32 SES 09 B, Innovation in/of Healthcare Organizations
Across international contexts public service policy is being brought together within interprofessional working to address a range of complex needs, including integration of refugee populations, with implications for educational settings and practices (Vyt et al 2015). This requires professionals increasingly to work together to meet multiple goals more holistically so that problems are prevented rather than addressed once they have become entrenched and expensive. Such policies have led to the development of complex interventions which increasingly require sophisticated levels of communication and collaboration of front line workers with daily interaction with families such as educators (Author 2017). Complex interventions are interventions with several interacting components that require different aspects of a change program to be successfully coordinated (Mays, Wyke & Evans, 2001).
Schön (1979) argues that a fundamental reason for the lack of progress in addressing many societal problems that professionals are tasked with addressing is not a matter of problem solving but of problem setting, that is, that we use the wrong metaphor or schematic frame to understand the problem in the first place. He goes on to argue this happens because schematic frames are often adopted uncritically and even unknowingly without first attempting to expand the possible range from which we choose or examining the criteria that inform our choice. This paper reports on longitudinal action research that worked with participants to identify underlying metaphors that influenced how they imagined their coordinated work together, developed their ability to visualise, compare and synthesise their different approaches and become much more effective. Whilst the importance of visual literacy has been well argued (Kress 2003), particularly as digital tools expand the range of visual resources available , their use in strategic learning and policy interpretation is under-researched (Lui 2013).
This longitudinal action research project used a Realist Evaluation analytic framework (Pawson & Tilley 1997) within which visual mapping played a particularly important role in making accessible professionals’ representations of quite complex multi-strand sequences of planning, action, measurement and evaluation in one such complex intervention. The action research group consisted of educators, health professionals and community partners tasked with rolling out a complex health education programme to address the growing crisis of obesity across three health board areas in Scotland. The key action research goals were to understand how well the intervention networked with people who could help reach families who could benefit by looking at:
- How effective partnerships were and how well their plans worked.
- How well they let others know how the programme worked and how well they passed on what they learned about how to make the programme better.
- How well they interested those who make decisions across Scotland so that more families could have the opportunity to benefit from the programme.
This research project used a Realist Evaluation analytic framework(Pawson & Tilley 1997) within which visual mapping played a particularly important role in making accessible professionals’ representations of quite complex multi-strand sequences of planning, action, measurement and evaluation in one such complex intervention. Realist Evaluation compares an intervention’s program theory, (how steps within policy are meant to effect change) with how program steps play out in reality across different contexts. Realist evaluation is particularly suited to examining complex interventions as it examines the complex inter-relations amongst contexts of implementations, the specific program steps as they are interpreted and enacted within each context, the mechanisms which these steps trigger (changes in attitudes, resources, and approaches) and the extent to which these inter-related factors lead to both intended outcomes (benefits, such as improvement in delivery of services and improved health outcomes for women and children) and unintended outcomes (disadvantages such as increased expense, resistance or disengagement) (Wand, White & Patching, 2010; Befani, Lederman & Sagar, 2007). A key aspect of realist evaluation is bringing to light the strategic thinking and the concepts and habits of practice that underpin them of those with lynchpin roles within a programme of change. Educators are such lynchpins as they are often at the nexus of communication between families and the range of services and specialists. Visual tools can help make explicit this strategic thinking and its premises and enable comparison and learning within interprofessional teams. The methodology consisted in raising awareness of the potential of visual mapping of strategy, providing activities to experiment with their use, leading to a sequence of activities where they mapped their strategies and compared the resulting schemata. Analysis of patterns and organising principles evident across schemata were then fed back to participants for their validation, interpretation and use in their continued strategic work together. Their use and adaptation of strategies was then observed and these observations fed back to participants as they continued to cycle around the action research steps (plan, do, measure, evaluate) of intervention implementation.
The paper outlines the sequence of activities that developed participant professionals’ visual reasoning skills. It documents the increasing capacity to develop, read and adapt schematic mapping of their strategies to bring them into better coordination. A key aspect of interviews and analysis tested the models or schemas participants articulated and acted upon in order to achieve a conceptual refinement process where the meanings of key concepts and the implicit criteria for assessing their application to work practice were clarified (Pawson & Tilley, 1997). Two quite distinct models of information sharing emerged, one premised upon a discrete assembly line metaphor, the other based upon the metaphor of a game play huddle where the expectation is that information will be acted upon simultaneously and with a high degree of coordination. As participants discovered these differences they accommodated them within their schematic depictions of their activity and made marked changes in how they used coordination meetings and shared information in between meetings. As partners moved to a more collaborative working improvement was seen in recruitment, retention and some project outcomes for families and communities. These findings have implications not just for the health education interventions, but for other complex interventions that require professionals from sectors with very different premises, cultures and habits of thinking to work together. As professionals work with increasingly diverse populations, these same visual mapping techniques can help overcome communication barriers and provide the bases for intercultural as well as interprofessional learning to meet the integration challenges faced across Europe.
Author (2017) Befani, B., Lederman, S., & Sagar, F. (2007). Realistic evaluation and QCA. Evaluation, 13, 171–192. Kress, G. (2003). Literacy in the new media age. London: Routledge. Lui, J. (2013). Visual Images Interpretive Strategies in Multimodal Texts, Journal of Language Teaching and Research, 4(6), 1259-1263 Mays, N., Wyke, S., & Evans, D. (2001). The evaluation of complex health policy: Lessons from the UK total purchasing experiment. Evaluation, 7(4), 405–426. Pawson, R. (2003). Nothing as practical as good theory. Evaluation, 9, 471–490. Pawson, R. and Tilley, N. (1997). Realistic evaluation. London, UK: Sage. Vyt, André, Majda Pahor, and Tiina Tervaskanto-Maentausta, eds. (2015). Interprofessional Education in Europe: Policy and Practice. Antwerpen, België ; Apeldoorn, Nederland: Garant. Wand, T., White, K. & Patching, J. (2010). Applying a realist(ic) framework to the evaluation of a new model of emergency department based mental health nursing practice. Nursing Inquiry, 17(3), 231–239.
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