The role of conversation in health care interventions: enabling sensemaking and learning

Jordan, Michelle E.; Lanham, Holly J.; Crabtree, Benjamin F.; Nutting, Paul A.; Miller, William L.; Stange, Kurt C.; McDaniel, Reuben R.

doi:10.1186/1748-5908-4-15

Cited by 131 publications

(167 citation statements)

References 34 publications

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“…64 They all require understanding the role of conversation and sensemaking in practice development and interventions. 65,66 Complexity theory reminds us that all interventions have both planned and unexpected aspects. 67,68 An intervention involves the development content as well as the tactics for implementation.…”

Section: Planning and Implementing Primary Care Practice Developmentmentioning

confidence: 99%

“…The genius of conversations is that they are constructible and spontaneous, formal and informal. 65,74 An aligned management model, facilitative leadership, effective work space, good teamwork, strong relationship characteristics, feelings of safety, time for refl ection, and high motivation all help to ensure appropriate spontaneous and informal conversations. This section focuses on the planning and creation of formal conversations.…”

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confidence: 99%

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Primary Care Practice Development: A Relationship-Centered Approach

Miller

Crabtree

Nutting³

et al. 2010

The Annals of Family Medicine

168

209

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PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to fi rst-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODSInformed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice.RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice's key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice's internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fi ts with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations.CONCLUSIONS Successful practice development begins with changes that strengthen practices' core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes. INTRODUCTIONF or more than a century, small, physician-led medical practices were the most common source of primary care throughout the western world.1 The future viability of this cottage industry is now in doubt, and primary care in the United States and elsewhere is seriously weakening. 2 Hopeful energy for changing and transforming primary care practices arises from this deteriorating situation.3 Practice development activities are emerging as part of state initiatives, Medicare pilot programs, health system projects, and independent innovations. [4][5][6] The diffi culties and resistances challenging this hard work are daunting, with few research-informed approaches available to help guide these critically important initiatives. [7][8][9][10] In this article, we offer a theory-based, evidence-informed relationship-centered approach for primary care practice development derived from 15 years of research on primary care practice improvement 11 and, most recently, from the American Academy of Family Physicians' National Demonstration Project (NDP) S69 R EL AT IONSHIP-CENT ER ED PR AC T ICE DE V ELOPMENTone of the fi rst research trials seeking to implemen...

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Section: Planning and Implementing Primary Care Practice Developmentmentioning

confidence: 99%

mentioning

confidence: 99%

Primary Care Practice Development: A Relationship-Centered Approach

Miller

Crabtree

Nutting³

et al. 2010

The Annals of Family Medicine

168

209

View full text Add to dashboard Cite

show abstract

“…It establishes the relevance of ''situated learning,'' which has been shown to be important in ''deep learning'' and the ''construction of knowledge.'' 30,31 Our study has several limitations. The small sample size in a single institution may limit the generalizability of our findings.…”

Section: Discussionmentioning

confidence: 99%

Internal Medicine Residents' Acceptance of Self-Directed Learning Plans at the Point of Care

Smith¹,

Kakarala²,

Talluri³

et al. 2011

Journal of Graduate Medical Education

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Objectives We implemented a curriculum using self-directed learning plans (SDLPs) based on clinical questions arising from the residents' practice, and we report on perceptions and attitudes from residents in internal medicine regarding the use of SDLPs conceived at point of care. Methods Internal medicine residents at a single community hospital in the Midwest were surveyed in 2006 regarding SDLPs. We report their perceived effectiveness in identifying knowledge gaps, the processes used to fill those gaps, and the resident outcomes using descriptive statistics. Results A total of 26 out of 37 residents (70%) responded. Most (24 of 26; 92%) perceived SDLPs helped them to identify and fill knowledge gaps and that their skills in framing questions (23 of 26; 88%), identifying resources (21 of 26; 81%), and critically appraising the evidence (20 of 26; 77%) improved through regular use. They also felt these plans led to a meaningful change in their practice or provided further direction for learning (17 of 26; 65%). Most (21 of 26; 81%) reported their intent to include point-of-care learning in their continuing education after residency. We found no significant differences in the responses of first-year compared with second- or third-year residents. Conclusions Questions arising during patient care are strong motivators for physician self-directed learning. The residents' responses indicated that they accepted the SDLPs and intend to use them in practice. Embedding the discussion of the SDLPs in preclinic conferences has ensured sustainability during the past 5 years and has enabled us to demonstrate teaching of practice-based learning and improvement.

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“…72,76 The theory of complex adaptive systems has been applied productively to the question of why practice interventions succeed or fail in the setting of primary care teams. 54,65 Palliative care scholars have argued that complexity theory is particularly well suited to palliative care because suffering and quality of life are usefully approached as emergent properties that result from the interactions among all agents in the palliative care system, including the patient. 77 This theoretical lens "honors the complex reality of human health" 78 and positions us to understand the system in a way that maximizes the chance of effective intervention.…”

Section: A Robust Theoretical Framework For Studying Hf Care Teamsmentioning

confidence: 99%

“…If we base a complex organizational intervention such as palliative care integration on individuals' knowledge alone, our efforts may yield unhelpful and uninterpretable outcomes. 54,65 Therefore, we describe a robust theoretical framework and innovative methodology to support research into the experiences of patients with HF, family caregivers, and health care providers as they interactively respond to emergent palliative needs.…”

Section: Introductionmentioning

confidence: 99%

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

Lingard

McDougall

Schulz

et al. 2013

Journal of Pain and Symptom Management

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Context-There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team.Objectives-To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team.Methods-This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams.Results-We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps.Conclusion-We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

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The role of conversation in health care interventions: enabling sensemaking and learning

Cited by 131 publications

References 34 publications

Primary Care Practice Development: A Relationship-Centered Approach

Primary Care Practice Development: A Relationship-Centered Approach

Internal Medicine Residents' Acceptance of Self-Directed Learning Plans at the Point of Care

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

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