Programme Theory – What is it and how will it help me to improve patient care?

Previously, I thought about how I have intuitively understood theory, and how I’ve been using it without realising it. But now, I have read a ‘using theory’ blog and a paper which proposes that better use of theory could enhance my improvement efforts. As I write this blog, I’m still not convinced if this extra reading will be helpful, but I’ll explore it a bit more before I decide.

I have always been a little wary of using theory in my clinical work because I thought it would probably be time-consuming to do it properly. But then, the more I read, the more I thought: “Perhaps recognising the theory I was always using in my natural day to day working life isn’t enough?” What I care about is being able to design and implement interventions with confidence that patient care can improve as a result. So, if delving deeper into theory can help me to become a better improvement scientist, then maybe I should give it a go!

Programme theory

I’m going to start by considering programme theory, as recommended by the paper I read in the hope that it will help me to:

• Shorten the time frame of the development of my intervention
• Optimise the design of my interventions
• Identify what will make my intervention a success

But what exactly is ‘programme theory’ and how is it going to help me do these things?

Programme theory could be termed a ‘small theory’ (meaning that it is quite specific to a particular intervention or programme and does not seek to operate at a very high level of philosophy). Programme theory seeks to identify the components of interventions and characterise the mechanisms through which they work. Programme theory should do two things –

1. It should specify the components of a programme or intervention.
2. It should describe the rationale and possible links between a programme’s interventions (e.g. the improvement activities like reflection, or feedback), processes (e.g. how the intervention is delivered), conditions (e.g. external factors that affect the processes such as leadership or resources), and outcomes (measurable impact on staff or patients).

I enjoy listening to classical music and to me this seemed a bit like how an orchestra might think about preparing for a concert. A conductor leading an orchestra needs to know all the pieces in the orchestra (wood wind, strings, percussion) and how they all come together in order to produce a score. Pitch (a highness or lowness to the sound), duration (how long a sound is held), intensity (loudness), and timbre (a particular sound produced by a particular instrument) could be regarded as some of the conditions necessary for the success of each component of the orchestra. The score should describe each of these things in such a way that the conductor can reproduce the correct tone while allowing the audience to hear a story beneath the noise. I remember marvelling at a conductor I once saw, and her remarkable ability to empower her audience to hear the technicalities of the piece as it was originally intended, whilst allowing a story to unravel which was able to touch each individual differently.

Using programme theory in a quality improvement intervention

Let me provide a hypothetical scenario of how using programme theory might practically benefit a quality improvement intervention. For my hypothetical intervention to work I need to know: what the components of the ‘improvement programme’ are; what affects how they work together; and how the intervention is ‘processed’ between the programme and the outcome.

I have retained a clinical role as an extended scope physiotherapist in orthopaedics. Let’s imagine I would like to engage staff to develop a ‘one-stop’ information book for elective hip and knee replacement patients. Currently patients may receive a baffling number of separate leaflets across their whole journey. Thus, a new patient book, with everything in one place, might ease communication, improve empowerment, reduce unnecessary visits to healthcare professionals, and thus, healthcare consumption.

As described in the paper I read[1], I could develop the programme theory for this intervention by reviewing the literature on the topic, meeting up with clinical staff, and conducting focus groups with staff and patients to identify relevance and acceptability of the book. I would then design the intervention – my new patient book. But a literature review and engagement of stakeholders is a fairly typical way of doing service improvement in my usual day-to-day practice, so what has programme theory changed? What differs is that having to develop a programme theory prompts me to think carefully about which additional factors, such as feedback from patients and staff, might impact the intervention.

How would programme theory help me?

I have to admit, I did have some initial reservations, so I was surprised to find that applying theory in a structured way was quite satisfying. This is because:

1. Programme theory can help to pin-point potential problems in advance. I saw that it might also prompt me to speak up about things which might otherwise have been left unsaid, for example – the difficulties of gaining consensus between staff about what should and should not be included in the book.
2. Programme theory could highlight where my causal logic (that better information results in better outcomes) might be flawed. For example, other interventions such as virtual follow up services for routine hip replacements and telephone check-ups after discharge already exist which might also reduce use of formal healthcare and improve patient empowerment, and might indeed be better than my proposed book.
3. Programme theory could help me to enact more structured teamwork because it explicitly requires feedback. Consequently, my hypothetical intervention design included plans to carve out dedicated time for the team to raise any issues/concerns they might have.

Although a programme theory does not need to conclude with a measureable outcome, I have incorporated a quantifiable outcome to help me understand the value of my intervention to the hospital trust.

So what have I discovered?

It’s easy to feel like theory is ‘boring’, ‘time-consuming’ or, ‘someone else’s job’, but if you can put these feelings aside it could be used to actually make a real difference to how well an intervention works. Theory should be all about improving practice – sometimes it just needs a bit of translation from academia into everyday workable actions. I’ve tried to do that for programme theory in this blog.

Let me know how I’ve done through twitter (@emmajonesPhysio) or by posting your comment on this page. Watch this space for the next blog when I’m going to be tackling the challenge of juggling two aspirations – one to be a better improvement scientist and another to be a better healthcare professional, which both require a commitment to improve care in different ways.

[1] Box 1, page 3, Davidoff et al.