narrative methods in quality improvement research
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Narrative methods in quality improvement research. Trisha Greenhalgh Professor of Primary Health Care University College London. Structure of this talk. Start with some stories Themes arising 10 advantages of stories for use in QI Storytelling template exercise - PowerPoint PPT PresentationTRANSCRIPT
Narrative methods in quality improvement
researchTrisha Greenhalgh
Professor of Primary Health CareUniversity College London
Structure of this talk
Start with some stories Themes arising 10 advantages of stories for use in QI Storytelling template exercise When does collecting and analysing
stories count as research in a QI setting? 4 methodological approaches to using
stories in QI research
Start with some stories
Storytelling exercise 1
In small groups of 2-5 Tell some stories about an encounter
with the healthcare system FOR EXAMPLE elderly person with
complex needs Don’t get sidetracked into debates
about clinical management
What is a story?
Account of a sequence of events Unfolding over time The unexpected Emplotment
Burke: A grammar of motive Act Scene Agent Agency Purpose
Mattingly: Narrative drama
Desire Trouble Risk Plot Suspense
Some themes arising from a story-telling exercise recently
Themes arising from stories Organisational culture
(formal/informal) Ethical codes, values, conflicts Leadership Embeddedness in a wider system Routines Identities
Themes arising from stories ‘Trouble’ Humour => absurdity, inflexibility of ‘the
system’ High drama => risk & risk management ‘Trivial’ problems in middle classes =>
how much worse for vulnerable / serious Subverting / working round the system
Themes arising from stories Social networks and ‘soft knowledge’ Triage by ‘the system’ (the system is
the character) Role conflict – hero and villain Staff failing to take ethical
responsibility – ‘collusion of anonymity’
Institutional racism / discrimination
Stories: 10 unique selling points as tools in quality
improvement
1. Stories are perspectival and rhetorical
2. Stories make sense of experience
3. Stories are non-linear
4. Stories are embedded in a context
5. Stories have an ethical dimension
“The singular case arises only in the act of narrating it and … duties are incurred in the act of hearing it” Rita Charon
6. Stories bridge the gap between formal and informal
space
7. Stories offer insights into what might have been (or
could be)
8. Stories are performative and action-oriented
9. Stories are inherently subversive (“breaking the
rules”)
10. Leadership is related to storytelling
Summary: stories in QI Stories convey the complexity of human
experience in particular contexts Stories are about ‘trouble’ and risk Storytelling is therefore a useful tool for
analysing complex and tragic situations Stories prompt reflection, inspire the
moral imagination, and ignite action
Storytelling exercise 2
Choose a good story from the ones you have shared
Fill out the template Give the story a different ending Re-vision the organisation(s) to
produce the key relationships, patterns, and choices that lead to this ending
WHEN DOES THE USE OF STORIES IN QI COUNT AS
RESEARCH?
Is it research?
Clear research question Recognisable methodological
approach, applied rigorously and transparently Choice of approaches/tools/instruments Method of data collection Choice of analytic method
Is it research?
Analysis Coherent theoretical framework Identifiable unit of analysis Rigour and transparency of analysis
Evidence of reflexive awareness Research process Researcher role
QUALITY IMPROVEMENT RESEARCH:
FOUR APPROACHES
1. NARRATIVE INTERVIEW
Narrative interview
Systematic sampling of informants “Tell me a story about X” Prompts
“How did you feel at that point?” “What happened next?” “How might this have gone differently?”
Narrative analysis
“It is the researcher's task not merely to celebrate the story or the narrative but to seek to use it as a vehicle for accessing deeper truths than the truths, half-truths and fictions of undigested personal experience.”
Yiannis Gabriel
2. NATURALISTIC STORY-GATHERING
Naturalistic story-gathering An aspect of ethnographic study Informal as well as formal stories Trade-off between accuracy in
recording and distortion of the situation
Analysis: within the wider ethnographic interpretation
Naturalistic story-gathering Impractical and unaffordable in
today’s highly managed and audited research culture?
Auto-ethnography as an option?
3. ORGANISATIONAL CASE STUDY
Organisational case study
The researcher’s story of what is going on in the organisation over time
Draws on multi-method data gathering (e.g. interviews, memos, observational data)
Story-telling as a method of prioritising and making sense of the data
Organisational case study
Complex and lengthy process Timescale may be too long for
today’s rapidly changing work environment
Not to be confused with superficial personal accounts from QI teams (i.e. easy to do this one badly)
4. ACTION RESEARCH (‘COLLECTIVE SENSE-
MAKING’)
Action research
“a mutual learning process within which people work together to discover what the issues are, why they exist, and how they might be addressed”
Paul Bate
Action research
Participatory Developing a shared perspective
and vision on the problem Igniting and sustaining collective
action ‘Let it happen’ rather than ‘make it
happen’ approach to change
Action research
Damn hard to get funding Very few published accounts in the
healthcare literature Easy to do it badly
Discussion: how did it go?
Conclusion
Stories are a flexible, fun and creative tool for engaging people in organisational change efforts
Storytelling is particularly useful when analysing and changing complex systems
Evaluation
Thank you for your attention
Trisha GreenhalghUniversity College London
A slant from complexity (general systems) theory
What is a complex system? Collection of actors/agents who can
act independently and creatively Share an environment or space Parts are interconnected: interfaces
and relationships between the parts are key
Action by any part affects the whole
Distinguish between
Simple system Complicated system Complex system
Simple (baking a cake)
Complicated(moon rocket)
Complex(raising child)
Standard recipeStandard product‘No experience necessary’Outcome predictableCake does not have a view on life
Lots of formulae Needs expertise & co-ordinationAll rockets similar in critical waysSending one rocket increases assurance that next will be OKRocket does not have a view on life
Child has a viewFormulae have limited applicationRaising one child gives no assurance of success with nextExpertise can help but not sufficientUncertainty of outcome
Complexity science: key principles
Relationships Patterns Simple rules Adaptation Non-linearity (small things, big effects) Embeddedness Attractor effects
Attractor effects
Throwing a rock
Throwing a bird
Making sense of complex systems
MUST THINK ABOUT relationships + patterns + simple rules + adaptation + non-linearity + embeddedness + attractors
Aaaugh!
Use a sensemaking device that incorporates and promotes all these perspectives
Tell a story
Making sense of complex systems