Exploring the determinants of evidence use within clinical network stewardship models: A q methodology study Jade Hart, The University of Melbourne Prof Margaret Kelaher, The University of Melbourne Prof Helen Dickinson, University of New South Wales 1
Research questions The overarching aim of this research is to understand how clinical network stewardship models influence the use of evidence in Australian State health system decision-making processes. 1. What are the clinical network stewardship models? How are they organised? And what are the broader operating contexts that the clinical networks operate within? 2. How is evidence understood? What are the evidence needs by type and how is evidence valued? 3. What are the features of clinical network stewardship models (and associated decision-making processes) that influence overall evidence use?
1. Background and concepts 3
The Australian health system is complex Lack of a single authority Continuous pursuits toward safety and quality Shift towards relational approaches to problem solving, but challenges with realising engagement in system decision-making Concerns over variable understanding and uptake of evidence – what works, where, and under what circumstances?
Evidence is ill-defined or multiply-defined Focus on evidence use in system decision-making and policy Evidence - “anything that establishes a fact or gives reason for believing in something” (Lomas et al., 2005, p.3) • Narrow definitions • Broad definitions – i) research, ii) quantitative data, iii) reports/grey literature, iv) colloquial evidence Evidence use (Weiss, 1979, Pelz, 1978) • Direct use – evidence is instrumental • Symbolic use – selective use of evidence • Enlightenment as use – enhancing understanding Evidence use as a process and/or outcome
Functions of health systems operationalised through stewards 1. Define the vision for health and strategies and policies to achieve better health 2. Make use of legal, regulatory and policy instruments to steer health system performance 3. Exert influence across all sectors and advocate for better health 4. Ensure the alignment of system design with health system goals 5. Ensure good governance supporting the achievement of health system goals 6. Compile, disseminate and apply appropriate health information and research evidence. (World Health Organization, 2000 and Veillard, 2012)
Australian Clinical Networks as stewards “Voluntary clinician groupings that aim to improve clinical care and service delivery using a collegial approach to identify and implement a range of strategies.” (Haines et al., 2012, p.16).
Clinical Networks and membership General Practitioners Managers Academia Cancer Cardiac Planners Neurosurgeons Peak associations Dietitians Midwives Maternity Emergency Physicians and newborn Pharmacists Consumers Community Health Pediatricians Renal Rural health Physiotherapists Clinical Nurse Specialists Occupational Therapists Clinical Psychologists Stroke Dementia Registered nurses Nurse Practitioners
Australian Clinical Networks as evidence stewards Key features of note • Inclusive with participation being voluntary in nature • Identify improvements in health service delivery and patient outcomes • Focused on embedding evidence • Seek to facilitate clinicians to implement evidence- informed practices. (McInnes 2012 and Cunningham et al., 2012)
2. Exploration of research questions using Q methodology 10
Exploration of the influence of clinical network stewardship models, evidence, and evidence use Q methodology explores meaning and significance of subjective data Facilitates analysis in relative rather than absolute terms Long list of the factors relating Systematic Viewpoints to how clinical comparison of List of Participant examined to network arrays – statements ranking of identify high stewardship identifying (concourse) statements and low scoring models can emerging statements influence the viewpoints use of evidence (Adapted from Meshaka et al., 2016, p.4)
Statements for participant ranking 1. Network participation arrangements 4x domains 2. The evidence base 3. Network management arrangements Constructs 4. Functional process to evaluate evidence 40x clustered statements
Statements for participant ranking From my experience within a Clinical Network, my view of the factors influencing evidence use Member Group culture of collective deliberation (e.g. culture of debate) [Statement 9] relations Leadership The clinical network lead's/chair’s leadership style [Statement 1] Evidence base The quality of the evidence [Statement 19] Network Clinical network approaches that examine whole-of-health system design management [Statement 29] 13
Exploration of the influence of clinical network stewardship models, evidence, and evidence use Based on your own knowledge of and experience within a clinical network, sort the statements in order of those that you think have had more influence or lesser influence on evidence use by the clinical network. From my experience within a Clinical Network, my view of the factors influencing evidence use Lesser influence More influence -1 -4 -3 -2 0 +1 +2 +3 +4
3. Findings and implications for dissemination and implementation research 15
Participant profile Clinical network role n % total Clinical network member 17 65.4% Clinical network manager or project staff 6 23.1% Clinical network clinical lead/chair or equivalent 2 7.7% Other departmental staff 1 3.8% Total 26 100.0% Professional background n % total Clinician – nursing, allied health, health professional 12 46.2% Clinician – medical 7 26.9% Public servant (non-clinical) 3 11.5% Academic/researcher 2 7.7% Consumer/community member 2 7.7% Total 26 100.0% 16
Factor analysis Factor characteristics Factor F1 F2 F3 F4 No. of Defining Variables 9 5 7 4 Average Rel. Coef. 0.8 0.8 0.8 0.8 Composite Reliability 0.973 0.952 0.966 0.941 S.E. of Factor Z-Scores 0.164 0.218 0.186 0.243 17
Factor arrays Factor arrays communicate the view points of the factor. These are expressed as a Q sort which shows how the concourse was reflective of the viewpoint. Factor One Less influence More influence -1 -4 -3 -2 0 +1 +2 +3 +4 3 6 1 17 19 2 8 7 38 12 11 5 20 28 4 16 27 39 18 14 9 21 30 32 40 35 15 10 22 33 37 24 13 25 34 36 23 26 29 31 18
Factor arrays # Statement F1 F2 F3 F4 1 The clinical network lead's/chair’s leadership style 0 2 2 0 2 The clinical network manager's management style -4 4 1 -3 Clinical network member trustworthiness derived from 3 their professional reputation (e.g. effects of direct experience and/or those of others) -2 1 1 -2 4 Clinical network member influence -4 3 3 -3 5 Clinical network member knowledge 0 2 1 2 Achievement of appropriate clinical network 6 representation through legitimate recruitment processes -1 -2 -2 1
Factor one - Evidence stewardship as a form of good governance to realise health improvement Viewpoint: Achieving improvements in the safety and quality of care is the agreed end goal. Realising this goal relies on good governance which is inclusive, evidence-based, and integrated within the broader policy, regulatory and legal framework. These are the features of effective health system stewards. Being evidence-based meets expectations for clinician and patient engagement, rational decision-making, and use of evidence that provides insight into “what works” in the local context for the betterment of patient outcomes. 20
Factor two - Evidence as a means to influence the suite of disparate and influential leaders Viewpoint: Health systems reflect disparate arrangements rather organisations working toward a shared vision. Individuals can serve as facilitators or barriers to system improvement at implementation. Clinical networks provide the clinical leadership and management supports to facilitate evidence use in ways that might not have been previously possible to address cross- boundary issues. Hence, the clinical networks membership and authorising environment provides the context for which evidence can shape the collective way forward. 21
Factor three - Evidence use as a mechanism to implement the vision for health system reform Viewpoint: Clinical networks are a health system stewardship model and use evidence to define the vision for how the health system should be configured to achieve best outcomes for patients. Providers and patients accessing the health system are ideally suited to provide insight into the priorities for change implementation consistent with the vision. Tailored solutions that are informed by diverse types of evidence are advantageous over universal approaches. 22
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