Exploring the use of technology in
NHS Community Services through
action research – Some
methodological reflections
Dr Lizzie Coates
School of Health & Related Research
University of Sheffield
Today’s seminar
• Background to the research
• Outline of methodology
• Methodological reflections
• Preliminary conclusions
13/04/2015 © The University of Sheffield
Background to the research
What is telehealth?
‘Telehealth … refers to services that use various
point-of-care technologies to monitor a patient’s
physiological status and health conditions’
NHS England (2014)
•Multiple conceptual and operational definitions
(Fatehi and Wootton 2012)
•Remote monitoring of patients at home
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STEP 1
Patient provides and uploads monitoring data
STEP 2
Patient data is checked and patients who alert are triaged
STEP 3
Patients requiring follow-up are contacted by a clinician
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Rationale for the MALT study
• Uptake and expansion of telehealth not
developed at pace and scale anticipated
• MALT study commissioned by the Technology
Strategy Board in 2011 to identify, explore and
seek to overcome key barriers and facilitators to
delivering telehealth at scale:
• Financial
• Organisational
• Operational
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Aims of the MALT study
Phase 1: Map and model current services
Interview all stakeholders
in four health services
sites
Review current practice
Design user acceptance
questionnaire
Design financial models
Phase 2: Implement, evaluate and refine
Implement action
research projects in sites
Test financial models
Test user acceptance
questionnaire
Develop future business
models
JAN 2012 – SEPT 2013
Phase 3: Disseminate
Produce guides and tools
to assist health and care
providers, commissioners
and industry
Share findings with
patients, carers and wider
public
APR 2013 – APR 2014
APR 2014 – NOV 2014
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Outline of methodology
Methodology – Phase 1
• Four community health settings remotely
monitoring patients with COPD and CHF in
routine practice
• In-depth qualitative case studies of each site:
• Explore referral and care pathways
• Examine usage and acceptance
• Identify barriers and enablers
Reported in Taylor et al (under review), Brewster et al (2013)
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Data collection – phase 1
Participants in each site
SITE A
SITE B SITE C SITE D
No. of frontline staff participants
21
17
21
25
No. of managerial staff participants
6
6
7
2
Staff Participant Role
No. of participants
Community matrons and nurse specialists
49
Other frontline nursing and support staff
25
Clinical leads and service managers
10
Organizational, strategic and commissioning
managers
21
Total
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105
Methodology – Phase 2
• Action research to identify key areas for
improvement and implement changes that will
help to address them
• Work with sites as they implement and evaluate
identified changes and improvements to
telehealth delivery
• Observe and measure change throughout phase
2 where possible, and conduct focus groups
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Methodology – Phase 2
• Action Inquiry Groups set up in each site:
• New developments, e.g. new roles, different utilisation
• Current barriers, e.g. improvements to existing
system
• 5/6 groups established in each site – members
include frontline staff and managers
• 58 participants in total – 4-14 per site per cycle
• Ran 2 ‘plan, do, study, act cycles’ over 6 months
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Participants – Phase 2
Participant Role
Site A Site B Site C Site D
Community Matrons and nurse specialists
8
4
5
4
Other frontline staff and support staff
1
1
7
7
Clinical leads and service managers
5
1
3
5
Organisational, strategic and
commissioning managers
0
1
5
0
Patient
0
1
0
0
Total 14
8
20
16
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Total
21
16
14
6
1
58
Methodology – Phase 2
Action research ‘proceeds in a spiral of steps, each of
which is composed of a circle of planning, action and factfinding about the result of the action.’
Lewin (1946:38)
‘Action research is the study of a social situation carried out
by those involved in that situation in order to improve both
their practice and the quality of their understanding.’
Winter and Munn-Giddings (2001: 8)
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Methodological reflections
Why consider this now?
• Reflexivity as practice, both generally (Mason
2002) and as marker of quality in action
research (Bradbury Huang 2010)
• Importance of process (and findings) from action
research (Winter & Munn-Giddings 2001)
• Incongruence between organic telehealth
service development and, conduct of robust
research, identified as barrier (Hendy et al 2012)
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Emerging issues
1. Access
2. Informed consent
3. Confidentiality and anonymity
4. Power and relationships
5. Role of the research team
6. Validity
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1. Access
• Initial problems with access highlight issues with
telehealth adoption writ large
• Recruitment and participation
• Staff engagement fragile (Taylor et al, under review)
• Scale of change currently affecting NHS
• Multiple perspectives and diffuse ownership
(May et al 2011, Greenhalgh et al 2012)
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1. Attrition over time
Site A
M1
M2
M3
Site B
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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M1
1
2
3
4
5
6
7
8
9
10
11
12
13
M2
M3
Site C
M1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
M2
M3
Site D
M1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
M2
M3
“There is a lot of uncertainty I think with
everything I think with integration in general,
in terms of your neighbourhood working, in
terms of new managers.”
“I think sometimes it’s very difficult to keep up
with what’s going on; not just the technology
but what’s going on in your own
community…” (Community Nurse 1)
“And this is going to go down your list of
worries to be honest.” (Telehealth Support 1)
Final Focus Group, Site D
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Community Nurse
1, Final Focus
Group, Site C
2. Informed consent
• Limits of informed consent in AR (Meyer 1993)
• A very clear issue in the MALT study
• What are people consenting to?
• Ethical requirements vs. practicality once
relationships established
• Linked to attrition over time
• Brydon-Miller & Greenwood (2006) suggest that
this collaborative process is more ethical, but…
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3. Confidentiality & anonymity
• Communication between participants – set
ground rules but only on site every 12 weeks
• Anonymity difficult to achieve within:
• a PPI world!
• an active practice environment – kudos from
collaboration with researchers
• Greater collaboration offers a solution (BrydonMiller and Greenwood 2006) but was this
feasible given staff engagement?
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4. Power & relationships
‘In essence I became everybody’s best friend.’
(Meyer 1993: 1070)
•Competing rationales and conflict between
participants
•Expectations of the research
•The guilt of being a ‘temporary stakeholder’
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“As expected, [telehealth champion] took the lead on
this by suggesting each of the areas. [Telehealth
champion’s] commitment to telehealth and the group
within [site] provides strong leadership for MALT
within this site, but it is important to ensure that all
stakeholders have the opportunity to contribute to the
decisions and the progress of the groups.”
“It has been a bit frustrating at times because
we have come and because we have got
interest in Telehealth and we get all
enthusiastic and we go back and try to share it
in the city-wide meetings only to be told that
another group that’s looking at Telehealth
steering group is blocking what we have come
up with, that’s been quite frustrating.”
Researcher 1,
Field Notes: Start of
Phase 2, Site A
Community Nurse 1, Final Focus Group, Site C
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4. Power & relationships
Continued access was contingent on:
• Engagement and trust in relationships between
research team and key stakeholders in each site
• Demands of project helped by alignment with
champions
Key role of key informants in AR (McKenna and Main 2013)
But there are risks in effecting change through small
groups/individuals (Hendy and Barlow 2012) and balancing
research independence with need to galvanise.
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5. Role of the research team
Our work in phase 2 was predicated on:
• A participatory action research design which
requires change
• An implicit assumption (within the project
commission) that more telehealth is a good thing
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5. Role of the research team
• This created a tension for the research team
• Given the ambiguity of evidence on telehealth
effectiveness (e.g. Steventon et al 2012)
• Balance between observer-as-participant and
participant-as-observer roles (Gold 1969)
• Are we active or passive? On-going negotiation of this
to help complete the research
• And was also a cause of great fatigue at times!
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6. Validity
• Phase 2 work helped validate phase 1 (Guba
and Lincoln 1994):
• Credibility – respondent validation
• Authenticity – identifiable, tangible service changes
but with questionable success
• But capturing incremental change was difficult
• A different concept of validity needed in action
research (Winter and Munn-Giddings 2001,
Bradbury Huang 2010)
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Preliminary conclusions
Preliminary conclusions
• Methodology was socially shaped over time
• Phase 2 became less active and more
observational to help address tensions
• Enduring operational barriers to telehealth
adoption impacted on the conduct of research
• Enduring organisational barriers to telehealth
adoption impacted on focus of research
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Preliminary conclusions
• What did we observe?
• Acceptance and uptake decreased over study period
• Achieving change was difficult
• Action research provided further space for ‘sensemaking’ and this need for coherence is a key
mechanism of Normalization Process Theory (May
and Finch 2009)
• Difficulties with achieving change highlight broader
issues with NHS England policy aspiration
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Sense-making
“MALT’s been the forum to be able to do that, hasn’t it? Because
we’ve been able to have discussions that I don’t think we
could’ve had in a provider or commissioner role in a meeting.
So, we’ve had the forum to have open discussions… ”
“I think from our perspective […] this is a god
send because it’s actually getting practical on
the ground feedback from the guys who are
using the service and it doesn’t always reflect
what we hear in the contract meetings. So
yes for me it has been hugely beneficial
irrespective of you know the findings of the
study just to actually be in the same room as
the people delivering the services…”
Manager - Private Telehealth Provider,
Final Focus Group, Site C
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General Practitioner,
Final Focus Group,
Site A
For more information
Visit our website:
www.malt.group.shef.ac.uk
Follow us on twitter: @MALT_YH
Contact us directly
Dr Lizzie Coates
[email protected]
Dr Jo Nicholson
[email protected]
References (1)
1. Bradbury Huang, H (2010) What is good action research? What the resurgent interest? Action Research 8(1): 93109.
2. Brewster, L et al (2013) Factors affecting frontline staff acceptance of telehealth technologies: a mixed-method
systematic review. Journal of Advanced Nursing (e-pub).
3. Brydon-Miller, M and Greenwood, D (2006) A re-examination of the relationship between action research and
human subjects review process. Action Research 4(1): 117-128.
4. Fatehi, F and Wootton, R (2012) Telemedicine, telehealth or e-health? A bibliometric analysis of the trends in the
use of these terms. Journal of Telemedicine and Telecare 18(8): 460-4.
5. Gold, R (1969) ‘Roles in sociological field observations’, in G McCall & J Simmons, (editors) Issues in participant
observation: A text and reader, London: Addison Wesley.
6. Greenhalgh, T et al. (2012) The organising vision for telehealth and telecare: discourse analysis, BMJ Open
:e001574.
7. Guba E. & Lincoln Y. (1994) Competing paradigms in qualitative research, in Denzin N. & Lincoln Y. (editors)
Handbook of qualitative research, pp105-117. Thousand Oaks, CA: Sage, cited in Bryman A (2001) Social
Research Methods. Oxford: Oxford University Press.
8. Hendy, J and Barlow, J (2012) The role of the organizational champion in achieving health system change, Social
Science & Medicine, 74(3).
9. Hendy, J et al. (2012) An organisational analysis of the implementation of telecare and telehealth: the whole
systems demonstrator, BMC Health Services Research 12(403).
13/04/2015 © The University of Sheffield
References (2)
10. Lewin, K. (1946) ‘Action research and minority problems, Social Issues, 2: 34–46, cited in Winter, R and MunnGiddings, C (2001).
11. Mason, J (2002) Qualitative researching (2nd edition), London: Sage
12. May, C and Finch, T (2009) Implementing, embedding, and integrating practices: an outline of normalization process
theory. Sociology, 43 (3): 535-554.
13. May, C et al. (2011) ‘Integrating telecare for chronic disease management: What needs to be done?’ BMC Health
Services Research 11(131), doi: 10.1186/1472-6963-11-131.
14. McKenna, S and Main D (2013) The role and influence of key informants in community-engaged research: A critical
perspective. Action Research 11(2): 113-124.
15. Meyer, JE (1993) New paradigm research in practice: the trials and tribulations of action research. Journal of
Advanced Nursing 18(7) 1066-1072.
16. NHS England (2014) 3 Million Lives website. www.3millionlives.co.uk (last accessed 30/03/2014)
17. Steventon, A et al. (2012) Effect of telehealth on use of secondary care and mortality: findings from the Whole
System Demonstrator cluster randomised trial. British Medical Journal 2012(344).
18. Taylor, J et al. (under review) Examining the utilization of telehealth in community nursing: four case studies
identifying the factors affecting frontline staff acceptance and telehealth adoption. Journal of Advanced Nursing.
19. Winter, R and Munn-Giddings, C (2001) A handbook for action research in health and social care. London:
Routledge.
13/04/2015 © The University of Sheffield
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Action research - Methodological Challenges