I remember being at an academic gathering of healthcare social scientists a few years back. A lot of withering talk of the dominant paradigm of biomedical research and the limitations of positivist thinking. Then one of the delegates had a heart attack. Complete panic until someone said: “I’m a doctor, a real doctor” and not one of those proud sociologists demurred. I’m glad to say, the person recovered, in no small part due to the quick attention of the physician. But we all felt a bit humbled. It was hard to see how an epistemic framework could have saved a person’s life.
It made me think about the place of social sciences research now. The current all too real crisis of covid-19 has, quite rightly, foregrounded clinical research. We have been impressed and indebted to the teams like Oxford CEBM producing high quality rapid reviews on the most pressing questions facing clinicians right now, such as what personal protective equipment (PPE) will keep me safe? How can I diagnose breathlessness over the phone? The epidemiologists, data analysts, modellers and behavioural science experts have all too been centre stage. Indeed, never has the hand wringing about the gulf between research and policy seemed so unnecessary. It comes from another time, in which it would have been difficult to imagine a single pre-print paper from Imperial landing so directly to the heart of Number Ten (and the White House).
But there are other disciplines and bodies of knowledge we can draw from at this time. I am thinking of anthropology, sociology, organisational and management studies, to name but a few. I am most familiar with the NIHR evidence base on health services delivery. Without doing a systematic trawl, I have dug out a few studies which have something to teach us at this time.
Technology and remote working: This includes careful observation and organisational case studies to understand staff “resistance” to technology through to applied knowledge on what are the best conditions for clinicians to deliver videoconsultations. Earlier evaluations of 111 services revealed the way in which call-handlers developed workarounds for problems with standardised algorithms and technology.
Decision-making and handover: There are also rich studies about how staff make decisions in difficult times. Ethnographic studies of paramedics highlighted the complexity of making decisions about whether or not to convey a frail older person to hospital. And a study of how doctors decide who would benefit from admission to intensive care showed how this was often opaque and implicit. This now seems very urgent. Similar qualitative studies of decisions on withdrawing life-sustaining treatments identified sources of conflict and resolution. Other studies have shown the degradation of important information on handover between paramedic and admitting hospital staff and how this can be improved.
Staff wellbeing and compassionate care: We know something about what keeps staff strong at times of pressure. This includes a recent realist review of doctors’ mental health highlighting the importance of belonging and relationality with spaces to connect (in the current climate, that may be whatsapp groups rather than staff rooms). An intervention to improve ward care through team-based reflective learning and dialogue is being scaled up. Evaluation of Schwartz rounds showed the benefits for staff of facilitated meetings to debrief on distressing patient encounters, now being tested in virtual form for our new times. Many health service research studies highlight the critical leadership role of the nurse ward manager in role modelling positive behaviour and driving high-performing teams.
Shock of the new: At the same time, on twitter I am coming across all sorts of rapid introduction and implementation of service changes, from virtual ward rounds by GPs of care homes to single points of access for paediatric and emergency department childrens services. We have also seen the unexpected fluidity or professional and specialty boundaries – as surgical teams switch to critical care. Social media has highlighted a cardiothoracic surgeon putting in stints (after one week training) as an intensive care nurse. The debate on medical generalism seems to have moved on apace. And the importance of some new roles such as emergency nurse practitioners or paramedic specialists have been foregrounded. Research has something to say about professional identity, skill substitution and scope of practice but we are also seeing fascinating new shifts at speed which demand future study and reflection.
Stories from the frontline: Like many people, I have become a bit of a news junkie and glued to my twitter stream. And the threads which stick with me are the firsthand accounts from the like of @leorahorwitzmd @mancunianmedic and @craigrsmithmd (aware that I am missing examples from other professions). It is part of our human need for stories. Tales of resilience, workarounds, compassion, camaraderie, collective learning and mutual support under pressure. It is an embodiment of what in patient safety circles is known as Safety 2 – what we can learn from what goes well, under pressure. In health service research terms, we have long known the power of positive deviance or studying high-performing outliers to see what they can teach us. It is important that social scientists help us to make sense of the experience of these exceptional times and the best parts which we can carry through to our new normal as the curtains lift.
Tara Lamont, Senior Scientific Adviser (Evidence Use), Wessex Institute.
Competing interests: None declared