were descriptive with little or no conceptualization, and thus limited transferability or generalizability. Consequently, qualitative evidence synthesis can be seen as a way of enhancing the contribution of qualitative research to healthcare, with its emphasis on credibility as well as transferability.

Pathways to addressing the problem

In this chapter I will focus on one method of qualitative evidence synthesis, namely meta-ethnography (Noblit and Hare 1988). It is one of the most widely used methods of QES. It uses explanations, theories or concepts as building blocks with the aim of producing conceptual innovation. Studies which are purely descriptive make little contribution to meta-ethnography (Campbell et al. 2012). By bringing together the results of several small-scale studies, qualitative synthesis can add to the weight of evi...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Contents
• List of boxes
• List of figures
• List of tables
• List of contributors
• Foreword
• Acknowledgements
• List of abbreviations
• Part 1 Ideas
• Part 2 Systems
• Part 3 Solutions
• Index