Narrative methods in quality improvement

researchTrisha Greenhalgh

Professor of Primary Health CareUniversity College London

Structure of this talk

Start with some stories Themes arising 10 advantages of stories for use in QI Storytelling template exercise When does collecting and analysing

stories count as research in a QI setting? 4 methodological approaches to using

stories in QI research

Start with some stories

Storytelling exercise 1

In small groups of 2-5 Tell some stories about an encounter

with the healthcare system FOR EXAMPLE elderly person with

complex needs Don’t get sidetracked into debates

about clinical management

What is a story?

Account of a sequence of events Unfolding over time The unexpected Emplotment

Burke: A grammar of motive Act Scene Agent Agency Purpose

Mattingly: Narrative drama

Desire Trouble Risk Plot Suspense

Some themes arising from a story-telling exercise recently

Themes arising from stories Organisational culture

(formal/informal) Ethical codes, values, conflicts Leadership Embeddedness in a wider system Routines Identities

Themes arising from stories ‘Trouble’ Humour => absurdity, inflexibility of ‘the

system’ High drama => risk & risk management ‘Trivial’ problems in middle classes =>

how much worse for vulnerable / serious Subverting / working round the system

Themes arising from stories Social networks and ‘soft knowledge’ Triage by ‘the system’ (the system is

the character) Role conflict – hero and villain Staff failing to take ethical

responsibility – ‘collusion of anonymity’

Institutional racism / discrimination

Stories: 10 unique selling points as tools in quality

improvement

1. Stories are perspectival and rhetorical

2. Stories make sense of experience

3. Stories are non-linear

4. Stories are embedded in a context

5. Stories have an ethical dimension

“The singular case arises only in the act of narrating it and … duties are incurred in the act of hearing it” Rita Charon

6. Stories bridge the gap between formal and informal

space

7. Stories offer insights into what might have been (or

could be)

8. Stories are performative and action-oriented

9. Stories are inherently subversive (“breaking the

rules”)

10. Leadership is related to storytelling

Summary: stories in QI Stories convey the complexity of human

experience in particular contexts Stories are about ‘trouble’ and risk Storytelling is therefore a useful tool for

analysing complex and tragic situations Stories prompt reflection, inspire the

moral imagination, and ignite action

Storytelling exercise 2

Choose a good story from the ones you have shared

Fill out the template Give the story a different ending Re-vision the organisation(s) to

produce the key relationships, patterns, and choices that lead to this ending

WHEN DOES THE USE OF STORIES IN QI COUNT AS

RESEARCH?

Is it research?

Clear research question Recognisable methodological

approach, applied rigorously and transparently Choice of approaches/tools/instruments Method of data collection Choice of analytic method

Is it research?

Analysis Coherent theoretical framework Identifiable unit of analysis Rigour and transparency of analysis

Evidence of reflexive awareness Research process Researcher role

QUALITY IMPROVEMENT RESEARCH:

FOUR APPROACHES

1. NARRATIVE INTERVIEW

Narrative interview

Systematic sampling of informants “Tell me a story about X” Prompts

“How did you feel at that point?” “What happened next?” “How might this have gone differently?”

Narrative analysis

“It is the researcher's task not merely to celebrate the story or the narrative but to seek to use it as a vehicle for accessing deeper truths than the truths, half-truths and fictions of undigested personal experience.”

Yiannis Gabriel

2. NATURALISTIC STORY-GATHERING

Naturalistic story-gathering An aspect of ethnographic study Informal as well as formal stories Trade-off between accuracy in

recording and distortion of the situation

Analysis: within the wider ethnographic interpretation

Naturalistic story-gathering Impractical and unaffordable in

today’s highly managed and audited research culture?

Auto-ethnography as an option?

3. ORGANISATIONAL CASE STUDY

Organisational case study

The researcher’s story of what is going on in the organisation over time

Draws on multi-method data gathering (e.g. interviews, memos, observational data)

Story-telling as a method of prioritising and making sense of the data

Organisational case study

Complex and lengthy process Timescale may be too long for

today’s rapidly changing work environment

Not to be confused with superficial personal accounts from QI teams (i.e. easy to do this one badly)

4. ACTION RESEARCH (‘COLLECTIVE SENSE-

MAKING’)

Action research

“a mutual learning process within which people work together to discover what the issues are, why they exist, and how they might be addressed”

Paul Bate

Action research

Participatory Developing a shared perspective

and vision on the problem Igniting and sustaining collective

action ‘Let it happen’ rather than ‘make it

happen’ approach to change

Action research

Damn hard to get funding Very few published accounts in the

healthcare literature Easy to do it badly

Discussion: how did it go?

Conclusion

Stories are a flexible, fun and creative tool for engaging people in organisational change efforts

Storytelling is particularly useful when analysing and changing complex systems

Evaluation

Thank you for your attention

Trisha GreenhalghUniversity College London

p.greenhalgh@pcps.ucl.ac.uk

A slant from complexity (general systems) theory

What is a complex system? Collection of actors/agents who can

act independently and creatively Share an environment or space Parts are interconnected: interfaces

and relationships between the parts are key

Action by any part affects the whole

Distinguish between

Simple system Complicated system Complex system

Simple (baking a cake)

Complicated(moon rocket)

Complex(raising child)

Standard recipeStandard product‘No experience necessary’Outcome predictableCake does not have a view on life

Lots of formulae Needs expertise & co-ordinationAll rockets similar in critical waysSending one rocket increases assurance that next will be OKRocket does not have a view on life

Child has a viewFormulae have limited applicationRaising one child gives no assurance of success with nextExpertise can help but not sufficientUncertainty of outcome

Complexity science: key principles

Relationships Patterns Simple rules Adaptation Non-linearity (small things, big effects) Embeddedness Attractor effects

Attractor effects

Throwing a rock

Throwing a bird

Making sense of complex systems

MUST THINK ABOUT relationships + patterns + simple rules + adaptation + non-linearity + embeddedness + attractors

Aaaugh!

Use a sensemaking device that incorporates and promotes all these perspectives

Tell a story

Making sense of complex systems