1 / 53

Narrative methods in quality improvement research

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

domani
Download Presentation

Narrative methods in quality improvement research

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Narrative methods in quality improvement research Trisha Greenhalgh Professor of Primary Health Care University College London

  2. 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

  3. Start with some stories

  4. 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

  5. What is a story? • Account of a sequence of events • Unfolding over time • The unexpected • Emplotment

  6. Burke: A grammar of motive • Act • Scene • Agent • Agency • Purpose

  7. Mattingly: Narrative drama • Desire • Trouble • Risk • Plot • Suspense

  8. Some themes arising from a story-telling exercise recently

  9. Themes arising from stories • Organisational culture (formal/informal) • Ethical codes, values, conflicts • Leadership • Embeddedness in a wider system • Routines • Identities

  10. 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

  11. 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

  12. Stories: 10 unique selling points as tools in quality improvement

  13. 1. Stories are perspectival and rhetorical

  14. 2. Stories make sense of experience

  15. 3. Stories are non-linear

  16. 4. Stories are embedded in a context

  17. 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

  18. 6. Stories bridge the gap between formal and informal space

  19. 7. Stories offer insights into what might have been (or could be)

  20. 8. Stories are performative and action-oriented

  21. 9. Stories are inherently subversive (“breaking the rules”)

  22. 10. Leadership is related to storytelling

  23. 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

  24. 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

  25. WHEN DOES THE USE OF STORIES IN QI COUNT AS RESEARCH?

  26. 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

  27. Is it research? • Analysis • Coherent theoretical framework • Identifiable unit of analysis • Rigour and transparency of analysis • Evidence of reflexive awareness • Research process • Researcher role

  28. QUALITY IMPROVEMENT RESEARCH:FOUR APPROACHES

  29. 1. NARRATIVE INTERVIEW

  30. 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?”

  31. 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

  32. 2. NATURALISTIC STORY-GATHERING

  33. 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

  34. Naturalistic story-gathering • Impractical and unaffordable in today’s highly managed and audited research culture? • Auto-ethnography as an option?

  35. 3. ORGANISATIONAL CASE STUDY

  36. 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

  37. 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)

  38. 4. ACTION RESEARCH (‘COLLECTIVE SENSE-MAKING’)

  39. 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

  40. 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

  41. Action research • Damn hard to get funding • Very few published accounts in the healthcare literature • Easy to do it badly

  42. Discussion: how did it go?

  43. 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

  44. Evaluation

  45. Thank you for your attention Trisha Greenhalgh University College London p.greenhalgh@pcps.ucl.ac.uk

  46. A slant from complexity (general systems) theory

  47. 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

  48. Distinguish between • Simple system • Complicated system • Complex system

  49. Complexity science: key principles • Relationships • Patterns • Simple rules • Adaptation • Non-linearity (small things, big effects) • Embeddedness • Attractor effects

More Related