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From rhetoric to reality: the need for external quality initiatives to understand and better relate to organisational inner worlds
  1. T Smith
  1. Senior Policy Analyst, Health Policy & Economic Research Unit, British Medical Association, London WC1H 9JR, UK;

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    Very often, central policy and locally managed initiatives fail to anticipate—or perhaps acknowledge—organisational culture and “the way things work around here”. The papers included in this JournalScan provide interesting insights into the disjunction between theoretical and actual views and suggest that one way to improve the success of initiatives is to contrast models of working with actual practise, leading to the improvement of both.

    The papers look at two issues: the development of initiatives to improve patient involvement and the use of guidelines and evidence to improve practise.

    Learning how external information is used in practice

    Importance of social interaction in the development of internal tacit guidelines ▸

    A paper from Family Practice begins by saying that “little is known about the types of decisions nurses make in routine practice and the sources of information that inform these decisions”. Research was undertaken in GP practices in the north of England through three case studies that involved interviews, observation, and documentary analysis. Interviews asked about “the use of research-based information in clinical decision making”. Observation (120 hours) sought to contrast the nurses’ accounts of their information seeking behaviour with observed “reality”.

    The types of decisions made by practice nurses and nurse practitioners can be divided into seven categories: (i) assessment; (ii) diagnosis; (iii) intervention (including (a) targeting, (b) timing and (c) prevention); (iv) communication (risks and benefits); (v) referral; (vi) service delivery and organisation (setting up a clinic, for example); and (vii) information seeking.

    Nurses used several sources of information in making clinical decisions. Personal experience was important, “particularly with regard to wound care, to the extent of their being dismissive of research evidence”. A nurse says she would ignore research evidence that contradicted her experience. Human sources of information are important where nurses experience clinical uncertainty. They preferred to seek information from a colleague rather than electronic or textual information. When information was sought using technology, nurses appeared to favour …

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    • Compiled by Tom Smith