In this chapter we conclude with a discussion of the potential implications of our findings for policy and practice and suggestions for future research.
Implications for policy and practice
In our empirical findings we presented systematically and in detail a large number of innovation decisions which unfolded across diverse health-care organisations. We described in detail 27 microcases of the ‘what’, ‘who’, ‘how’ and ‘why’ along the decision-making and implementation process. This included the level of involvement of diverse stakeholders at different stages of the process, the issues they encountered, the sources and types of evidence mobilised at each stage and the final outcomes of these decisions. The varied role played by different professionals in how evidence is collectively used has implications for ‘who to involve’ and ‘for what purpose’. An EBMgt approach that inflexibly applies the principles of EBM neglects how evidence is actioned in practice. The nuanced and processual consideration of evidence gives rise to an iterative exchange between codified, systematised knowledge generated from research and other forms of evidence that are also valued by decision-makers. This research demonstrates that experience, personal knowledge and expertise, perspectives and preferences of stakeholders, policy mandates and endorsement, and evidence from the local context all may contribute as credible and relevant evidence sources.
Clinicians and managers were influenced by central or national-level institutions (e.g. The Cochrane Library, NICE, National Service Frameworks, the NPSA), some of which have been active in producing research and disseminating knowledge about the organisation and delivery of health care. There was, however, disconnect between what was perceived as credible (as these sources were) and what was deemed relevant to the decision-making process. How do managers use the research produced by these institutions or influence its production? Our findings showed that the impact of these central institutions differed greatly owing to varied awareness and perceptions of these sources. This leads to the question: is there a need for a central evidence database/depository for managerial practice? Although some informants were aware of NHS Evidence, they rarely used it to source evidence in decisions. The NIHR HS&DR and the NHS Institute for Innovation and Improvement were rarely mentioned and never used (phase 2). There appears currently to be a gap in credible evidence sources relevant to managerial practices in the studied context. The open-access HS&DR journal, which is part of the new online NIHR Journals Library, has the potential to play the role of the management decisions evidence portal, provided that the awareness, credibility and relevance of the journal can be established among practitioners.
The issue of who in organisations searches for, synthesises and presents evidence to others is important. As doctors invariably hold the unique position of being perceived as highly credible at the decision-making table, they need to be engaged. The case of IPC puts nurses at the frontline; in our cases, nurses were the most involved group in innovation processes and charged ‘by default’ with making the case within organisations. The lack of involvement of key stakeholders (e.g. doctors, procurement, the research and development department) was perpetuated in some of our cases to avoid ‘counterproductive interactions’ among professional groups. Nonetheless, the delayed involvement of key stakeholders gave rise to the possibility of decisions being challenged at a later stage. This differential engagement positioned the evidence templates (biomedical-scientific, rational-policy, practice-based) in competition, unless the organisational culture mediated a consensus approach. This lack of involvement of doctors (phase 2) not only contributed to slowing the adoption of innovations, but also curtailed opportunities to draw upon diverse evidence templates.
The NHS and other health systems have explicit policy goals to promote the uptake of innovations and systematise new practices across health-care organisations.10 Our findings suggest that local processes, and professional and microsystem considerations, play a significant role in adoption and implementation. On the basis of this, and significant other research,16,104–106 this policy goal of systematisation appears to be infeasible, because of the idiosyncrasies of situated circumstances and cultures. This has substantial implications for the effectiveness of large-scale projects and systems-wide policy.
Reported missing research
Respondents in phase 1 reported that areas of missing research comprised behavioural studies, implementation research and organisational studies or management research. They were particularly interested in how to tackle non-conformance behaviour and better understand implementation challenges. In particular, pharmacists reported a lack of research in this area, followed by nurses and non-clinical managers. Doctors were less attuned to this aspect of organisational change. Frequently reported medical resistance towards IPC practices confirm this finding – doctors representing the professional group least aware of behavioural change. T1, T3, T6 and T9 appeared to be more behavioural-change conscious than other trusts. This could be linked to their proactive organisational culture or relevant research strategies set up through collaboration with local universities, as documented in
Chapter 6
.
Suggestions for future research
This study has provided original insights into the use of evidence by health-care managers in organisational technology adoption. Whereas we investigated in detail the individual and collective sensemaking processes as managers sourced and applied evidence during the innovation journey, future research can further develop such insights and assess their transferability and relevance to other contexts. We suggest the following ideas that can inform future research (these are not listed in order of priority or importance):
While we elicited complex dynamics of the innovation process, from initiation to implementation, our study draws primarily on data derived from self-reported accounts. An understanding of the discourse between professional groups and non-verbal cues would provide further insight into the actual decision-making processes. Direct observation using in-depth ethnographic studies would be the most appropriate approach.
Further exploration of the evidence templates and how they link to broader shared cognitive frames of rationality in the form of institutional logics in the field of health care
107,108 is needed to address the following questions: what are the constitutive elements of these templates?; what role do the templates play in knowledge production as well as utilisation and what are the consequences for practice?; and how does the interplay of diverse templates occur in practice in different contexts? A longitudinal research design with multiple case studies at the level of the organisational field focusing on evidence use by health-care managers from diverse professional backgrounds can be a fruitful option for this stream of inquiry.
An in-depth study looking at the theme highlighted in this research regarding ‘making sense for others’ and a more focused research question about interprofessional power dynamics.
In this study we included technology products bounded within NHS acute trusts. We suggest similar dynamics are explored for innovations across different boundaries (sectoral, level of care) and with less clearly defined boundaries (process, organisational innovations). This is particularly relevant given the restructuring of the English NHS, with public health-functions based in local government.
We also point out that the dissemination of such research needs to transcend mainstream management and organisational literature. Respondents cited a lack of relevant empirical studies in peer-reviewed management journals largely because there is a discord between where such literature is published and the sources used by these decision-makers.
A large-scale population-based survey of the structured questionnaire. Such a survey would help determine the extent to which the reported differential preferences on access and use of evidence sources and types by professional groups in our purposeful sample can be generalised.
Although this study allowed for investigating the full innovation process from initiation to adoption decision and implementation, as a result of time constraints we were not able to study the later stages of assimilation and routinisation for all technologies. Moreover, because of the study’s focus on sensemaking processes, emphasis was given to decision-making rather than practice adaptation and assimilation. Future research could investigate in more detail how front-line users implement and assimilate technologies into their established day-to-day routines, which are issues that have received limited attention in current empirical studies.
