managing complexity: evidence and real world impact

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Managing complexity: Evidence and real world impact Soo Downe Health Research With Real Impact Conference UCLan Wednesday 15th May, 2013 With thanks to women and families for permission to use the photographs

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Managing complexity: Evidence and real world impact. Soo Downe Health Research With Real Impact Conference UCLan Wednesday 15th May, 2013 With thanks to women and families for permission to use the photographs. What complexity is not…. Random Complicated Chaotic Predictable Linear. - PowerPoint PPT Presentation

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Page 1: Managing complexity:  Evidence and real world impact

Managing complexity: Evidence and real world impact

Soo Downe

Health Research With Real Impact ConferenceUCLanWednesday 15th May, 2013 With thanks to women and families for permission to use the photographs

Page 2: Managing complexity:  Evidence and real world impact

What complexity is not…• Random• Complicated• Chaotic• Predictable• Linear

Page 3: Managing complexity:  Evidence and real world impact

The nature of linear evidence….

Page 4: Managing complexity:  Evidence and real world impact

• Theory-practice gap

• ‘Ivory towers’ and real life…

Page 5: Managing complexity:  Evidence and real world impact

On the high ground, manageable problems lend themselves to solution through the application of research method and theory…

Page 6: Managing complexity:  Evidence and real world impact

In the swampy lowland, messy confusing problems defy technical solution.. [these are]…the problems of greatest human concern’

Schon 1983 p14

Page 7: Managing complexity:  Evidence and real world impact

… a tale of two techniques

•Routine electronic fetal monitoring, low risk women

•Vaginal Breech Birth

Page 8: Managing complexity:  Evidence and real world impact

Electronic Fetal Monitoring

Date of introduction: 1960s

Dates of trials: 1976-1993

Nine trials (of 13), 18,561 pregnant women, 18,695 infants in both high- and low-risk pregnancies, seven clinical centers in the United States, Europe, and Australia

Page 9: Managing complexity:  Evidence and real world impact

Electronic Fetal Monitoring

Findings: Statistically significant decrease in neonatal seizures (relative risk

(RR) 0.51, 95% confidence interval (CI) 0.32-0.82), no decrease in cerebral palsy

An increase in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30).

Page 10: Managing complexity:  Evidence and real world impact

NICE 2001

For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation should be offered and recommended in labour to monitor fetal wellbeing.

…In the active stages of labour, intermittent auscultation should occur after a contraction, for a minimum of 60 seconds, and at least:

Every 15 minutes in the first stage. Every 5 minutes in the second stage.

Page 11: Managing complexity:  Evidence and real world impact

Although the skills necessary to implement

evidence into obstetrical practice are still

available, evidence based research results do

not seem to be of great importance, when

midwives decide which method to use for

intrapartum FHR monitoring. Hospital

policies and the professional training

received were more important factors. Luyben AG, Gross MM.2001

EFM practice: Switzerland

Page 12: Managing complexity:  Evidence and real world impact

Term breech presentation

First trial: 1980, second 1983, same centre

Main trial 2088 women 121 centres 26 countries (Hannah et al 2000)

Three trials (2396 participants) included

Page 13: Managing complexity:  Evidence and real world impact

Primary outcome, term breech trial

Page 14: Managing complexity:  Evidence and real world impact

Media spin

Page 15: Managing complexity:  Evidence and real world impact

Evidence based real world impact?(mindlines… illness scripts…chunking…)

• 80 centres, 23 countries. 92.5% changed clinical practice to planned CS for most or all term breech babies.

• 66.3% had no difficulties or concerns with implementing a policy of planned Caesarean section for term breech babies.

• 85.0% indicated that an analysis of relative costs would not affect clinical practice in their setting.

Hogle KL et al 2003

Page 16: Managing complexity:  Evidence and real world impact

…counter stories

• Local studies of consecutive cases varied:

• from evidence that CS confers benefit (eg Rietberg et al 2003)

• to evidence of no difference (Hellsten et al 2003)

• to evidence of benefit for vaginal breech birth (Sibony et al 2003).

Page 17: Managing complexity:  Evidence and real world impact

2 year follow up:death or serious morbidity

Page 18: Managing complexity:  Evidence and real world impact

How these sources interact:the reification of knowledge…

The power of authoritative

knowledge is not that it is

correct, but that it countsJordon B 1997 In: Davis-Floyd and Sargent (eds) Childbirth and Authoritative Knowledge,

University of California Press.

Page 19: Managing complexity:  Evidence and real world impact

Research with real world impact..

Page 20: Managing complexity:  Evidence and real world impact

Initial conditions, tipping points and simple rules

• separation– don’t collide with

your flockmates • alignment– go where most of

the others are going• cohesion:– move towards the

middle

Page 21: Managing complexity:  Evidence and real world impact

Explanatory theories…

• Diffusion of innovation• Theory of planned

behaviour• Technology adoption

theory• Baysian theory…• &etc

Page 22: Managing complexity:  Evidence and real world impact

Simple rules for evidence based medicine?

Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient value… when these three elements are integrated, clinicians and patients form (an)…alliance which optimises clinical outcomes and quality of life…’

Sackett et al 2000

Page 23: Managing complexity:  Evidence and real world impact

Ways of knowing: Best evidenceEpisteme

Science: what is: (theōria)

Page 24: Managing complexity:  Evidence and real world impact

Ways of knowing: Clinical expertiseTéchnē

Art/technology: bringing into being:

production (poiēsis)

Page 25: Managing complexity:  Evidence and real world impact

Ways of knowing: ValuesPhronēsis

Practical wisdom:ethics, values

action (praxis)

Page 26: Managing complexity:  Evidence and real world impact

Evidence that takes account of real world complexity

• Mixed methods

• Participatory Action Research

• Experience based co-design

• Realist research

‘what works, for who, in what context’?

Context + mechanism = outcome

Pawson and Tilley 1997

Page 27: Managing complexity:  Evidence and real world impact

‘good’ evidence – accounting for ‘initial conditions’: how, when, where, who, as well as ‘what works’

Page 28: Managing complexity:  Evidence and real world impact

Expertise in complex real world context..

• no longer relies on an analytic principle (rule, guideline, maxim)

• intuitive grasp of each situation - zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions.

• deep understanding of the total situation. • performance fluid, flexible and highly

proficient.• Uses analytic problem solving where

necessary.

Page 29: Managing complexity:  Evidence and real world impact

Stories as evidence of values in complex real life practice

‘hearing the moral impulse in others’ stories enables us to become part of their struggle to re-enchant a disenchanted world’. Sylvia Barton p18

Page 30: Managing complexity:  Evidence and real world impact
Page 31: Managing complexity:  Evidence and real world impact

Where Bacons origin story for science spoke of the intimate connection of knowledge and power, the feminist critique of science …has spoken of the danger of knowledge without love… Hilary Rose 1994 Love power and knowledge towards a feminist transformation of the sciences. polity press

…Lessons for complex real world research from Francis….