Implementing and learning from change

We have described how generalist clinicians implement and learn from change every time they work with patients to make sense of their condition, and so negotiate a treatment plan. This process is discovering, integrating, applying, and learning in everyday clinical practice.

Figure 1. Step by step process to becoming a future WiseGP – The implementing and learning step

We can apply the same principles when working to make changes at a wider level such as changing how we work at a practice level. All GPs are now required to take part in Quality Improvement (QI) work.

Why don’t you share examples of QI projects you have been involved in before in the discussion box below?

We are going to consider how we can use the knowledge work ideas and principles we have discussed in previous weeks to also develop our skills such as QI. As we build skills and confidence in using our scholarship skills with patients, we can translate these to making practice-level changes through approaches like QI. We can then start to build further and embark on new approaches such as implementation projects to achieve a larger-scale transformation of practice.

We know from research^{1, 2, 3, 4} that for change to become embedded in everyday practice, we need to pay attention to four interacting components that are necessary to change processes and behaviours. These are described by Normalisation Process Theory (NPT) and shown in Fig 2.

Figure 2. Diagram explaining how the 4 elements of Normalisation Process Theory interact¹.

Often multiple interacting components are necessary to change processes and behaviours. Looking at this model, can you think of ways it could help you think differently about a problem in everyday practice? Think about the case study from week one, we met Margaret who was struggling with chronic back pains but who also had a history of B12 deficiency. How does NPT help you think about things that might need to change? Can you use QI to help try out some of those change ideas in your own practice?

Share your thoughts in the comments below.

Next, we can work with research colleagues to build on these individual practice-based ideas to develop ideas that can be applied across many practices and healthcare settings. In other words, we start to use our practice-based learning to add to the evidence base available from academic research studies. By working in collaboration with our academic primary care colleagues we can grow a QI idea from practice, into a model for change that other practices could use, so sharing our knowledge and helping to develop a wider community of practice that can be supportive of each other.

The next step is to think about if, and how, we can put our idea into practice. NPT is one of the theories used in implementation science. Implementation science is a research approach that helps us translate knowledge into practice and is defined as the scientific study of methods to promote the uptake of research findings into routine practice to improve the quality and effectiveness of healthcare⁴.

Research projects can tell us that an idea could work and that it might be possible to roll out our practice-based idea more widely. Actually putting research into practice is another opportunity to use our clinician scholarship, our knowledge work skills, to think about how we implement research into practice. NPT is one of the theories used in implementation research.

So, we start to see how we can take clinician ideas, your ideas, from practice and use our scholarship skills and research to develop them into new ways of thinking or working that can help wider general practice and improve primary care.

Your journey as a clinician scholar has started!

Changing practice is a process, not an event. It is a necessary element of the process of gaining new knowledge and skills and changing attitudes. Small steps can lead to big changes in practice and a culture of change can encourage an attitude of evolution. Achieving change by ‘trial and learn’ is a skill we use in clinical practice. Here we are thinking about extending it to other areas of professional practice too and will be giving you examples of how other GPs have done just that.

References

1. Bryce C, Flemming J. Reeve J. Implementing change in primary care practice: lessons from a mixed-methods evaluation of frailty initiative. BJGPOpen. 2018. DOI: 10.3399/bjgpopen18X101421
2. Eccles M. Grimshaw J. Walker A. Johnston M. Pitts N. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol. 2005. 58. 107–12. DOI: 10.1016/j.jclinepi.2004.09.002
3. Fox R D. Bennet N. Education and Debate. Continuing medical education: Learning and change: implications for CME. BMJ. 1998. 316: 466-468.
4. Thomas A. Ellaway RH. Rethinking implementation science for health professions education: A manifesto for change. Perspect Med Educ 2021. 10. 362–368 DOI: https://doi.org/10.1007/s40037-021-00688-3