Revisiting the Roles of Health and Medical Culture(s) in Implementation Sciences

1. Dr. Simon Kitto Revisiting the Roles of Health and Medical Culture(s) in Implementation Sciences Scientist, Li Ka Shing Knowledge Institute, St. Michael's Hospital Assistant Professor, Department of Surgery, University of Toronto Scientist, Wilson Centre Director of Education Research, Office of Continuing Education and Professional Development University of Toronto simon.kitto@utoronto.ca

2. Overview of Presentation Research interests outside of Health and Medicine Theoretical and methodological influences Current research interests in Health and Medicine Case Study: Evidence and Australian Surgery Re-injecting culture and power into Implementation Science

3. Research interests outside of Health and Medicine Technology implementation Unintended effects of the implementation of online education software in Universities

4. Theoretical and Methodological Influences

5. Current Research Interests Interprofessionalism

6. Current Research Interests Implementation Science

7. Implementation Science and clinical practice change: The Problem We have a plethora of models and implementation strategies Passive dissemination Model Educational Model (continuing education) Stimulus/Reward Model Change Management Model (behavioural) Systems (diffusion of innovations, QI) General consensus that multifaceted interventions are more effective than single interventions(Bero et. al 1998)

8. BUT..... The question is How do we effectively ascertain the composition and sequence of implementation strategies within any given implementation activity? Theoretically, there is at tendency for Psychological approaches to dominate which can result in: Methodological individualism (KTA, Human Factors) Acontextual techniques (Simulation) A focus on interviewing the practitioner as the centre of the problem (Michie, S et al. 2005) Social Systems (DOI) which seeks to further categorise individuals in terms of a continuum of non(compliance).

9. Bringing Health and Medical Structures and Cultures Back In Health care system is increasingly heterogenous with new specialisations emerging Power relationships in and between health professions and medicine are increasingly fluid on a day-to day level Many competing ‘voices’ in the health care system with their own pre-existing values (beliefs) and norms (patterns of behaviour) about treatment and the delivery of care “Each health care profession has a different culture, including values, beliefs, attitudes, customs and behaviours passed on to the neophytes in a given profession which remains obscure to other professions” (Hall, 2005; Schroeder et al., 1999)

10. EBM and Surgery Methodological Individualism Passive dissemination model in Surgery • Rational actor approach - “build it (show it) and they will come” (underpinned by a command and control structure/power) • Awareness of CPGs does not equate to automatic uptake by medical professionals in practice. (Pope et. Al., 2002; Lomas et. Al., 1989) Ongoing frustration associated with a perception that Australian surgeons are slow to adopt EBM due to a shared personality trait of ‘fierce individualism’(Maddern, 2001)

11. However… While Surgeons generally are primarily considered to be ‘active’ clinicians rather than ‘passive’scientists (Katz, 1999) There are many surgical styles, all surgeons are not the same and, by extension all surgical groups are not the same Also it is clear from the literature on EBM that there is ‘an enormous range of perceptions and associations with this notion’.(Antes et. Al., 2006)

12. EBM and SurgeryThe Research Design: Mixed Methodology Cross sectional survey of surgical approach to, and experience in, EBM • 91 Surgeons (25 urban, 66 rural) Semi-structured, in-depth interviews • 22 Specialists • 32 Regional/Rural surgeons

13. Surgeons and Evidence Preliminary results from our mixed methodology study of Rural and Urban surgeon’s suggest that: Understanding and usage of EBM differs by: Generation (Age) Specialty (perceived need for EBM in area) Rates of adoption (the more they use – better understanding) Location (Urban/Rural) Academic Role (Teaching Roles) Private/Public (Workload) Contact, number and type of relationship with Colleagues Surgeons in combination with other health professional colleagues and IS specialists are best placed to understand and translate these issues into change management performances

14. THE RESULTS:Ambivalent and Contradictory Attitudes toward EBM Good understanding of principles of EBM Not concerned about being ‘managed’ by EBM (unlike international peers) EBM marginalises patient involvement in decision-making

15. THE RESULTS:Ambivalent and Contradictory Attitudes toward EBM Primary research is a more useful resource in clinical practice than clinical practice guidelines EBM-generated knowledge is useful in daily clinical decision-making. However, not using EBM does not adversely affect their clinical decisions High confidence in own judgment and low confidence in CPGs versus other evidentiary sources (more pronounced amongst urban specialists)

16. Urban (red) and Rural (blue) Surgeons’ Confidence in CPGs

17. Surgeons and Confidence/Competence Results from our study of Rural and Urban surgeons are yet to be further tested, but also seem to suggest that: Perceived competence is related to • Confidence • Personal empirical surgical experience • A sense of control drawn from personal empirical surgical experience

18. Surgeons and Confidence/Competence Further Understanding of surgery as an art tends to predominate And The apprenticeship experience and craft culture is integral to the development of a surgeon’s confidence and competence Which in turn Is linked to the very generation (and reproduction) and maintenance of the personal and professional identity of surgeons

19. Re-injecting Culture and Power in Implementation Science Activities More broadly, changing routinised clinical/organisational behaviour is extremely difficult as it requires displacing clinical activities, or ‘networks in place’, that are embedded within any clinical organisation (Berg, 1997) that are situated within their own power and cultural frameworks. If new Implementation Science models don’t fit existing cultural and identity ‘networks of practice’ that are important to surgeons, ‘resistance’ and ‘workarounds’ will occur

20. How? Successful surgical behaviour is integral to sense of professional identity – confidence and competence are formed in training years based on experiential knowledge Epistemologically, Clinical Experience and EBM need to be ‘translated’ and made ‘equivalent’ early in the career of surgeons. Vertical Integration of Implementation in surgery (from trainee through to independent practitioner)

21. Back to the operating table:Training the next generation “… we [senior surgeons] should be seen to be using it. You know, just like we use a scalpel. We could be saying, the onus should be put on us in clinics, in the operating theatre, say, “Well, I’m doing this because through EBM I know that this is the best way to do it.” I mean that’s one of the potential appeals of EBM to surgeons is because it’s a doing thing, it’s very, you know, I did this and the consequences were that. In front of your very eyes would suggest you could apply it quite easily if you wanted to. And almost use it as a prefix to each sentence, “Well, I’m cutting the skin with the scalpel because it cuts …” [USS]

22. But … What about this generation?Practical problems of ascertaining the ‘implementation readiness’ conditions of a surgical (or any) culture The situated performance of surgery and contingencies (Pope, 2002)

23. Researching ‘Change Readiness’ of a Group Triangulation of Methods/Data to Move beyond methodological individualism and situate clinical practice Documents, observation, interviewing Professional context Subspecialty context Institutional context Interprofessional context Health care context Rigorous Ethnography that is applied and relevant to everyday clinical implementation problems

24. My Approach to Implementation Science The process of application of change management strategies needs to be informed based upon the concept of clinical experience generated from situated within heterogenous surgical/medical/health cultures Clinical experience (internalised/bodily knowledge) needs to be translated (made equivalent to) with EBM (external rational/scientific knowledge) – epistemologically equivalent

25. Generalisable Lessons Evidentiary sources are translated into professionals’ situated and culturally mediated knowledge, practice and rationality systems Which in turn, are mediated by culture and power structures in the workplace structure Therefore any successful implementation strategies must be attuned to these processes to be effective

26. Thank You QUESTIONS PLEASE!

27. Presentation References Bero LA, Grilli R, Grimshaw JM. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal 1998; 317:465-468. Maddern GJ. Evidence-based medicine in practice-surgery. Med.J. Aust. 2001; 174: 528–30. Katz P. The Scalpel’s Edge: The Culture of Surgeons. New Jersey: Allyn and Bacon, The Johns Hopkins University School of Medicine, 1999. Pope C. Contingency in everyday surgical work. Sociol. Health Illn. 2002; 24: 369–84. Lomas J, Anderson G, Domnick-Pierre K, Vayda E, Enkin M, Hannah W. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N. Engl. J. Med. 1989; 321: 1306–11. Kitto S,Villanueva EV, Chesters J, Petrovic A, Waxman, B, Smith JA. (2007) ‘Surgeons' attitudes towards and usage of evidence-based medicine in surgical practice: A pilot study’ Australian and New Zealand Journal of Surgery;77:231-236 [doi: 10.1111/j.1445-2197.2007.04022.x; Web Access] Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, on behalf of the "Psychological Theory" Group: Making psychological theory useful for implementing evidence-based practice: a consensus approach. Qual Saf Health Care 2005, 14(1):26-33 Technology implementation in Higher education publications Kitto, S (2003) ‘Translating an electronic panopticon: educational technology and the re-articulation of lecturer-student relations in online learning’, Information, Communication and Society 6, (3):1-21. Kitto, S and Higgins, V (2003) ‘Online University education: Liberating the Student?’ Science as Culture 12, (1):23-58. Gale, T and Kitto, S (2003) ‘Sailing into the wind: New disciplines in Australian Higher Education’, British Journal of Sociology of Education 24, (4): 501-514. Kitto, S and Saltmarsh, S (2007) ‘The production of ‘proper cheating’ in online examinations within an Australian University’, International Journal of Qualitative studies in Education, 20, (2):151-173, March-April Kitto, S, Higgins, V (in press) ‘Working around ERPs in Technological Universities’, Science, Technology and Human Values Saltmarsh, S, Sutherland-Smith, W & Kitto, S (2008) ‘Technography and the technological landscapes of teacher education’, Asia-Pacific Journal of Teacher Education, 36 (3):175-178. Saltmarsh, S, Sutherland-Smith, W & Kitto, S (2008) ‘Technographic research in online education: context, culture and ICT consumption’, Asia-Pacific Journal of Teacher Education, 36 (3):179-196. Kitto, S, Higgins, V (in press) Pedagogical Machines: ICTs and Neoliberal Governance of the University, Nova Science Publishers Inc ISBN-10: 1606927086 ISBN-13: 978-1606927083