Elsevier

Social Science & Medicine

Volume 47, Issue 11, December 1998, Pages 1729-1738
Social Science & Medicine

Achieving clinical behaviour change: a case of becoming indeterminate

https://doi.org/10.1016/S0277-9536(98)00250-0Get rights and content

Abstract

This paper is based on an empirical study of attempts to achieve change in clinical behaviour across a United Kingdom National Health Service (NHS) Health Authority (HA). We suggest that the evidence based medicine (EBM) movement underpinning such attempts is premised upon a highly rationalistic conception of change. Here the generation and implementation of research findings into clinical practice is understood as movement between discrete entities. Drawing upon poststructural philosophy, social studies of science and technology, social anthropology, and gender studies, we challenge such linear perspectives through a more immanent alternative. We conceive of change as movement within indeterminate or ambiguous relationships. We then proceed to discuss the implications of this modality for the management of clinical behaviour change.

Introduction

Following a 1988 report by the House of Lords Select Committee on Science and Technology, a U.K. National Health Service (NHS) research and development (R&D) national strategy was launched in 1991 (Central Research and Development Committee, 1995; Department of Health, 1995). Arising out of this strategic programme, there is increasing policy level interest in the evidence based medicine (EBM) movement, which argues for the generation of research evidence and the implementation of its findings where these could make clinical practice more effective. The implementation of such EBM principles, however, depends on an ability to achieve significant and planned clinical behaviour change. This raises interrelated issues of professional power, scientific knowledge, and clinical interests, especially where the interface between research and practice is revealed as problematic.

From a social science point of view, some EBM arguments can be seen as overly mechanistic and rationalistic: linear “technology transfer” models which assume a non problematic relation between the R&D base and clinical behaviour change. Evidence in this context is taken to be both discrete and isolatable; an unequivocal and empirically tested explanation of the clinical world and its motivating mechanisms. However, these models may underestimate the impact of other confounding circumstances. In particular, a number of organisational and behavioural factors, such as the institutional and financial arrangements in a setting; the resources, skills and competencies available to access scientific information; the motivation to overcome discipline, geographical and cultural barriers; will all influence the extent to which it is possible to change patterns of clinical practice in a planned direction (Dawson, 1995). Nor is the scientific base of clinical research always incontrovertible, as long running and unconcluded scientific controversies are apparent in certain clinical and medical fields, as participants attach different meanings to available scientific knowledge (Dawson, 1995).

This paper sets out to examine these scientific, organisational and behavioural factors, in order to highlight the problematic connection between the generation and implementation of biomedical research. Drawing centrally upon the distinct, yet related, poststructural ideas of Gilles Deleuze and Jacques Derrida, we consider how the perceived “Cartesian gap” between research and practice has become ubiquitous, before discussing whether we should talk of a research/practice gap at all, or of the division that separates and yet connects them. Illustrating our argument with examples drawn from substantial empirical work, we suggest that rather than being a pure source, research evidence informs, and is informed by, a heterogeneous framework of political power, professional knowledge, and agency interests. We conclude that meaning is not an inherent property of information and, therefore, that evidence is not put into practice (Watson et al., 1995). This corresponds with the poststructural view that theory cannot be placed outside practice and highlights the need to move away from linear transfer models and towards more flexible modalities, in which both are seen as necessarily cyclically paired (Watson et al., 1995).

Section snippets

Bodies of evidence?

Reports of biomedical research point to the centrality of science and its neutrality in producing formal, objective accounts of knowledge. Such accounts continue to be dominated by a long standing, Cartesian epistemology of differentiation – a reality of distinct subjects and objects – in which research evidence and clinical practice are seen as dualistically opposed. Evidence, in this context, is seen as a commodity, whose better, quicker, easier to access, and increasingly electronic

Methodology and study design

The objectives or our research were two-fold. First, to study the career of four acute sector initiatives designed to secure changes in clinical practice across a U.K. Health Authority (HA). Second, to establish the relative uptake/impact of each initiative, so as to assess their relative success in securing change. The project utilised a qualitative and comparative, two-stage case study methodology, and the four change issues encompassed a mix of medical and surgical initiatives and instances

Character and outcomes of the case studies

In this section we review the history, character, and outcomes of each of the four change initiatives. This will provide the context(s) for a subsequent analytical discussion of the data to follow.

Discussion

In this section, we discuss the four change initiatives in relation to the heterogeneous framework of political power, professional knowledge, and agency interests, in which they are embedded. Our analysis traces the negotiations and alignments that emerge among the different stakeholder groups in each context. In so doing we highlight how these differing positions inform, and are informed by, a complex mix of scientific, organisational, and behavioural factors. We will show the connections

In-conclusion

Drawing on the poststructural theme of indeterminate becoming, this paper has highlighted the need to shift away from notions that research evidence and clinical practice are diametrically opposed. It has moved towards models that engage the complex and dynamic network of interactions supporting the appearance of a phenomenon (Chia, 1997). A key feature of our case studies has been the extent of boundary indetermination – science/practice; universal/local; presence/absence – as a part of the

Acknowledgements

We would like to thank the two anonymous referees for their critical comments on an earlier version of this paper and for drawing our attention to Derrida's concept of the frame. The support of the NHS executive (North Thames) is also gratefully acknowledged.

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