Using Theory in Improvement Research

A recently published paper seems the perfect start to this blog, exemplifying as it does SAPPHIRE’s concern with integrating the theory of social science academia with the practical world of healthcare improvement research. Mary Dixon-Woods and colleagues propose that better use of theory could enhance improvement efforts in quality and safety in healthcare.

A popular view of theory is that it is removed and abstract, overly complex and irrelevant to the reality of situations. But really, it’s just about producing explanations. We all do this naturally in our day-to-day life; theory’s purpose is just to formalise these explanations.

Theory in improvement

Using theory in improvement practices does not necessarily mean having to shoehorn a lot of complex conceptual thought into the planning of interventions. As the paper explains, not all theory works at a high level of abstraction. For most improvers, “small theories” – concrete working models – are what will be most useful.

For instance, many improvement projects include some component of feedback. The small theory of their project may therefore specify that feedback will be provided to staff, based on the assumption that getting feedback motivates people, helps them learn, and focuses action. This small theory can be shown to be consistent with big theories in the research literature that suggest that, done right, feedback can indeed achieve these things.

Benefits of theory

For anyone doing improvement, using theory explicitly can be very practical. Articulating any unvoiced, and sometimes unrecognised, assumptions that guide interventions can help in detecting any lack of consensus among team members and any weaknesses or incoherence in the logic of the proposed intervention. It’s about making clear what should be happening, so that you have something to assess what is happening against.

Having a good theory can reduce the risk of being vague about important specifics – including why change is happening, or why not. And if your initiative has worked, having a well-specified theory helps explain to others what they would need to do to replicate the success.

Making theory accessible

Dr Damian Roland, an NHS consultant in paediatrics and keen improver, had this to say:

“It was great to read Davidoff et al. article on de-mystifying theory, as the authors recognised that the term ‘theory’ in itself is off-putting. As a clinician in the NHS I am very aware that most health care practitioners have had little or no training in improvement. One of the challenges facing improvement experts in teaching others is to reclaim the ability to be consciously incompetent – remembering what it is like not to have the experience and knowledge they have gained.”

He notes for clinicians, academic approaches to the importance of theory often don’t have the desired effect of encouraging its use:

“The authors discuss a middle or big theory of improvement as being described as ‘all-inclusive speculations comprising a master conceptual scheme’. I cannot think of a more powerful way to turn off those who primary duty is to deliver care to patients than using this type of language. Theory is vitally important to deliver quality care to patients so the key challenge is how to enable staff of all levels and backgrounds to utilise it.”

He raises an important point, and one which SAPPHIRE is very concerned to address. Indeed, over the coming weeks Emma Jones, a PhD student currently working within SAPPHIRE, will be bringing her own clinical experience as a physiotherapist to bear on the subject of theory. Her blog-series will address the problem of using theory in everyday clinical work, explaining the concepts and any practices they might give rise to in ways that don’t require an academic background to understand.

In an ideal world theory in general, and the use of pre-existing theories in improvement work in particular, would be considered a resource, which can help to guide and clarify interventions, rather than as shackles or unnecessary obfuscation. Good theory should do neither of those things.