Some impressions of the inaugural QUEX Symposium

QUEX is the University of Queensland and University of Exeter Institute for Global Sustainability and Wellbeing. It is a partnership between the two universities with three themes – Healthy Ageing, Environmental Sustainability, and Physical Activity and Nutrition – that has joint PhD studentships as a central element. Each year ten studentships are available and these will lead to jointly awarded PhDs from the two universities; other funding streams are available to research, teaching, and professional services staff in the two universities to develop and support joint projects and visits.

The first cohort of students started in January 2018 and the first symposium was held last week in Exeter. I attended in my role as Exeter theme lead for the Health Ageing Theme.

At the symposium I was struck by three things I thought were three great about QUEX:

First, the students: they are all very impressive. QUEX students spend two years at one of the universities and one year at the other, usually sandwiched in the middle. The students are getting a very international experience and are themselves from all over the world: we have (from memory) three people from Britain, one from Australia, one from Fiji, two from Portugal, one from the US, one from New Zealand, and one from Japan. There were over 700 applications for the studentships so everyone who is in this cohort has had to really stand out and I thought they did: each of them is a great ambassador for QUEX and I was impressed by how good they are.

Second, the opportunities created. One motivation for the formation of QUEX was the observation that papers on which researchers from both Exeter and Queensland were both authors were cited more than papers in which only one university was involved. I would see this as in part coming from the fact that dual-institution papers are able to tap into more than one national network of citing (an example of the strength of weak ties, in social network terms). The advantage to students and to research teams is the same: they are able to tap into networks of scientists and knowledge that are likely relatively unconnected and so they will automatically extend the reach and influence of their work simply by virtue of being part of QUEX.

Third, this kind of international PhD arrangement seems like one version of the future of postgraduate study. I’m going to avoid using the phrase “in our increasingly globalized world” but it is the case that people who can work comfortably and well in different settings have more avenues open to them and, as researchers, more opportunities to join excellent research groups and to address problems that are global in nature: problems like this associated with the QUEX research themes. Going beyond shared supervision or short-term visits, arrangements like QUEX permit people to gain extended experience in more than one research (and cultural) setting. The presence of, and talks given by, the VCs of both universities at this symposium indicates that university leaders also see the importance of such undertakings.

I was also struck by three challenges that programmes like QUEX face:

The first is around communication. With students and supervisors spread across multiple campuses in universities thousands of miles apart, excellent internal and external communication are essential to creating and maintaining an esprit de corps as well as simply to ensuring the smooth running of the programme and ensuring everyone is up to date with progress and opportunities. Some dedicated comms resource is important to making this happen.

The second challenge is around sustaining things: this applies to QUEX itself, which is currently dependent on funding from both universities, and also to the careers of the researchers involved. One difficulty is that a lot of funding can’t be used to pay for people from other countries; for example, most research council (government) funding in the UK can’t be used to pay for the time of researchers based in Australia. Doing this kind of cross-national research runs the risk of being a bit like doing interdisciplinary research: everybody talks it up and it’s clearly worthwhile but funders and journals and assessment panels are all set up around single disciplines and you risk falling between stools. Part of the ongoing behind-the-scenes work in QUEX is going to involve identifying fellowships and funding schemes that support international collaboration.

Finally, there is a challenge around environmental sustainability. Flying researchers and other university staff around the world is important and exciting but, as far as I know, flying is one of the worst things you can do for the environment. I think we all have to work out how we can do this kind of work without screwing the planet up. In a programme that has environmental sustainability as one of its themes we would be troubling if we were not to address this.

As a programme, QUEX is going to go from strength to strength. At the time of writing, the second cohort of studentships is being advertised (see https://scholarships.uq.edu.au/scholarship/quex-phd-scholarships). You can read more about QUEX here: https://www.exeter.ac.uk/quex/.

Implementation barriers in dementia care: the Machine Trick

My colleague Jo Thompson Coon and I were invited to attend Alzheimer’s Society Annual Research Conference last week and give a workshop on implementation in dementia research – a topic in which we’ve a particular interest and on which the Society is funding us to do some work.

'Myee'_chaff_cutter_from_The_Powerhouse_Museum

We ran the session based around a shortened version of Howie Becker’s “Machine Trick”; the trick involves coming to understand a social problem better by imagining that you have to design a machine that would produce the situation you have observed: in this case, the failures of knowledge mobilisation around dementia research and the practice of dementia care. (A future post will go into more detail on Becker’s trick and how it can be used in implementation workshops.)

The workshop was attended by just over 40 people, a mix of researchers and research network volunteers – that is, the lay people who review and advise on Alzheimer’s Society research projects. After a brief introduction we challenged those in the room to split into small groups and identify the components that they thought our machine should have. Each of the six groups then fed back the three most important bits they had thought of, and a few people shouted out other things they though important at the end.

The components the workshop participants identified are listed below. Those that came up more than once are marked (“x2)”.

• Use of different languages by different parts of the machine x2
• Lack of understanding of barriers at outset of (research) project x2
• No patient and public involvement x2
• Lack of willingness to change or accept innovation
• Research not grounded in or exposed to reality
• Lack of leadership
• Poor quality research
• Lack of polish in presentation of findings to wider audience
• Reactive workplace with no time to plan – both for researchers and practitioners
• Poor communication and/or excessive communication between parties
• No use of experience or prior learning from previous work – for both researchers and practitioners
• Lack of appreciation of time it takes to evaluate something
• Lack of trust between parties
• Kudos and benefits only accrue to one side (typically researchers)
• Priorities geared towards immediate clinical care – lack of time and resources to think about research
• Funding geared towards finding out new stuff rather than implementing or disseminating – and no time in grants to think about implementation and dissemination
• Stifling of innovation and creativity – no time or attention available for new things
• Lack of understanding of politics – both with a small ‘p’ and a big ‘P’

These components are pretty clear and need little interpretation: the problems inherent in them, if we wanted to fix or correct the machine, are readily apparent. They also cover a lot of ground and capture some of the complications and complexities inherent in implementing healthcare research – and I use that term purposefully, since most if not all of them could be applied to many care situations, not just to dementia. In a longer workshop we might have gone on to explore how the challenges represented in the machine could be overcome or negotiated; as it was I think the format was useful in bringing researchers and non-researchers together to think about, discuss, and identify the challenges of implementation.

There are no heroes in knowledge mobilisation

As a child I never really had a hero. I’m reminded I should have had one, or at least that other people did, when I have to fill in “secret questions” for password recovery: alongside “mother’s maiden name” and “place of birth” you sometimes see “childhood hero”. I never had one.

Now I’m interested in implementation science and K* and I wonder: should I have a hero now? Or more broadly: who are the heroes of knowledge mobilisation?

So many heroes, so little time

There are lots of heroes in the world: footballers, actors, musicians. Some heroes are super: Superman, Silk Spectre, Jean Grey. And some heroes are real, and professional: in public health, Edward Jenner is known for pioneering the development of the smallpox vaccine, John Snow is famed for “removing the pump handle” as part of his investigations into the causes of cholera, and Louis Pasteur recognised for his work on vaccination and pasteurization.

Except… that if you read Bruno Latour’s book The Pasteurization of France (originally published as Les Microbes: guerre et paix) you find presented a different perspective on Pasteur’s work and legacy. Once you’ve read that it’s a lot harder to regard other heroes in quite the same way as you once did.

Alongside the apparently heroic scientific work of Pasteur, work which has led to his lasting fame and celebrity within France and elsewhere, Latour sets all the other work that was necessary for Pasteur’s activities to change the way people thought and acted. Some of this work was conducted by Pasteur himself and will be familiar to anyone working in knowledge mobilisation: the work of reasoning and convincing and persuading and enrolling and so on. He played an important part in enrolling the various “actors” (that is, the individuals and groups and organisations) necessary to the success of his work (and there is an interesting sociological understanding by which we may think not only of the people involved in this but in the non-human actors too: Michel Callon’s (1986) account of the role played by scallops in debates over the scientific and economic debates about conservation and fishing in St Brieuc Bay in Brittany is exemplary).

There is no issue, then, that what Pasteur did was anything less than very important and scientifically remarkable. But much of it was conducted by others who worked for or around or simply at the same time as Pasteur, who supported Pasteur for reasons that range from the altruistic to the self-interested, the pragmatic to the political, and who were medical practitioners or farmers or local politicians or industrialists or rival scientists or something else entirely.

In short: we talk of Pasteur’s work and of pasteurization but in doing so we focus only on the activities of the person apparently at the centre and neglect all the work that went on around them, work that not only supported and publicized Pasteur’s activities but in many ways enabled and constructed it.

Latour describes the complexity of what occurred and the importance of the network of alliances that led to the production of scientific results and the construction of what is science. In Art Worlds (1982) Howie Becker proposed that the answer to the question “what is art?” is to be found among the individuals and groups that collectively define, through their discourse and their actions, what is and what is not art. Latour here addresses how the question “what is science?”, or perhaps “what comes to be regarded as scientific?” can be answered; the answer lies among all the individuals and groups that have an interest (or can be made to be interested) in the scientificity of a given claim or set of claims or proposed action.

And in emphasizing the absence of a boundary between science and society Latour addresses the claims of (some) scientists that those engaged in social studies of science don’t really understand science. His response seems to be that those who argue this don’t really understand society and that insisting on science as an undertaking of pure reason neglects the important of force (or power) in the making of any claim to truth or the realisation of any change. Latour’s concern is thus not simply with Pasteur’s scientific achievement but, perhaps, with how the science came to be regarded as an achievement (a process which took many years) and how the achievement, constructed in this way, ultimately led to practical changes in human health in France and worldwide. If we regard Pasteur as a hero then we might also consider how he came to be regarded in that way and what was necessary for the establishment of that regard.

superman

So are there heroes in K* and implementation science? Sure, if you want there to be: go ahead and pick some. But for my money the always-already collaborative and systems-based nature of implementation means that there thinking of individual heroes means ignoring the complex ways in which change really occurs and knowledge mobilisation actually takes place.

 

On the Battle of Poitiers (1356) as a failure of implementation

There were three noteworthy English victories over France in the Hundred Years War. The best-known is the final one, the Battle of Agincourt (1415), but the earlier battles are just as historically and strategically interesting.

The second of these was the Battle of Poitiers (1356) in which a combined English and Gascon army led by Edward, Prince of Wales (later known as the Black Prince) defeated a much larger French force. The French had a number of apparent advantages: they were on home territory, they had many more men (probably around 16000, twice the size of Edward’s force of around 8000), and they were eager to drive the English out of France because English forces had been at large for years and had pillaged and killed widely. Yet the French lost, and lost badly: their King, Jean II, was taken prisoner and the Oriflamme, the sacred French battle standard, was captured. The defeat was met with surprise across France and Europe and marked a turning point in the status and authority of the French nobility.

Historians have proposed a number of reasons for this unexpected loss. I think that our current understandings of implementation can be used to understand some of the failures of the French army. I suggest three implementation issues were involved and in relation to each we can see how Edward’s forces were successful in making beneficial changes that the French army failed to enact.Battle-poitiers(1356)

First, English longbowmen were made central to their army. Archers were an important contributor to the English victory at Poitiers, first firing upon the French cavalry head-on and then, when the knights’ armour proved too tough to penetrate, moving to one side and felling the horses with an attach on their flanks. The successful implementation here lay first in the English recognition of the power of the longbow and second in ensuring that the archers were effectively deployed in practice. The French also had archers and knew their power: they had suffered under the fire of English longbows in the Battle of Crécy ten years earlier. But they failed to integrate the archers into their fighting force as the English did, a failure that Barbara Tuchman ascribes to established social and cultural norms on the part of the French nobles: the French archers “were never properly combined in action with knights and men-at-arms, because French chivalry scorned to share its dominance of the field with commoners.” (153) In the English side this attitude was less dominant and they were able to benefit from the ranged power of the longbow.

A second factor played out in the tactics adopted by the French during the battle. The English force was very short of water and had dug in on a hill. Marshal Clermont, an experienced general and one of the senior French nobles present, proposed blockading the English and starving them out. Edward feared that the French would try this and the approach would likely have had an excellent chance of success. However, King Jean opposed the idea because it was at odds with the rules of chivalry. He chose instead to engage with the English and Clermont was among those killed in the fighting that followed.

Third, Edward had been able to organise his forces in a new way with some semblance of what we might recognise as a military hierarchy, with soldiers answerable to officers and officers to more senior commanders (this is not strictly true but captures the general idea). The French had no such structure and their commanders were at risk, as was often the case in medieval armies, from the fact that individual nobles and their followers might decide at any point that they had had enough and make a unilateral decision to leave the field of battle. With no notion of military discipline and troops’ loyalty in the first instance to their feudal overlord, the turning tide of the battle eventually led to a rout with surviving French nobles and foot soldiers fleeing before the rampaging English.

These were not the only things that contributed to the French defeat but they were important. The French lost, in part, because: their prevailing culture did not permit the effective implementation of a new technology (longbows); sociocultural factors prevented them from acting in a tactically beneficial way in reaction to the course of the battle; and they were tied to a harmful and outmoded organisational structure.

If we turn to contemporary writing on facilitators and barriers to implementation we find similar barriers to implementation recognised. Implementation science has been described as a discipline that focuses, in part, on “the discovery and identification of social, organizational, and cultural factors affecting the uptake of evidence-based practices and policies” (Luke 2012). The “evidence” available in the fourteenth century was not the type of evidence we might want to inform policy decisions today but it seems clear that social, organisational and cultural factors were key aspects of the French failure to implement new ways of thinking and acting that became major contributors to a French military disaster. Then, as now, social, organisational and cultural factors are central elements of what we have to recognise, consider, and address when considering implementing new practices or ways of doing things.

Plus ça change, plus c’est la même chose…

REFERENCES

My understanding of this topic has been informed by Barbara Tuchman’s outstanding A Distant Mirror: The Calamitous 14th Century (Knopf, 1978).

Luke DA. Viewing Dissemination and Implementation Research through a Network Lens. In Brownson RC, Colditz GA, Proctor EK. Dissemination and Implementation Research in Health: Translating Science to Practice. (Oxford: OUP)
Iain

Iain

Senior Lecturer and Associate Dean at University of Exeter Medical School
I am interested in dementia, older people's health and wellbeing, and implementation science.
Iain

Why a health service is like a bicycle OR the importance of deimplementation

Much of the emphasis in knowledge mobilisation is on getting new things into practice. The term “implementation science” conveys this too: we want to implement stuff. But just as important can be getting things out of practice: de-implementation. The rationale is straightforward. A health service is much like a bicycle, and the case of Mrs Armitage makes clear the problem.

Mrs Armitage on her bike - so far, so good

Mrs Armitage is a creation of English writer and illustrator Quentin Blake. She appears in three books: Mrs Armitage on Wheels, Mrs Armitage and the Big Wave, and Mrs Armitage, Queen of the Road. In both Wheels and Big Wave Mrs Armitage engages in similar behaviour. She takes something that works – in the first case a bicycle, in the second case a surfboard – and, perceiving various shortcomings, adds to it until disaster threatens. (I’ll come back to Queen of the Road, which is different.) On the bicycle Mrs Armitage is concerned that hedgehogs won’t hear her coming so she adds a selection of motorhorns; worried that she may need tools in case of breakdown so adds a toolbox; alarmed that her dog Breakspear is tiring so adds a seat for him; and so on: a snack box, a radio-cassette player, a mouth organ… etc.

So it is, all too often, with our health services. New technologies, new ways of working, new diagnostics come along and, if they seem to work and we can implement them, we add them to what we provide. But we often don’t or can’t remove or reduce the form of care or technology that the new one was intended to replace. In other situations, things are implemented on the basis of little or no evidence, never challenged, and persist indefinitely as established practice. Like Mrs Armitage’s bike, the health service gets bigger, more expensive, more unwieldy.

Mrs Armitage's bike: overburdened, disaster beckons

And what happened to Mrs Armitage’s bike? Overburdened and out of control, it crashes and she and Breakspear find themselves sitting amongst the wreckage.

To avoid the looming possibility of expensive and unwieldy health services that risk crashing whole economies we need, rather than constantly thinking about implementing and adding, to think also about how to disimplement and take things away. Implementation Science published a useful short article on this by Vinay Prasad and John Ioannidis in which the authors set out a conceptual framework for evidence-based de-implementation and followed by a note from the editors stating they welcomed further contributions on de-implementation. De-implementation is not just the opposite of implementation and is likely to require different approaches and thoughtful ways to identify practices and technologies that should be de-implemented, then work to find strategies and techniques to de-implement and sustain the necessary changes.

Perhaps Quentin Blake thought about this too. In Queen of the Road Mrs Armitage begins with an antiquated car from which bits gradually fall off – hubcaps, roof, doors, and so on, always received by Mrs Armitage with a statement such as “Hubcaps? Who needs them?” – until she’s finally left with a stripped-down and efficient-looking roadster and annointed, by her uncle and his friendly biker friends, as Queen of the Road.

Hubcaps. Who needs them?

Getting to a stripped-down and efficient health service is the ultimate aim of both implementation and de-implementation. We just have to make sure we don’t forget the second part.

 

References

Prasad V, Ioannidis JPA. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci. 2014; 9: 1. http://www.implementationscience.com/content/9/1/1

Cake-making and implementation

Becky wrote an interesting post recently about KM and cakes. She made the very good point that knowledge mobilisation isn’t something that happens at the end of the research process, like adding the icing to a cake, but that it is part and parcel of research. I thought this was a great metaphor and want to take it a little further.

portal-cake

Let’s stick with the idea that research is like making a cake. A certain understanding of research is that cake-makers (clever researchers) make a fantastic new cake (do some research), present the cake (do some dissemination, probably through the standard academic routes of peer-reviewed publication and conference presentations) to a room full of hungry people (an imagined audience of practitioners or clinicians or policy-makers or members of the public, etc.) and then the people consume it (it is taken up and becomes part of routine practice). Or at least that’s how some people seem to imagine it works.

More commonly, in my experience, the cake is made and then one of a number of things happen, including:

– lots of people hear about the cake and eat it (this doesn’t happen often)
– some people see the cake but think it’s for someone else so they don’t eat any
– some people hear about the cake and one or two people nibble the cake but they think it looks funny or smells funny or just plain don’t like the way it tastes
– a few people hear about the cake but there are so many cakes to choose from that they are distracted elsewhere
– a few people hear about the cake but already have a cake so don’t pay any more attention
– the cake sits in a cupboard for a while. Eventually it gets so mouldy nobody would ever eat it. Perhaps it’s sitting there still. (This happens a lot.)

So sometimes this approach works but very often it does not. A lot of the time this is because it’s simply the wrong cake.

It’s your birthday and someone brings along a wedding cake: wrong cake.
It’s breakfast time and someone brings along a rich chocolate cake: wrong cake.
Everyone’s asked to bring along a salad and you turn up with your delicious pineapple upside-down cake: wrong cake – in fact, wrong food altogether.

The cake need not be totally wrong – maybe you’re happy to eat wedding cake on your birthday or have chocolate cake for breakfast – but for a lot of people it will be. And so it goes with research, at least according to the model outlined above: something is prepared with limited or not understanding of the context in which it’s going to be used.

Wouldn’t it be better if we could avoid this problem? How about, instead of turning up with a cake and hoping the people in the room will like it, we speak to them beforehand and find out what kind of cake they would like? A birthday? Great – I can make you a birthday cake! Going even further, we can keep speaking to the people who will eat the cake throughout the process to find out what they need and have them contribute to the cake-making: How many people is the cake for? A little less sugar? How thick do you like your icing? You’re not going to produce the perfect cake but you’re going to come a heck of a lot closer to producing the kind of thing people want to eat than if you just turn up with your random cake.

Cake making. It’s an implementation thing. (The cake is not a lie.)

Metaphors we implement by

In their influential book Metaphors We Live By (2003[1980]), the cognitive linguists George Lakoff and Mark Johnson argue that metaphors are not just ways of communicating but that they shape the way we think about the world as well as how we act. In this understanding, metaphors are not just poetic devices or characteristics of colourful language but are pervasive in everyday life and as important to thought and action as to language.

They write: “The concepts that govern our thought are not just matters of the intellect. They also govern our everyday functioning, down to the most mundane details. Our concepts structure what we perceive, how we get around in the world, and how we relate to other people. Our conceptual system thus plays a central role in defining our everyday realities. If we are right in suggesting that our conceptual system is largely metaphorical, then the way we think, what we experience, and what we do every day is very much a matter of metaphor.” (p.4). As an initial example they refer to the conceptual metaphor “argument is war”, pointing out that is picked up in a wide variety of related expressions: She attacked the weak point in my argument, I shot down all his arguments, Your claims are indefensible, and so on.

In relation to knowledge mobilisation, Huw Davies and colleagues (2008) picked up on the implications of the terms “knowledge transfer” and “knowledge translation”. They suggest that “the metaphor invoked by these terms is, at best, one of gathering and integrating evidence from research, condensing this into convergent knowledge, and neatly packaging this knowledge for transfer elsewhere. More often, it simply implies the dissemination of relatively undigested findings from single studies. In other words, knowledge parcels for grateful recipients. Such a view belies the inherent and, we would argue, largely insurmountable challenges of doing so for any but the most simple and incontrovertible of findings. Moreover, if the challenges of delivering convergent knowledge are large, the subtlety and complexity of research use in context further militate against simple models of ‘translate and transfer’” (Davies et al. 2008: 189) We might think about the implications of some of the other metaphors used for this and related activities: knowledge utilisation, knowledge mobilisation, knowledge management, technology transfer, and so on. Each of these terms implies something about what the activity involves, and is limited to, and could be critiqued in a similar way: we’re simply making knowledge mobile (because we don’t want stationary knowledge?) or using it (which raises questions who is using it and to what end)?

If Lakoff and Johnson are correct then we should pay attention to what each of these metaphors implies. That each is limited is perhaps unavoidable and make partly explain why the KM field is split by different terminologies rather than united by an agreed-upon one. But we should go further and examine in more detail the consequences of these metaphors. If it is the case that they are not mere linguistic ornamentation but are orienting concepts that shape the way we think and act then we need to consider whether they are shaping our thought and actions in the most appropriate and productive ways.

A long chapter in the Sage Handbook of Organisation Studies is devoted to metaphors of organisational communication. It opens with a commentary on the growth in studies of organisational communication, a growth which has been accompanied by a shift from linear transmission within organisations to “the way that social interaction, discursive processes and symbolic meanings constitute organizations” (Putnam and Boys 2006: 541). To date there has been no similar investigation of and reflection upon the metaphors of KM and their consequences. We might ask a number of questions: what are the key metaphors of KM? How are they employed? How do they influence the expressions we use when talking about KM (in line with the expressions about argument mentioned above? How have they changed over the time, and what underlying changes in our practice and understanding do these changes reflect? And, most importantly, how do these metaphors constitute the things we do when we do KM?

A maturing science needs a degree of awareness and reflection of itself, of what it is and what it is not. KM would benefit from a greater sense of itself and understanding the metaphors we use in doing this work would be one way to approach this.

 

References

Davies H, Nutley S, Walter I. 2008. Why ‘knowledge transfer’ is misconceived for applied social research. Journal of Health Services Research & Policy. 15:188-190.

Lakoff G, Johnson M. 2003. Metaphors We Live By. (New ed.). Chicago: University of Chicago Press.

Putnam L, Boys S. 2006. Revisiting metaphors of organizational communication. in Clegg SR, Hardy C, Lawrence TB, Nord WR. The SAGE Handbook of Organisation Studies. London: Sage Publications. pp.541-577)