Patient Involvement in Safer Surgery: A Realist

Analysis

Dominic Roche, PhD Student

Cardiff University School of Nursing and Midwifery

Studies

3rd Doctoral Colloquium Trinity College Dublin

6th November 2012

A discussion on the processes and experiences that led to the design of my research protocol

This study will focus on attempts to improve patient safety through promoting the involvement of patients in the planning and delivery of surgical care through an Enhanced Recovery After Surgery (ERAS) programme.

The broad aim of this study is to explore the extent to which patients are involved in attempts to improve their own healthcare safety, specifically considering the mechanism of effect and investigating the conditions and circumstances that are required for patients’ to adopt safety roles.

The underpinning theoretical framework of this proposal is realist evaluation, which explores what is it about an intervention that works (or not), for whom and in what circumstances, and develops explanations about how the effects of a programme intervention are achieved.

What is my research?

Aspirations...

The Initial Idea

Under Pressure!

It’s all so abstract

Imposter Syndrome

So, how do I write a research protocol?

The research question

When making observations, scientists look through telescopes, study images on electronic screens, record meter readings, and so on. Generally, on a basic level, they can agree on what they see, e.g., the thermometer shows 37.9 C. But, if these scientists have different ideas about the theories that have been developed to explain these basic observations, they can interpret them in different ways. Ancient scientists interpreted the rising of the Sun in the morning as evidence that the Sun moved. Later scientists deduce that the Earth is rotating. For example, if some scientists may conclude that certain observations confirm a specific hypothesis, skeptical colleagues may suspect that something is wrong with the test equipment. Observations when interpreted by a scientist's theories are said to be theory-laden.

Whitehead wrote, "All science must start with some assumptions as to the ultimate analysis of the facts with which it deals. These assumptions are justified partly by their adherence to the types of occurrence of which we are directly conscious, and partly by their success in representing the observed facts with a certain generality, devoid of ad hoc suppositions."[22]

Observation involves both perception as well as cognition. That is, one does not make an observation passively, but is also actively engaged in distinguishing the phenomenon being observed from surrounding sensory data. Therefore, observations are affected by our underlying understanding of the way in which the world functions, and that understanding may influence what is perceived, noticed, or deemed worthy of consideration. More importantly, most scientific observation must be done within a theoretical context in order to be useful. For example, when one observes a measured increase in temperature with a thermometer, that observation is based on assumptions about the nature of temperature and its measurement, as well as assumptions about how the thermometer functions. Such assumptions are necessary in order to obtain scientifically useful observations (such as, "the temperature increased by two degrees").

Empirical observation is used to determine the acceptability of hypotheses within a theory. Justification of a hypothesis often includes reference to a theory – operational definitions and hypotheses – in which the observation is embedded. That is, the observation is framed in terms of the theory that also contains the hypothesis it is meant to verify or falsify (though of course the observation should not be based on an assumption of the truth or falsity of the hypothesis being tested). This means that the

observation cannot serve as an entirely neutral arbiter between competing hypotheses, but can only arbitrate between hypotheses within the context of the underlying theory that explains the observation.

Thomas Kuhn denied that it is ever possible to isolate the hypothesis being tested from the influence of the theory in which the observations are grounded. He argued that observations always rely on a specific paradigm, and that it is not possible to evaluate competing paradigms independently. By "paradigm" he meant, essentially, a logically consistent "portrait" of the world, one that involves no logical contradictions and that is consistent with observations that are made from the point of view of this paradigm. More than one such logically consistent construct can paint a usable likeness of the world, but there is no common ground from which to pit two against each other, theory against theory. Neither is a standard by which the other can be judged. Instead, the question is which "portrait" is judged by some set of people to promise the most useful in terms of

scientific "puzzle solving". For Kuhn, the choice of paradigm was sustained by, but not ultimately determined

by, logical processes. The individual's choice between paradigms involves setting two or more "portraits" against the world and deciding which likeness is most promising. In the case of a general acceptance of one paradigm or another, Kuhn believed that it represented the consensus of the community of scientists. Acceptance or rejection of some paradigm is, he argued, a social process as much as a logical process. Kuhn's position, however, is not one of relativism.[23] According to Kuhn, a paradigm shift will occur when a significant number of observational anomalies in the old paradigm have made the new paradigm more useful. That is, the choice of a new paradigm is based on observations, even though those observations are made against the background of the old paradigm. A new paradigm is chosen because it does a better job of solving scientific problems than the old one.

The fact that observation is embedded in theory does not mean observations are irrelevant to science. Scientific understanding derives from observation, but the acceptance of scientific statements is dependent on the related theoretical background or paradigm as well as on observation. Coherentism, skepticism, and foundationalism are alternatives for dealing with the difficulty of grounding scientific theories in something more than observations. And, of course, further, redesigned testing may resolve differences of opinion.

Theory Laden?

K.I.S.S.Keep it Simple

StupidOccam’s RazorSimplicity is the

ultimate sophistication

Less is more

Peer support and supervisors

The final design Patient Involvement in Safer Surgery: A Realist Analysis

D. Roche*

School of Nursing and Midwifery Studies, Cardiff University, Eastgate House, Newport Road, Cardiff CF24 0AB

*Corresponding Author: (roched1@cf.ac.uk) Abstract Research has shown that healthcare systems can cause harm to patients, much of which is avoidable, and there is reliable evidence to suggest that this avoidable harm is a widespread and recurring phenomenon. This paper describes how the researcher will use a realist evaluation approach to study attempts to involve patients in the planning and delivery of safer surgical care. Keywords: Patient safety, Involvement, Surgery

1. Background Patients are the only individuals present during every treatment and consultation and they carry with them important contextualised information as they move through a complex and distributed process of care. As a result, patients have been increasingly seen as a valuable resource in helping to ensure the safe delivery of care and effective treatment systems (Unruh and Pratt 2006; Coulter 2006). However, a recent scoping study of almost 2,000 papers by Peat et al (2010) of interventions intended to involve patients in patient safety programmes concluded that rigorous evaluations of such programmes are desperately needed. A similar conclusion was reached by Davis et al (2008; 2011) who agree that future questions regarding patient involvement in attempts to improve patient safety in hospitals should include focus on what conditions and circumstances are required for patients to adopt safety roles.

This study will focus on attempts to improve patient safety though promoting the involvement of patients in the planning and delivery of surgical care. The broad aim is to explore the extent to which patients are involved in attempts to enhance their own healthcare safety, specifically considering the mechanism of effect and investigating the conditions and circumstances that are required for patients’ to adopt safety roles. All

participants will be involved in an Enhanced Recovery after Surgery (ERAS) programme in one of three surgical units in a single University Health Board in Wales. 2. Enhanced Recovery after Surgery ERAS is a multi-modality evidence based approach to improving the quality of patient care after major surgery. It embodies a selected number of individual interventions which demonstrate a greater impact on outcomes when implemented together than when implemented as individual interventions (NHS Wales 2010; 2011). The basic principles of ERAS include ensuring that the patient has the best possible management before, during and after his or her operation. The ERAS programme also has an economic imperative relating to increased patient throughput. The ERAS programme is grouped into ‘care bundles’, in which the key drivers or interventions are grouped together to promote their delivery. This research will focus on the Pre-operative Assessment care bundle, which plays an essential role in how the patient understands, considers and ultimately participates in the ERAS pathway, and the Peri-operative Assessment care bundle, which is designed for optimal management of the patient and is a key aspect of the programme (NHS Wales 2010; 2011). Patient safety is just one element of the

Reflections