The group (i) highly valued genuine intent and relationship building as elements to combat tokenism; (ii) noted that early genuine attempts at engagement may superficially resemble tokenism as researchers build enduring and trusting relationships with patient/community partners and (iii) emphasized the importance of seeking and utilizing patient experiences throughout research. These observations may contribute to more formal methods to help researchers (and reviewers) evaluate where engagement processes sit along the 'genuine-token' continuum.
Background The success of practice-based research (PBR) depends on the willingness of clinicians and staff to incorporate meaningful and useful research protocols into already demanding clinic schedules. The impact of participation on those who implement multiple projects and how to address the issues that arise during this complex process remain incompletely described. This article reports on a qualitative evaluation of the experiences of primary care clinicians and clinic staff who participated in multiple PBR projects with the Wisconsin Research and Education Network (WREN). Also included are their suggestions to researchers and clinicians for future collaborations. Methods For program evaluation purposes, WREN conducted four focus groups at its 2014 annual meeting. The main focus group question was: “How has participation in PBR impacted you and your clinic?” Twenty-seven project members from 13 clinics participated in 4 groups (physicians, nurses, managers, and other clinical staff). The two-hour sessions were recorded, transcribed, and analyzed by the authors to identify recurring themes. Results Five major focus group themes emerged: receptivity to research; outcomes as a result of participation; barriers to implementation; facilitators of success; and advice to researchers and colleagues. Focus group members find research valuable and enjoy participating in projects that are relevant to their practice, even though many barriers exist. They indicated that research participation produces clinical changes that they believe result in improved patient care. They offered ways to improve the research process, with particular emphasis on collaborative early planning, project development, and communication before, during, and after a project. Conclusions Clinics that participate in WREN projects remain willing to risk potential work constraints because of immediate or impending benefits to their clinical practice and/or patient population. Including a broader array of clinic personnel in the communication processes, especially in the development of relevant research ideas and planning for clinic implementation and ongoing participation in research projects, would address many of the barriers identified in implementing PBR. The themes and supporting quotes identified in this evaluation of WREN projects may inform researchers planning to collaborate with primary care clinics and clinicians and staff considering participating in research endeavors.
ne-half of Americans are projected to be living with at least one chronic condition before 2020. 1 For that reason, the health care system must work toward reducing the burden on primary care for disease management by facilitating the development of activated, informed patients who are proficient in self-management skills. Self-management support (SMS) helps enable people to manage their conditions day-today. SMS is defined as the efforts of the health care team to promote patient engagement in behaviors that positively impact their Purpose With one-half of Americans projected to be living with at least one chronic condition before 2020, enhancing patient self-management support (SMS) may improve health-related behaviors and clinical outcomes. Routine SMS implementation in primary care settings is difficult. Little is known about the practice conditions required for successful implementation of SMS tools. Methods Four primary care practice-based research networks (PBRNs) recruited 16 practices to participate in a boot camp translation process to adapt patient-centered SMS tools. Boot camp translation sessions were held over a 2-month period with 2 patients, a clinician, and a care manager from each practice. Qualitative case comparison and qualitative comparative analysis were used to examine practice conditions needed to implement SMS tools. The Consolidated Framework for Implementation Research guided data collection and analysis. Results Four different practice conditions affected the implementation of new SMS tools: functional practice organization; system that enables innovation and change; presence of a visible, activated champion; and synergy and alignment of SMS changes with other work. Qualitative comparative analysis suggested that it was necessary to have an enabling system, a visible champion, and synergy for a practice to at least minimally implement the SMS tools. Sufficiency testing, however, failed to show robust consistency to satisfactorily explain conditions required to implement new SMS tools. Conclusions To implement tailored self-management support tools relatively rapidly, the minimum necessary conditions include a system that enables innovation and change, presence of a visible champion, and alignment of SMS changes with other work; yet, these alone are insufficient to ensure successful implementation.
Under American policy, healthcare organizations have strong incentives to adopt and use electronic health records (EHRs) (US Department of Health and Human Services, n.d.). However, current EHRs do not provide the cognitive support needed for clinicians to adequately evaluate, diagnose, or treat patients (Stead & Lin, 2009). Consequently, patient care outcomes suffer (Karsh et al., 2006). The cognitive complexity of primary care is vastly underappreciated (Beasley et al., 2006; Wetterneck et al., 2011; Pham et al., 2009), and teamwork in primary care brings an additional intricacy to the cognitive needs of clinicians and staff. Addressing the mismatch between technology and cognitive requirements in actual work processes is needed to prevent further obstruction of team workflows and quality patient care. To do so, it is necessary to understand these cognitive requirements and how they relate to decision-making. One way of looking at this is through examining primary care teams' Situation Awareness (SA). SA refers to a person's perception (level 1), comprehension (level 2), and projection (level 3) of elements in an environment (Endsley, 1988), and is a "key foundation for human decision-making" (Endsley & Jones, 2013). Since primary care teams work in a highly dynamic environment, their decision-making strongly relies on their SA. This research aimed to identify the SA requirements and decision-making processes of individual primary care clinicians and their teams to inform EHR design. Data were collected from two community-based clinics. Participants included two primary care teams comprised of a physician, advanced practice providers (APPs) working with the physician (i.e., physician assistants or advanced practice nurses), and registered nurses (RNs) or medical assistants (MAs) that assist with or deliver care to the physicians' or APPs' patients. Data collection and analysis were guided by a cognitive task analysis method called Goal-Directed Task Analysis (GDTA). GDTA investigates tasks and corresponding SA requirements of a person by studying his/her work-related goals. The outcomes are GDTA maps, where goals, decision-making processes and SA requirements are mapped in a hierarchical structure to show interrelationships. GDTA has proved promising in a variety of teamwork-focused areas, including aviation and the military (Matthews, Strater, & Endsley, 2004) for understanding cognitive requirements of operators. This method provides the basis for developing training courses and designing user-friendly technologies. However, it has seldom been used in healthcare or health IT design. For each clinic, the following procedures were followed: tandem observations were conducted on the dyad of a physician/APP and the RN/MA rooming patients in order to capture the teamwork between these two positions. Researchers took detailed observation notes, focusing on work roles, team structure, information gathered, decision-making and technology used. Additionally, up to three 90-minute semi-structured interviews per partici...
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