ACHIEVING CLINICAL BEHAVIOUR CHANGE: A CASE

OF BECOMING INDETERMINATE

MARTIN WOOD,1* EWAN FERLIE2 and LOUISE FITZGERALD3

1Centre for Creativity, Strategy and Change, Warwick Business School, University of Warwick,Coventry CV4 7AL, U.K., 2The Management School, Imperial College, 53 Prince's Gate, London SW72PG, U.K. and 3St. Bartholomew School of Nursing and Midwifery, City University, 20 Bartholomew

Close, London EC1A 7QN, U.K.

AbstractÐThis paper is based on an empirical study of attempts to achieve change in clinical behaviouracross a United Kingdom National Health Service (NHS) Health Authority (HA). We suggest that theevidence based medicine (EBM) movement underpinning such attempts is premised upon a highlyrationalistic conception of change. Here the generation and implementation of research ®ndings intoclinical practice is understood as movement between discrete entities. Drawing upon poststructural phil-osophy, social studies of science and technology, social anthropology, and gender studies, we challengesuch linear perspectives through a more immanent alternative. We conceive of change as movementwithin indeterminate or ambiguous relationships. We then proceed to discuss the implications of thismodality for the management of clinical behaviour change. # 1998 Elsevier Science Ltd. All rightsreserved

Key wordsÐevidence based medicine, knowledge, management of change, poststructuralism

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 implemen-

tation of its ®ndings where these could make clini-

cal practice more e�ective. The implementation of

such EBM principles, however, depends on an abil-

ity to achieve signi®cant and planned clinical beha-

viour change. This raises interrelated issues of

professional power, scienti®c knowledge, and clini-

cal 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 mo-

tivating mechanisms. However, these models may

underestimate the impact of other confounding cir-

cumstances. In particular, a number of organis-

ational and behavioural factors, such as the

institutional and ®nancial arrangements in a setting;

the resources, skills and competencies available to

access scienti®c information; the motivation to

overcome discipline, geographical and cultural bar-

riers; will all in¯uence the extent to which it is poss-

ible to change patterns of clinical practice in a

planned direction (Dawson, 1995). Nor is the scien-

ti®c base of clinical research always incontroverti-

ble, as long running and unconcluded scienti®c

controversies are apparent in certain clinical and

medical ®elds, as participants attach di�erent mean-

ings to available scienti®c knowledge (Dawson,

1995).

This paper sets out to examine these scienti®c, or-

ganisational 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 knowl-

edge, and agency interests. We conclude that mean-ing 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

Soc. Sci. Med. Vol. 47, No. 11, pp. 1729±1738, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0277-9536/98/$ - see front matter

PII: S0277-9536(98)00250-0

*Author for correspondence.

1729

outside practice and highlights the need to moveaway from linear transfer models and towards more

¯exible modalities, in which both are seen as necess-arily cyclically paired (Watson et al., 1995).

BODIES OF EVIDENCE?

Reports of biomedical research point to the cen-trality of science and its neutrality in producing for-mal, objective accounts of knowledge. Such

accounts continue to be dominated by a long stand-ing, Cartesian epistemology of di�erentiation ± areality of distinct subjects and objects ± in whichresearch evidence and clinical practice are seen as

dualistically opposed. Evidence, in this context, isseen as a commodity, whose better, quicker, easierto access, and increasingly electronic transfer, from

the research pole to that of practice will lead to themore e�ective clinical management of patients (see,for example, Smith, 1996). Whilst the appeal of this

dualist model is its maintenance of stable bound-aries and ®rm divisions: objective/subjective,research/practice, facts/values, such thinking isalmost always structured so as to privilege one side

of the dualism over the other. This has made poss-ible the hierarchical distinction between, forexample, the objective ``facts'' of biomedical

research and the subjective ``mere knowledge'' ofclinical practice (Lomas et al., 1993; Haines andJones, 1994). Here, an analytic and disembodied

(scienti®c) organisation of knowledge is privilegedover more tacit and situated experiences: a body ofevidence, separated from its social context, that can

be unilaterally transmitted from the research setting± where it is known ± to the world of practice ±where it is not.Social studies of science, however, have long been

interested in the content of scienti®c work, ratherthan simply its ideological claims. Early work in theUnited States by Merton (1973) on citation analy-

sis, suggested that science was indeed ``disinterested,communistic, and universal''. Meanwhile in theU.K., studies were concerned to show that scienti®c

work was not neutral, communicative, nor uni®ed,but determined more by structural arrangements,political commitments, and institutional interests.These studies were exempli®ed by the ``strong pro-

gramme'' (Bloor, 1976) in the sociology of scienti®cknowledge and have become associated with the``Edinburgh School'' (Barnes, 1977). These and

other works (see for example, Mulkay, 1972;Pickering, 1984; Collins, 1985) proposed an inver-sion in the traditional relationship between science

and nature. They suggested the representationalpractices of science constituted the objects of theworld, rather than being their simple re¯ection

(Woolgar, 1988). For them, science was socially andhistorically constructed.Precisely because these approaches accept the

constructivist thesis, however, they incorrectly

retain an ontological commitment to a discrete andconceptually isolatable natural world made up of

objects, and a constitutive social world made up ofpeople (Latour, 1993, 1998). By adopting the relati-vist position that nature re¯ects and embodies so-

ciety, they ignore the ontological and oftenrecalcitrant character of nature. That is to say,whilst they invert the traditional realist hierarchy:

society re¯ects nature, they simply replace it withanother: nature is constituted by society, and sopreserve the Cartesian di�erence between them.

There have been an increasing number ofapproaches, however, that have sought to questionthis duality. Drawing on poststructural philosophy(Deleuze and Parnet, 1987; Derrida, 1978, 1987;

Deleuze and Guattari, 1988), social studies ofscience and technology (Callon et al., 1986; Latour,1987), social anthropology (Strathern, 1991), and

gender studies (Anzaldu a, 1987; Haraway, 1991),notions of ®xedness and certainty have begun to beswept away, signalling instead a destabilisation of

boundaries and a dislocation of centred identities.Through them, attention has been paid to under-standing evidence not as a necessarily independent

and enduring source, but as a transient moment inan indeterminate process of stabilisation and desta-bilisation. These approaches posit that no matterhow discrete and pre-existent its appearance, evi-

dence is always inextricably combined with theactions, interactions and relationships of clinicalpractice. That is to say, following Latour (1987),

that a body of established evidence should not beunderstood as representative because it is true.Instead, a body of evidence is established as true

precisely because it is held to be representative.

METHODOLOGY AND STUDY DESIGN

The objectives or our research were two-fold.First, to study the career of four acute sector in-

itiatives designed to secure changes in clinical prac-tice across a U.K. Health Authority (HA). Second,to establish the relative uptake/impact of each in-

itiative, so as to assess their relative success insecuring change. The project utilised a qualitativeand comparative, two-stage case study method-ology, and the four change issues encompassed a

mix of medical and surgical initiatives and instancesof favourable and less favourable or contested eva-luative evidence (Wood et al., 1998).

Whilst this methodology cannot o�er statisticalgeneralisability, it is better suited to an in-depthanalysis of the complexities of iterative and uncer-

tain change processes, unfolding over time andbetween settings (Pettigrew, 1985). This can bemissing in a more super®cial, quantitative analysis

of a larger data set, typical of randomised con-trolled trial (RCT) methods. RCTs may be widelyapplicable within biomedical and pharmacologicalresearch, however they are premised upon a

Martin Wood et al.1730

Mertonian notion of science as disinterested, com-munistic and universal. In this view, the disinterest-

edness of a disciplinary community works toguarantee the universality of science by separatingknowledge itself from both the speci®c, local situ-

ation of its production, and its uniform applicationas scienti®c knowledge (Lave and Wenger, 1991).Instead, we have sought to locate our empirically

derived data within a deliberate, interpretativeframework. Whilst this is based upon detailedempirical enquiry, it does not rely on an over

simple revelatory model of social science (Giddens,1979), grounded within a purely inductive function-alist methodology (Wilson, 1970). The often com-plex, necessarily open-ended and sometimes

incommensurable, views of a range of di�erent sta-keholders: their pasts, current preoccupations andmotivations, are necessarily framed as indeterminate

texts (Kets de Vries and Millar, 1987). This methodis more sensitive to the interconnectedness of sys-tems as a whole. It seeks to maintain the continuity

of networks, rather than to create and employ wellde®ned categories: ``scienti®c'', ``political'', ``legal'',``economic'', ``social''.

Stage 1 of the research design comprised a broad,exploratory, sweep of the four clinical change in-itiatives across the region. Stage 2 consisted of amore intensive analysis of a particular acute setting

for each of the four initiatives. Accordingly, twosemi-structured interview schedules were developedand used with a total of 119 respondents. To reduce

variance and allow comparative analysis, these wereissue speci®c and represented a customised versionof the common schedule adapted for each of the

four cases. This was supplemented by secondaryanalysis of published material, including guidelines,trial results, retrospective exchanges of letters tojournals, non-participant observation; and ad hoc

discussion.

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 subsequentanalytical discussion of the data to follow.

Managing anticoagulation service provision

Evidence suggests that stroke is the third mostcommon cause of death in the U.K. after ischaemic

heart disease and cancer. According to the BritishSociety for Haematology (1989) Guidelines on OralAnticoagulation, there is strong clinical evidence

that a signi®cant proportion of ®rst strokes can beprevented by treatment with an appropriate oralanticoagulant such as Warfarin, which prevents

thrombo-embolism (coagulation or clotting of theblood). Moreover, there appears little controversythat the demand for long-term oral anticoagulanttherapy is rising exponentially as the indications for

patients with a higher risk of stroke are widened,and the expected volume of treatment increases.

What is equivocal, however, is how best to managethe growing logistical and ®nancial pressures ofdelivering such a widespread and, potentially, long-

term therapy.Speci®c interventions remain limited, and those

that do exist have ``ring fenced'' funding and con-

cern only a small number of pilot studies. Howeverthose that have been conducted indicate thatadvances in near-patient testing techniques and

computer based information and advisory systemswould enable the safe and e�ective transition of thelong-term management of anticoagulant therapyfrom a clinical to a medical responsibility and from

acute to outreach managed, primary care settings(FitzMaurice et al., 1996; Vadher et al., 1997).Furthermore, this service modality is seen as ®tting

broader policy shifts away from hospital stays andtowards more community based and locally accessi-ble care and services. Yet despite these favourable

indications, current initiatives remain slow moving.Why should this be so? And, what are the impli-cations for the relationship between research evi-

dence and clinical change?

Impact of the ``Changing Childbirth'' document onobstetric care

Historical concern for infant mortality rates hasled to a shift in the location and processes of sup-

port for women in childbirth from home to mater-nity unit. As childbirth shifted to a hospital setting,so the role and importance of technology and

obstetrics grew. Concomitant with this rise was thedemotion and marginalising of the role of the mid-wife. As a result, there is a long history of obstetriccare, which has progressed through stages of devel-

opment and become increasingly professionalisedand ``medicalised'' (Richards, 1975). But it is anarea of clinical practice which has many contestable

practices. Most signi®cantly of all are major contro-versies around where care is provided and who pro-vides it. Most recently these di�erent views have

been incorporated into a speci®c, national initiativeconcerning the care of women during childbirth,resulting in the production, in 1993, of aDepartment of Health document entitled Changing

Childbirth. This document contains a number ofprecise recommendations regarding targets andchanges in practice. It also sets out a timescale for

the ful®lment of these objectives.However, to implement the changes proposed

often requires a considerable shift in the roles and

interactions between members of di�erent pro-fessions, namely the obstetricians and the midwives.Here, there is evidence that the Changing Childbirth

document has had impact, is quoted and widelyknown and has created debate amongst many pro-fessionals in the area. Although there are still widevariations in practice, there is some, albeit limited,

Clinical behaviour change 1731

evidence that it is being enacted. Successful im-plementation has occurred in those maternity units

where the use (and in some instances the introduc-tion) of jointly prepared and jointly agreed guide-lines and protocols, together with good group and

inter-professional relationships, which have beenbuilt up between medical sta� over time, have beencombined.

The use of laparoscopic surgery for inguinal herniarepair

The commonest hernia is the inguinal hernia. Itinvolves organs of the abdomen extruding throughthe abdominal lining into the groin. This is tra-

ditionally repaired by laparotomy involving theopening of the abdomen above the groin through a10 cm incision, returning any herniated organs to

their proper place and repairing the defect withsutures. More recently, inguinal hernia repair hasinvolved experimentation with mono-®lament``open'' mesh repairs and ``closed'' or ``keyhole''

laparoscopic techniques. The latter allows the abdo-men to be examined and repaired by inserting asimilar mono-®lament mesh through three small

tubes ± ports ± which in turn are inserted throughsmall holes made in the abdominal wall, therebyreducing the physical trauma of access associated

with the open laparotomy (Stuart, 1994).Laparoscopic inguinal hernia repair (LIHR)

developed rapidly despite being the subject ofintense scienti®c controversy and volatility. Central

to this development have been the body of generalsurgeons themselves. They exhibit a strong sense ofprofessional individualism and craft based expertise,

within a framework of collegial governance. Thevolatility of the LIHR controversy has highlightedboth a fascination and a seduction for new method-

ologies amongst surgeons and patients alike, whoappear to be equally pro-innovation. Most recentlythere has been a retreat from early heraldic predic-

tions, in the belief that LIHR is not a panacea forall hernias (Lawrence et al., 1995). The currentphase of development is centred upon the pro-duction of rigorous evidence, and the provision of a

more structured programme of training throughspecialist minimal access therapy training units(MATTUs).

Low molecular weight heparin and anti thrombolyticprophylaxis following elective orthopaedic surgery forhips and knees

Within elective orthopaedic surgery for knees andhips, there is a danger of post operative deep vein

thromboses (DVTs) which may on occasion lead tofatal pulmonary emboli (PEs). A number of preven-tive methods, including mechanical devices and a

number of anticoagulant drugs, have been con-sidered in dealing with this. However, the preven-tion of DVTs and PEs has to be weighed againstthe possible increased risk of wound haemotomas,

especially given that any subsequent infection posesmajor di�culties.

Clinical applications of chemical anticoagulantswere developed from the early 1970s, leading to anew generation of low molecular weight heparins

(LMWHs) marketed by drug ®rms by the 1980s.LMWH is a chemical agent which held out thepromise of much easier administration and fewer

haemorrhagic events, although they were more ex-pensive. It also remains an area of continuing scien-ti®c controversy and volatility, as there is dispute

that the current event rates in elective orthopaedicsurgery are of an order of magnitude lower thanthat which is generally quoted and that thereforethe potential bene®t of prophylaxis is small and

may not justify the risks (Chesterman and Chong,1993).This debate is driven exclusively by orthopaedic

surgeons, who represent a highly professionalised,distinctive, and resilient clinical community, despitethe macro level reorganisations apparent in the

NHS since 1990. Policy towards prophylaxis is nowbeing taken seriously with all groups adopting oneposition or another. However, this is a ®eld where

extensive and rapid change in clinical practice is evi-dent and the pattern of practice continues to evolvein volatile waves of change. There is still wide vari-ation in practice and the scienti®c controversy has

if anything reopened.

DISCUSSION

In this section, we discuss the four change initiat-

ives in relation to the heterogeneous framework ofpolitical power, professional knowledge, and agencyinterests, in which they are embedded. Our analysistraces the negotiations and alignments that emerge

among the di�erent stakeholder groups in each con-text. In so doing we highlight how these di�eringpositions inform, and are informed by, a complex

mix of scienti®c, organisational, and behaviouralfactors. We will show the connections within thosefactors where change was successfully achieved and

what Cartesian di�erentiations remained, where itwas not.

Connectivity and heterogeneity

By attending to the representational detail ofhow knowledge is produced, the duality separatingbiomedical research from clinical practice begins to

appear unsound. In rejecting such a duality bothextremes are collapsed: neither occupying a privi-leged position from which to judge the ``other''

dependent. The deconstructive writing of JacquesDerrida is an exemplar of such poststructural analy-sis. Derrida's thesis develops as a critique of

Cartesian di�erentiation and Hegelian idealism ±the primacy of the mind over the body ± in that itseeks the deconstruction of an emanative: di�erencefrom an external other, world of fully constituted

Martin Wood et al.1732

internal subjects and external objects. For Derrida,

nothing enjoys a presence in and of itself, but rather

carries the trace of its interweaving with a sup-

plementary ``other'' (Derrida, 1978).

According to Derrida the search to secure distinc-

tions between subjects/ objects, intellect/corporeal,

inside/outside, is as a result of an ontology of logo-

centrism. From the Greek, logos: to give order and

form to the world, logocentrism acts to legislate a

dominant source of reason (scienti®c research)

which serves to direct an external other (clinical

practice), and thus provide the illusion of mastery

over it. Derrida asserts that the root of this division

is the mistaken assumption of an existent source/

mode hierarchy. Derrida uses the invented word dif-

ferance ± embodying the irreducible use of the

French verb di�erer: to di�er, or disagree in space,

and defer: to adjourn in time ± to illustrate how

meaning cannot be grasped by constructing simple

inside/outside distinctions, but must always be situ-

ated within the interaction of a presence and its in-

ternal supplement. To locate meaning in di�erence

is to do so within things, part of which is present,

but part of which will always remain the property

of what it is not, what is present by being absent ±

deferred.

The impossibility of holding onto either/or dialec-

tics and analogical distinctions is also the nub of

Gilles Deleuze's materialist ontology. Rather than

dualist separation, he too suggests a more imma-

nent: internally di�erentiated, system of connection

and disconnection, in which the central issue is the

question of priority to body and mind (Hardt,

1993). Hegelian idealism explicitly places thought

outside (and over) being. Deleuze, following

Spinoza, alternatively contends that being is not

found in thought, and insists that we shift our focus

to recognise the importance of mind and body for

existence as a whole. In this way we can see how

the real distinction between research and practice is

in fact a relational di�erence founded on negation

(i.e. research is not practice). Deleuze eliminates the

negative aspect ``is not'', in favour of the notion of

a positive di�erence; an a�rmative di�erence, di�er-

ence in itself ± an internal di�erence.

According to Deleuze and Guattari (1988) this in-

ternal di�erence constitutes a whole made up of

lines of articulation: segmentation or strata which

give it a kind of disconnected objectivity, but also

counter lines of ¯ight, which set up movements of

destrati®cations, and which continuously rupture

and dismantle an object to produce a body without

organs. Hence, no once and for all determination

can ever be made about a body's interior strata,

only what it functions with, that with which it con-

nects. Change in this situation ceases to be connec-

tion between things ± there are no-things to become

± but is instead the vacillating interaction (Cooper,

1987) between ®xedness and movement within an

originary whole. Deleuze calls this internal inter-action becoming (Deleuze and Parnet, 1987).

Becoming denies both the ®xedness of being thatdualisms imply, and the simple interlocutionbetween two separate terms (e.g. research and prac-

tice). Instead, the two terms gather together in theelaboration of a third position, an indeterminateposition ``in'' and ``between'' both: never complete,

always becoming one or the other without everachieving totality. Deleuze o�ers the well knownencounter of a wasp and orchid as an example. He

argues that we cannot say once and for all thateach exists in parallel to the other, nor can we dis-tinguish where one ®nishes and the other starts.Instead Deleuze focuses on the extent to which the

orchid is a becoming-wasp and the wasp is abecoming-orchid (Deleuze and Parnet, 1987, p. 2):

The orchid seems to form a wasp image, but in fact thereis a wasp-becoming of the orchid, an orchid becoming ofthe wasp, a double capture since ``what'' each becomeschanges no less than ``that which'' becomes. The waspbecomes part of the orchid's reproductive apparatus at thesame time as the orchid becomes the sexual organ of thewasp.

The relation between ®xedness and movement issimilar to that of Callon et al. (1986) and the con-cept of Law (1992) of the actor-network. At its

centre lies the attempt to build a symmetrical ±thatis simultaneous ± account which considers the pro-liferation of continual networks of natural, socialand technological resources, and their collective role

in framing identity. Actors ± natural, human andtechnical ± are seen as nothing other than orderede�ects, as transient moments of a network of het-

erogeneous interactions, where no a priori distinc-tion exists (Law, 1992). For Callon et al. there is nogiven order of things, nothing exists in and of itself.

Instead, identity is continually performed by animmanent system of heterogeneous, social, textual,and material relations. Its puri®catory appearance

is not an originary presence, rather a meaningmade, brought into being and actually dependentupon the continual production and reproduction ofthe networks of heterogeneous interactions that

frame it. This is as much as to say that there mayindeed be privileged places, hierarchies and asym-metrical dualities, but that they are the outcome of

action, not its beginning (Latour, 1987).

A problem of (dis)connection?

Taken together, these approaches have importantimplications for the generation and implementationof biomedical research. Through such theorising it

is di�cult to accept the privileged claims ofresearchers as being somehow external to, and soindependent of, its counter position, practice, with-

out necessarily questioning the usefulness and val-idity of the research itself. Hence we are left withthe question of deciding where the generation ofresearch ends and its implementation begins.

Clinical behaviour change 1733

Following this lead, commentators such as

Brown and Dugiud (1991), Lave and Wenger(1991), and Star and Griesemer (1989), havesuggested that the local situation in which a prac-

titioner operates appears to be a potent mediator ofeveryday experience. It follows, therefore, thatresearch is rarely, if ever, self-evident to the prac-

titioner, but varies according to the context withinwhich it is received. Contextualisation is the conse-

quence of a particular organisation of thought andday-to-day experience. To contextualise is to supplya hitherto indeterminate body without organs

(research evidence), with organs (a practical appli-cation). It facilitates the creation of a relativelystabilised, but precariously balanced determination

of research by relating it to an already establishedand locally embodied structure for thinking andacting. Such ``situated knowledges'' (Lave and

Wenger, 1991) supply local regularities whichenable purposeful action by rendering remote and

obdurate evidence more acceptable and amenableto control (Chia, 1997). That is to say, theymomentarily ``arrest'' (Chia, 1997), or at least slow

down, the perpetual movement of becoming.Our empirical research has found broad support

for the idea that health professionals do not simplyapply abstract, disembodied scienti®c research,about which they have only scant knowledge of the

context or circumstance of its production, rigidly tothe situation around them. Whilst they may notnecessarily deny the researched phenomena, they

collaborate in discussion and engage in work prac-tices which actively interpret and (re)construct itslocal validity and usefulness (Brown and Dugiud,

1991). According to Knights (1997) it is not expertsrepresenting problems at a distance that are needed,

but practitioners actively participating in producingcontext related and localised responses to a set ofpolitical, economic, and social conditions with

which they are confronted.In other words, practitioners do not rely simply

on the implementation of disembodied, global the-

ory. They are not fooled by ``god tricks'' promisingvision from everywhere and nowhere (Haraway,

1991), but want to see the connections betweenwhat is advocated and their own situated knowl-edges. They look for a locatable position, a view

from somewhere (Haraway, 1991). This pragmaticperspective suggests that clinical practice containsmany judgements, much tinkering, reckoning, and

tacit knowledge, more reminiscent of craft skillsthan traditional conceptions of disinterested, com-

munistic and universal science (Ravetz, 1971). So,in promoting an innovation or piece of research evi-dence we are not dealing with the uncomplicated

dissemination of ®ndings to a largely passive andreceptive audience ± a simple problem of ``puttingtheory into practice'' in the hackneyed sense of the

phrase ± but with the question of reconnectingresearch with its supplementary other: practice. The

key point here is how evidence is translated (Callon,1986; Latour, 1987, 1993) within the assumptive

world of practitioners.

Reconnection: from implementation to translation?

The question of reconnection is the focus ofBruno Latour's anthropological analysis of modern-

ism (Latour, 1993). For Latour, the apparent sepa-rateness of politics, science, technology, and natureare as a result of the modern scienti®c method's

reluctance to mix nature and society.Modernisation: revolution in science, rupture fromthe past, and the birth of liberalism, made it poss-ible to distinguish between and administer par-

titions in which everything is assigned to onecategory or another. However, the proliferation ofquasi-objects: hybrid systems and problems that

consistently mix politics, science, technology, andnature, make it increasingly di�cult to maintaintraditional nature/culture distinctions. Latour

suggests we should rethink our constitution oftranscendent things and begin to recognise theirimmanent connectivity. He argues that the ``mod-erns'' posed an, unnecessary, ontological asymmetry

between puri®cation: the de®nition and implemen-tation of entirely distinct partitions and frames ±objects or people or techniques; nature or society or

technology ± on the one hand, and translation: thecreation and proliferation of continual links andnetworks ± objects and people and techniques;

nature and society and technology ± on the other.The proliferation of quasi-objects clearly demon-

strates that the developmental path followed by a

given innovation is neither natural or inevitable,but constantly negotiated and aligned ± a pathforged within an assemblage of scienti®c and organ-isational and behavioural factors. First, the quantity

and quality of local inter-relationships are factors inthis process. In settings where good interpersonalrelationships exist there is greater opportunity for

modalities of practice to be discussed and a com-mon way forward found. Where this was the case,our evidence suggests practitioners would be better

able to respond to information and decide tochange practice, or not, on the basis of it. In cases3 and 4, surgeons were far more likely to listen tothe views of others whom they thought were im-

portant and who in turn thought their own point ofview was important. Similarly, in case 2, good re-lationships built up over time between the medical

sta� and midwives, and the respect each group hadfor the others judgement, had led to a degree oftrust and independence for midwives which would

not exist everywhere.Second, the strength of any pro-change move-

ment is also a�ected by the ability to enrol a range

of product leaders. Such advocates can bring localcredibility to a project. They can help establish ameasure of agreement among professional groups,and use their position to make an initiative di�cult

Martin Wood et al.1734

to refuse. This pattern is illustrated in case 4, for

example, by the complaints from pro LMWHresearchers operating outside the orthopaedic com-munity about their inability to feed the results from

research through into practice; in the tacit experi-ence and problematic reproduction of laparoscopictechniques in case 3; and by the variable strength

and commitments of di�erent stakeholder groups ±obstetric/midwifery/patient ± to changing childbirth

protocols in case 2. Indeed, whilst respondentsspoke of the importance of grounding their practicein sound, scienti®c evidence, many acknowledged

that only exceptionally did research evidence alonechange practice. This pattern is found in the longand well organised process of consultation found in

the Changing Childbirth document (Department ofHealth, 1993), described in case 2, in which thepublished targets were clearly supported by a wide

and respected constituency of representatives of allthe key stakeholder groups, making outright and

public disagreement more di�cult. Thus, stake-holders were enrolled by virtue of it being costly, interms of reputation, credibility, medico-legal threat,

to not do so.Each of the initiatives studied is also broadly in

line with wider policy (for example: day case andde-medicalisation). However, it appears that localclinician ``buy in'' is essential if the policy is not to

remain abstract and under used. Professionals,therefore, still have a key role to play as changechampions, ``actioning'' national policy. Key aca-

demic researchers are particularly important here,quite often providing the ``hub'' of particularknowledge communities, from which innovations

and research themes radiate out into service depart-ments. In this way professionals provide the link

between, for example, an instance where the widerevidence calls for a change in practice and the needfor that change being recognised in a particular

knowledge or professional community. This point isrecognised in the recent government white paper,The New NHS: Modern, Dependable (Cmnd 3807,

1997), in which individual health professionals willcontinue to be responsible for their own clinical

practice.Those seeking to be legitimated as a universal

spokesperson for a research problem, cannot do so

without taking account of the locally-situated prac-tices that inform and are informed by it. Evidencecannot be put into practice because it was never

external to it in the ®rst place. Following Derrida,such a position implies the deconstruction of an

existent source/supplement hierarchy between thevisible ``body'' of evidence and the always invisiblenetwork of interactions supporting its appearance.

This suggests that research evidence cannot betaken to be a discrete and ®xed entity: a transparentexplanation of an existent clinical world and its mo-

tivating mechanisms. Instead, its apparent discre-tion and ®xedness is a result of the momentary

slowing down or arresting (Chia, 1997) of an essen-tially indeterminate process of becoming.

Evidence is important, but not that important!

The generation and implementation of biomedicalresearch has traditionally been theorised as depen-dent upon the delineation of set boundaries ± strat-

egy, R&D, policy, management, service delivery ±leading to the achievement of preconceived goals.But these distinctions are more implied than real,

and may be more productively conceived as a pro-visional presence/supplement determination.Our research suggests that scienti®c evidence is

not a clear, accepted and bounded source. There is

no such entity as ``the body of evidence''. There aresimply (more or less competing) (re)constructions ofevidence able to support almost any position. Much

of what is called evidence is, in fact, a contesteddomain, constituted in the debates and controver-sies of opposing viewpoints in search of ever more

compelling arguments. This is apparent if one con-siders the apparent unity of the evidence for antic-oagulation described in case 1. The unanimity hereis dependent upon, and not the cause of, the contin-

ued taking of the INR as a standard baselinemeasure; in the lasting association of certain medi-cal conditions and an increased risk of stroke; in

the predictability of the decision support system.Our ®ndings suggest that an identical process

underscores all bodies of evidence, no matter how

``hard'' and monolithic their appearance. This pos-ition is not necessarily divisive, however, but couldbe interpreted as demonstrating a more pluralistic

attitude towards clinical practice. Looking at thingsfrom di�erent perspectives is not intrinsically wrongand indeed may be an inevitability in a modernhealth care system. In any event, it underscores our

contention that evidence cannot be viewed as a rela-tively neutral ``medium'' for expressing the natureof reality, but exists only as a stabilised moment in

an indeterminate process of becoming.Evidence from trials and published material in

prestigious journals may be in¯uential in setting

indirect climates of opinion, yet they rarely changepractice on their own. This may be explained by thefact that the evidence base often fails to capture thetacit and experiential nature of practice. For

example, in talking about the Changing Childbirthdocument (Department of Health, 1993) and why itshould or should not be implemented, few respon-

dents used evidence as their main argument. Whereit suited individuals, they ignored the evidence orthey did not appear to know about it. Moreover,

whilst some aspects of an evidence base can beframed to appear much clearer, stronger and lessrefutable than others, this situation is always (more

or less) precarious ± the extreme limit of the slow-ing down of movement (Chia, 1997). This meansthat one requires precision in talking about ``evi-dence'', i.e. evidence on what speci®cally?

Clinical behaviour change 1735

The outreach modality of anticoagulation service

delivery in case 1 is an exemplar of an initiative

with a strong evidence base, but which remains

severely limited in its development. Why should this

be? The study was described as both a ``top-down''

regional initiative, together with the ``bottom-up'',

local activities of an interested clinician. However,

di�erentiating between notions of top/bottom and

regional/local may be of limited utility, as both

appear to rely on the other for their meaning.

Consequently, initiatives may require an internally

di�erentiated relationship of tolerance from the

``top'' and buy in from the ``bottom'' for success

(for example, the Changing Childbirth (Department

of Health, 1993) initiative is top down but clinicians

acting in a speci®c situation may choose to buy in,

opt out, betray or divert the initiative).

Likewise, surgical specialisms are exemplars of

highly individualistic practices. Practitioners exhibit

a high level of embodied skill, yet seldom, if ever,

simply disregard the scienti®c basis of their practice.

This was rarely presented as a choice: experience or

science, but as an awareness of the need to balance

both. For example, despite its strongly contested

evidence base and the fact that LIHR has not

replaced more traditionally based procedures in

case 3, it has, nevertheless, had a signi®cant impact

on surgeons' attitudes, in terms of a re-opening of

debate and forcing re¯ection on the e�cacy of long

standing practices. So, we can say that even with a

strong evidence base, an initiative's development is

not likely to be natural or inevitable, but complex

and long term, and will not be achieved without the

involvement of interested practitioners.

Attitudes towards EBM were also found to be

typically varied, although generally speaking, they

can be characterised as follows. First, it is seen as a

mechanism for delivering real improvements in

practice. Second, EBM is simply a jargon phrase,

popularised in order to give a name to what had

always been there. A third characterisation drew

attention to a wider political agenda lying behind

its advocacy, whilst a fourth highlighted the fact

that practices existed for which there was no evi-

dence base available. Fundamentally the question is

whether there can ever be a perfectly explicit and

transparent evidence base. From our research, the

answer is no. However, EBM appears to represent

and has come to be representative of just such a

logocentric view of evidence as a dominant source

of scienti®c reason which serves to direct an exter-

nalised clinical practice and thus provide the illu-

sion of a source/supplement hierarchy. As we have

seen, however, this view is erroneous and partial, in

that it fails to re¯ect the aspect of evidence which is

constructed in situ. As it is currently perceived,

EBM is spuriously premised solely on a unilinear

model of information gathering and dissemination.

As such, it fails to recognise the shifting, contextual

and intractable reality of knowledge (re)construc-tion.

The parergon

We have seen how Derrida and Deleuze bothadopt a poststructural episteme that does not oper-ate around subject/object distinctions. And, how

they refuse to reduce anything to a unitary pre-sence, but rather argue for indeterminate assem-blages of connection and disconnection. Instead of

either/or determinations, we ®nd only a folding ofrelative ®xedness and movement and of a presenceand its (always present by being deferred) sup-plement. But, what do we see when we pay atten-

tion to this fold?In The Truth in Painting, Derrida (1987) is con-

cerned to show that jurisdiction over the truth is

not so much an essential presence, as a kind ofmeaning made, brought into being and actuallydependent upon that which frames it. The concept

of the frame (parergon) acts just like the lens of acamera, or the stage in a theatre, it delineatesbetween what is inside and what should remain out-side: which pole of a binary opposition is privileged

and which will remain supplementary. The framecan give rise to a judgement, or determination; anarresting of the indeterminate edge (aÁ-bord),

between the work (ergon) and the absence of work± the distinctive either/or characteristic of dialecticthought.

Derrida, however, considers what is incompre-hensible about the frame (par-ergon: literally, by thework) of a painting, is its indeterminateness as a

surface which separates itself not only from thebody proper of the work, but also from the wall onwhich the painting is hung. The frame stands outfrom both the work and the background, but it also

connects the one to the other. For Derrida, thisabsence, or lack of presence, cannot be situatedinside or outside of the work, but remains a compo-

site of outside and inside. The whole frame isneither internal or external. It does not fall, unilat-erally, on one side (outside) of the work, but is

gathered together as the supplement of an internalindetermination of the work it comes to frame:``No `theory' no `practice', no `theoretical practice'can intervene e�ectively in this ®eld if it does not

weigh up and bear on the frame'', maintainsDerrida (1987, p. 61). The frame is the ``decisivestructure'' in determining what is internal, seen, and

what is excluded, unseenThis is particularly apparent in the surgical cases

3 and 4, where not only was there no challenge to

the issue being seen as a clinical dominion, but alsoone in which other, allied professional groupsenjoyed only limited in¯uence. Thus, following

Derrida, we can see how certain dissonant voicesare being excluded (Fox, 1997). The ability tosecure distinctions between included/excluded voicesappears to be as a result of the production and

Martin Wood et al.1736

structuring (framing) of (usually unequal) logo-

centric power relations. Similarly, in case 2 juridicalissues have been historically enduring since the sec-ond part of the 19th century, when obstetrics was

established as a surgical speciality, and care inchildbirth shifted to the hospital setting. This shiftled to a growth in the role of the doctor and the

use of technology and was concomitant with themarginalisation of the role of the midwife.

In case 1, however, whilst the service is framed inthe sense that it is super®cially possible to deter-mine what it is from what it is not, its e�ectiveness

remains indeterminate. For example, to be e�ectivethe service has to satisfy the many, variant andloosely coupled practices and idiosyncrasies of

many burdened hospital clinicians, the ephemeral,(often) fragmented and frequently indecipherable

written inscriptions which (sometimes) followpatients between GPs, hospital, and laboratory, aswell as compensating for and replacing the de-

®ciencies in public transport, failing bodies andarduous clinic visits. No one framing has estab-lished itself as the truth: it has not been possible to

make an e�ective/ine�ective determination. Its e�ec-tiveness remains an internal indetermination of the

service, a composite of the demands and practicesof several partially connected (Strathern, 1991)voices.

Moreover, the historical juridical delineation incase 2, between the highly medicalised, hospitalbased interventions of obstetricians and the more

tacit based care o�ered by midwives, has nowbecome one of the critical determining variables in

the changes proposed. It is still unclear whether theopening of the old frame will result in a consider-able shift in the historical role and professional

responsibilities for care from obstetricians to mid-wives. What is clear, however, is that the hithertoreal inside/outside distinction between obstetrics

and midwifery has been displaced by the fact that itis only an apparent closure of an internal presence/supplement relationship after all. What might

hitherto have been seen as an existent inside/outsidehierarchy between two separate, disconnected voices,

can now be seen as the internal indetermination ofwhose voice should be heard. The framing of thediscussion can be seen as the necessary connection

within the interaction of a presence and its internalsupplement.

Hence, as we move towards a ``shared care''regime in the U.K. NHS, perhaps we should resistthe monolithic appearance of many traditional

inside/outside frames that insist we do not mixresearch and practice. We should stop dealing withresearch and practice as uncontaminated, uni®ed

things in themselves and begin to recognise theincreasing incidence of indeterminate, mixed-upa�airs. Thus, in our exegesis of clinical behaviour

change, we might expect to concentrate on edgesand interfaces: on ¯ows across boundaries and not

the integrity of logocentric divisions. Practitionersneed to move away from ambitions of hierarchical

stability and ontological purity, and instead becomeopen to the indeterminate ¯ux and transformationof becoming.

IN-CONCLUSION

Drawing on the poststructural theme of indeter-minate becoming, this paper has highlighted the

need to shift away from notions that research evi-dence and clinical practice are diametricallyopposed. It has moved towards models that engagethe complex and dynamic network of interactions

supporting the appearance of a phenomenon (Chia,1997). A key feature of our case studies has beenthe extent of boundary indetermination ± science/

practice; universal/local; presence/absence ± as apart of the change process. Di�erentiating betweenresearch and practice is of limited utility, as in our

®ndings the boundary between driver and driven isalways indeterminate: there is a practice-becomingof research at the same time as there is a research-

becoming of practice. Within this model, prac-titioners are not passive, but in¯uence the uptakeand must be engaged.Furthermore, whilst evidence is often discussed as

if it constituted a clear and distinct entity, our ®nd-ings suggest this is erroneous. The nature of evi-dence is ambivalent. It is constructed into debates

and controversies, which are often equally suppor-tive of opposing viewpoints. Such issues appearrecursive and intractable not linear and incremental,

so that a ®nal resolution remains unlikely in manycases. The ``progress'' of science serves only towiden the debate. Here, the ability of EBM to

become the perfect analogue of the complexity ofpractice is in doubt, as its current methodology isnot readily amenable to accessing the tacit andexperiential knowledge of practitioners. Hence, it

seems likely that its implementation will be complexand long term, and may achieve only patchy suc-cess.

In conclusion, there is a need for those involvedin a�ecting clinical behaviour change to movebeyond unilinear models of information gathering

and dissemination, and towards research strategiesthat address the local ideas, practices, and attitudesof professionals. A key function here will be toengage the interest and involvement of practitioners

in future change programmes by (re)connecting evi-dence with its supplementary ``other''. In movingfrom an over reliance on simple production±disse-

mination models of change, there is a need to incor-porate evidence and practice in a more immanentrelationship and perhaps to recognise that this has

always been so.

AcknowledgementsÐWe would like to thank the twoanonymous referees for their critical comments on an ear-lier version of this paper and for drawing our attention to

Clinical behaviour change 1737

Derrida's concept of the frame. The support of the NHSexecutive (North Thames) is also gratefully acknowledged.

REFERENCES

Anzaldu a, G. (1987) Borderlands/La Frontera: Toward theThe New Mestiza. Aunt Lute Books, San Francisco.

Barnes, B. (1977) Interests and the Growth of Knowledge.Routledge and Kegan Paul, London.

Bloor, D. (1976) Knowledge and Social Imagery. Routledgeand Kegan Paul, London.

British Society for Haematology (1989) Guidelines on oralanticoagulation: second edition. Journal of ClinicalPathology 43, 177±183.

Brown, J. S. and Dugiud, P. (1991) Organizational learn-ing and communities-of-practice: towards a uni®ed viewof working, learning, and innovation. OrganizationScience 2(1), 40±55.

Callon, M. (1986) Some elements of a sociology of trans-lation: domestication of the scallops and the ®shermenof St. Brieuc bay. In Power, Action and Belief,Sociological Review Monograph 32, ed. J. Law, pp.196±233, Routledge and Kegan Paul, London.

Callon, M., Law, J. and Rip, A. (Eds.) (1986) Mappingthe Dynamics of Science and Technology: Sociology ofScience in the Real World. Macmillan, London.

Central Research and Development Committee (1995) Anagenda for evaluation of methods to promote the im-plementation of research ®ndings in the NHS. CentralResearch and Development Committee, April.

Chesterman, C. N. and Chong, B. H. (1993) Uses ofheparin. British Medical Journal 306, 871±872.

Chia, R. (1997) Essai: thirty years on: from organizationalstructures to the organization of thought. OrganizationStudies 18(4), 685±707.

Cmnd 3807 (1997) The New NHS: Modern, Dependable.HMSO, London.

Collins, H. M. (1985) Changing Order: Replication andInduction in Scienti®c Practice. Sage, London, LosAngeles.

Cooper, R. (1987) Information, communication and or-ganisation: a post-structural revision. Journal of Mindand Behaviour 8(3), 395±415.

Dawson, S. (1995) Never mind solutions ± what are theissues? Lessons of industrial technology transfer forquality in health care Quality in Health Care 4, 197±203.

Deleuze, G. and Parnet, C. (1987) Dialogues. Trans. HughTomlinson and Barbara Habberjam. The Athlone Press,London.

Deleuze, G. and Guattari, F. (1988) A Thousand Plateaus:Capitalism and Schizophrenia. Trans. Brian Massumi.The Athlone Press, London.

Department of Health (1993) Changing Childbirth, Reportof the expert maternity group, part 1. HMSO, London.

Department of Health (1995) Methods to promote the im-plementation of research ®ndings in the NHS-prioritiesfor evaluation report. HMSO, London.

Derrida, J. (1978) Writing and Di�erence. Trans. AlanBass. Routledge, London.

Derrida, J. (1987) The Truth in Painting. Trans. Geo�Bennington and Ian McLeod. University of ChicagoPress, Chicago.

FitzMaurice, D. A., Hobbs, F. D. R. and Murray, J.A. (1996) Monitoring oral anticoagulation in primarycare. British Medical Journal 312(8), 1431±1432.

Fox, N. J. (1997) Texts, frames and decisions over dis-charge from hospital: a deconstruction. Social Sciencesin Health 3(1), 41±51.

Giddens, A. (1979) Central Problems in Social Theory:Action Structure and Contradiction in Social Analysis.Macmillan, London.

Haines, A. and Jones, R. (1994) Implementing ®ndings ofresearch. British Medical Journal 308, 1488±1492.

Haraway, D. (1991) Simians, Cyborgs and Women: TheReinvention of Nature. Free Association Books, London.

Hardt, M. (1993) Gilles Deleuze: An Apprenticeship inPhilosophy. UCL Press, London.

Kets de Vries, M. and Millar, D. (1987) Interpreting or-ganizational texts. Journal of Management Studies 24(3),233±247.

Knights, D. (1997) Organisation theory in the age ofdeconstruction: dualism, gender and postmodernism re-visited. Organization Studies 18(1), 1±19.

Latour, B. (1987) Science in Action: How to FollowScientists and Engineers Through Society. HarvardUniversity Press, Cambridge, MA.

Latour, B. (1993) We Have Never Been Modern.Translated by Catherine Porter, Harvester Wheatsheaf,Hemel Hempstead.

Latour, B. (1998) Politics of nature. Lecture series given atthe London School of Economics and Political Science,London, January±March.

Lave, J. and Wenger, E. (1991) Situated Learning:Legitimate Peripheral Participation. CambridgeUniversity Press, Cambridge.

Law, J. (1992) Notes on the theory of the actor-network:ordering, strategy and heterogeneity. Systems Practice 5,379±393.

Lawrence, K. et al. (1995) Randomised control trial oflaparoscopic verses open repair of inguinal hernia: earlyresults. British Medical Journal 311, 981±985.

Lomas, J., Sisk, J. E. and Stocking, B. (1993) From evi-dence to practice in the United States, the UnitedKingdom and Canada. The Millbank Quarterly 71(3),405±410.

Merton, R.K. (1973) The Sociology of Science: Theoreticaland Empirical Investigations. University of ChicagoPress, Chicago.

Mulkay, M. (1972) The Social Process of Innovation: AStudy in the Sociology of Science. Macmillan, London.

Pettigrew, A.M. (1985) The Awakening Giant: Continuityand Change in ICI. Basil Blackwell, Oxford.

Pickering, A. (1984) Constructing Quarks: A SociologicalHistory of Particle Physics. Edinburgh University Press,Edinburgh.

Ravetz, J.R. (1971) Scienti®c Knowledge and its SocialProblems. Clarendon Press, Oxford.

Richards, M. P. M. (1975) Innovation in medical practice:obstetricians and the induction of labour in Britain.Social Science & Medicine 9, 595±602.

Smith, R. (1996) What clinical information do doctorsneed? British Medical Journal 313, 1062±1068.

Star, S. L. and Griesemer, J. R. (1989) Institutional ecol-ogy, `translations', and boundary objects: amateurs andprofessionals in Berkley's Museum of VertebrateZoology, 1970±39. Social Studies of Science 19, 387±420.

Strathern, M. (1991) Partial Connections. Rowman andLittle®eld, Savage, MD.

Stuart, A. E. (1994) Taking the tension out of herniarepair. The Lancet 343, 748.

Vadher, B. D., Patterson, D. L. H. and Leaning, M.L. (1997) Evaluation of a decision support system forinitiation and control of oral anticoagulation in a ran-domised trial. British Medical Journal 314, 1252±1256.

Watson, H., Wood-Harper, T. and Wood, B. (1995)Interpreting methodology under erasure: between theoryand practice. Systems Practice 8(4), 441±468.

Wilson, B. R. (Ed.) (1970) Rationality. Blackwell, Oxford.Wood, M., Ferlie, E. and Fitzgerald, L. (1998) Achievingchange in clinical practice. Final report, CCSC,Warwick Business School, University of Warwick,February.

Woolgar, S. (1988) Science: The Very Idea. EllisHorwood, Chichester.

Martin Wood et al.1738