Fidelity or flexibility: An ethnographic study of the implementation and use of the Patient Activation Measure

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Abstract

Objective: To evaluate the use of the PAM in the English National Health service. The PAM is a validated scale that measures ‘activation’ (people’s knowledge, skills, and confidence in managing their health) and assigns patients to four categories of activation (low-to-high). Some evidence suggests that higher activation levels correlate to better clinical outcomes and patient experiences, and lower healthcare costs. Empirical studies of implementing the PAM are scarce.

Methods: An ethnographic study of six healthcare organisations’ PAM implementation focused on ‘core-teams’ who designed projects, and frontline staff and patients’ experiences of those. Data comprised 123 hours of observation, 112 interviews, and document reviewing. Analysis used a constant-comparative approach.

Results: The PAM appealed as it fitted with different logics of measurement, offering a means of quantifying soft, process-oriented qualitative constructs used in tailoring care, whilst simultaneously producing reliable high-level outcome metrics. Data revealed challenges to these logics. The PAM’s developers emphasised fidelity to ensure reliability but, in practice, flexibility was commonplace and often perceived as appropriate and beneficial by frontline staff.

Conclusion: The intended logic of measurement is important in determining an appropriate balance of fidelity and flexibility and, therefore, reliability and patient benefit.