- Email: [email protected]
Interpreting official statistics
Book reviews
the issues; however, choice and responsibility could have been explored. The reviewer believes this would have added to the depth of the chapters and represented the reality of the clinical environment, where anaesthetists work not in isolation but in partnership with women, midwives and obstetricians.
Wendy Jessiman Lecturer Practitioners in Action Judith Lathlean Butterworth Heinemann, 1997 ISBN: 0 7506 2449 3, Price: s 15.99 This book reports a 4-year research study of lecturer practitioners (LPs). Nationally, the number of LPs is steadily rising. The premise is that the practitioner who works in the clinical as well as the educational setting, is ideally placed to bridge the theory-practice gap. The main piece of research underpinning this book is a small scale, in depth qualitative study of LPs, which was triangulated with interviews with colleagues and students of the LPs, and a postal survey of all LPs in post at the time. The aim of the book is to describe what it is like to be a lecturer practitioner, and this it achieves. Thorough accounts are given of the way in which the lives of six LPs are organized. The strength of the book lies in its intricate detail. I would recommend it to LPs who are interested in how colleagues in a similar position organize their work, or to anyone who is in the process of conducting or writing up a piece of qualitative research. The book reads very much like a thesis. A review of the literature explores the background to the development of the LR and a methods chapter describes in detail the principles and processes of data collection. The middle section of the book contains descriptive accounts of 'being a lecturer practitioner', 'lecturer practitioners and student learning' and 'theory and practice' ('findings' Chapters 4, 5 and 6 respectively). Chapter 7, the final findings chapter, is rather more analytical in its exploration of the viability of the role of the LP. Particularly interesting were the interview data from the colleagues and students of the LPs. The LPs were able to explain the process of being an LP, but it was the accounts of their colleagues and students that began to illustrate their achievements. Chapter 8, entitled 'conclusions and beyond', presents a short discussion of the implications of the findings. Although Lathlean suggests that the reader might skip or skim the methods chapter, for the research minded it is essential reading; not least because such detailed accounts of qualitative methods are all too infrequent. In the 'findings' chapters Lathlean describes in great detail the ways in which the LPs organized their work and, to an extent, analysis of the data is left to the reader. Any difficulty experienced in following these detailed descriptions is offset by a thorough explanation of why the study was carried out and presented in this
49
way, which is found in the philosophy of Lathlean as 'ethnographer'. The accounts of the LPs are presented unadorned in her attempt neither to influence the data during collection, nor in the reporting. What is missing in Lathlean's approach, however, is an analysis of the data throughout the findings by, for example, drawing parallels with other literature, or setting the data in a policy context or, for the readership of this journal, relating it to the concepts of evidence-based practice and clinical effectiveness. This is the main weakness of the book, which gives it the impression of being rather out of date. This may in part be because the data were collected between 1989 and 1994, and a lot has happened in the world of the LP since then, yet I would contend that Lathlean could have made links with current contextual issues. I was left wondering whether the employment of LPs can help to bridge the theory-practice gap, and contribute to clinically effective practice. I was unclear about what the LPs in the study even meant by 'theory': was this sociological or psychological theory perhaps, or were they also talking about research evidence? The emphasis by the LPs on organizational issues at the expense of the application of research to practice may be rather discouraging to the readers of this journal. But Lathlean was reporting a small study and her findings might not reflect current duaI roles in the health service. It is clear that the role of the LP is an important topic for further research and this book starts that process.
Jane Griffiths Interpreting Official Statistics R. Levitas,W. Guy (eds) Routledge, 1996 ISBN 0 415 10836 5, Price s 13.99 The title of this book does little to inspire the reader; however, I would suggest perseverance as the contents of the book are essential reading for anyone undertaking nursing research or health services research at either undergraduate or postgraduate level. It is also useful reading for health professionals in public health and primary care taking forward current health policy, as it covers national statistics on health, poverty, unemployment and crime as well as the social divisions of class, gender, ethnicity and disability. The book is well written and affordable. It is edited by Ruth Levitas and WitI Guy and comprises 10 chapters with eight of the contributing authors all coming from the sociology department of the University of Bristol. The book contains detailed analyses of key official data sets, such as Households Below Average Income, Administrative and Survey Measures of Unemployment and Crime, General Household Survey, Population Census Data on Ethnicity, Data Sources on Women and Work, The Relationship
51}
Clinical EffectJveness in Nursing
Between Class and Health, and Safety at Work, the Disability and the Labour Force Survey. As well as analyses, the book also covers ways in, which information has been suppressed, manipulated or misinterpreted since 1979. The first chapter sets the book in context and covers the growth of official statistics and the 1980 Rayner Review of the Government Statistical Service within the UK. This review led to cuts in the service resulting in problems with the reliability of official statistics quoted by government ministers and loss of public confidence in official data. In 1996 the Central Statistical Office (CSO) and the Office of Population Censuses and Surveys (OPCS) were merged to form the Office for National Statistics (ONS) with its Director being Registrar General for England and Wales as well as the Director of the CSO and Head of OPCS. The second chapter deals with poverty and details how government manipulation of the statistics can paint a positive picture when the reality is somewhat different. The thresholds for poverty (sometimes also termed inequality) are selectively arbitrary within and between countries and between governments. It is argued that new scientific criteria and alternative definitions and measures of poverty are required in order to be able to measure trends and accurately reflect this aspect of social inequality. In Chapter 3 it is recognized that unemployment figures and the claimant count are politically sensitive and are grossly underestimated. The claimant count is described as one of the worst official statistics there is although the unemployment figures have been able to reflect contradictory trends within the previous 15 years. The Labour Force Survey has provided alternative information which lends itself to useful secondary analysis although caution should prevail as the definitions used reflect the interests of the state monitoring the labour market. Social class is covered in Chapter 4 which informs us about the historical context of social class measurement, which reflects status based upon productive and unproductive labour. This social grading is economic in its basis and does not include culture, status, power or esteem and has been mainly used for social stratification. Prior to 1991 The Registrar General's Classification of Occupations used for the basis of social class considered the economic head of household as being male. Women did not feature, which means the information and trends associated with women were not available in official statistics that governments used to base their policies. Technical modifications, particularly since 1971, have meant that some occupational groups have been lost and some have been added, rendering comparisons of populations on the basis of social class over time meaningless. As social class cannot measure the dynamics of social change, what we are really measuring is stratum or
hierarchical systems at one point in time. This absence of women from official statistics has helped forge the emerging body of knowledge on women's studies, feminism andxelated research. The absence of information on women or their views has led to official statistics being questioned and alternative research methods, predominantly qualitative methods, have been used to obtain their views and describe the context of important issues for women such as work, health, caring, and disability. For social scientists in general, the book also describes how the recognition of the limitations of quantitative data and statistics has contributed to the use of qualitative research methods for providing information on the contexts of health, poverty, unemployment and crime as well as class, gender, ethnicity and disability for populations and sub groups within populations. In Chapter 5 the issue of health and measuring health is covered. At present, official statistics deal mainly with mortality and better methods are required to measure morbidity and health, which are sensitive to cultural and behavioural differences, so that health services can be planned and targeted and population changes in health improvement may be evaluated over time. Chapter 6 looks at the monitoring of safety and accident rates in British Manufacturing and Chapter 7 goes on to look at working women in relation to part time work (which has been the main growth area in the last decade), ethnicity, social class, working mothers and the information available from official data sets. The Labour Force Survey provides important information on women and demonstrates the inequalities between men and women as well as the inequalities between women themselves. Chapter 8 covers ethnicity and related social inequalities which are difficult to assess as it was only in the 1991 Census that a measure of independent group had been included. As the book points out, many people from black and ethnic minorities did not make a return and it is too early to say what the effects of racial disadvantage and social inequalities are. Disability is covered in Chapter 9, which contends that disability is a social construct and the preponderance of a medical model definition has meant that data (claimed to be made on an oppressive theory) have been collected on (in)ability rather than addressing how society disables impaired people. The present government may do well to reflect on this. There is evidence that disability causes poverty. Finally, in Chapter 10 crimes and victimisation are covered where it contends that crime and deviance are behaviours people wish to hide, by stealth and disguise, and so they are difficult to measure. Unreported crime is difficult to record and can be captured from regular crime surveys. Evidence was cited that property crime drops when economic indicators improve while violent crime becomes worse.
Book reviews
Each chapter provides a useful introduction and conclusion and the main introduction to the book sets the context of social science and social statistics. This is an excellent book, which I highly recommend.
Brenda Roe The New Dictionary of Medical Ethics M. Boyd, R Higgs,A.J. Pinching (eds) BMJ Publishing, 1997 ISBN: 0 7279 1001 9, Price: s 19.95 As straight-forward textbooks on ethics are no longer selling well, dictionaries on ethics have become popular. Perhaps the realization that ethics cannot be taught like anatomy, and that wider access is needed by many more people than would read a textbook has made this form of book attractive. The original Dictionary of Medical Ethics was published in 1977, and the present editors (a different editorial team and a different publisher) have deliberately taken a different format and approach while building on the original text. With around 700 entries, the New Dictionary of Medical Ethics is an impressive work, as is the list of contributors. The contributors are only listed by name, not by job, so it is a question of picking out the names recognized rather than identifying professions. Inevitably, I first turned to the entries on nursing. 'nursing education' is a long entry compared to some others. Sadly, I found this entry to have a negative ring about it, detailing what used to happen and not mentioning Project 2000. On the other hand, the entry under 'nursing' is excellent and to the point. The cross-references given under 'nursing' are an interesting insight into some other entries in the book: 'accountability'; 'care'; 'codes'; 'competence to practice'; 'duty of care'; 'guidelines'; 'healthcare systems'; 'health education'; 'holistic'; 'incompetent professionals'; 'misconduct'; 'multidisciplinary teams'; 'nurse education'; 'professionalism'; 'quality assurance'; and 'statutory bodies'. Other entries which are intriguing to find in such a volume are 'humour', 'jester', 'parsimony', and 'heartsink patients'. The concluding sentence under this last title is: 'Difficult patients' are usually the creation of 'difficult professionals'. The entries are written in a very easy, sometimes snappy, style that is refreshing. There is no verbiage. Indeed, many of the entries are very short and certainly to the point. This is much to be commended and actually makes this book almost compulsive reading. This dictionary is unlikely to be bought by individual nurses unless they are studying the subject of ethics. But, libraries should have several copies because any nurse involved in academic study will benefit from concise definitions of so many subjects that touch on nursing, professional caring, and ethics.
VerenaTschudin
5
Epidemiology for the Uninitiated D. Coggan, G. Rose D.J.P. Barker BMJ Publishing Group, 1997 ISBN 0 7279 I 102 3, Price: s The fourth edition of this popular text provides a concise and relatively accessible introduction, or aide memoire, to epidemiology. In the words of its authors it is 'an ABC of the epidemiological approach, its terminology and methods'. The first chapter introduces central underlying concepts such as epidemiology's focus on populations, the importance of careful population definition and the use of comparisons among groups. Most of the explanations are clear, but for the totally uniniated it might have been helpful to define, at this stage, rather than later such terms as false positive and bias. Additionally, an opportunity was lost to just briefly indicate the range of epidemiological approaches, i.e. traditional, clinical, social, and lay, which readers may encounter. Measures of disease frequency and the comparison of disease rates are covered in the second and third chapters. A clear explanation of the difference between prevalence and incidence is provided and this would be useful to many nurses who may erroneously use these concepts interchangeably. Although the discussion of disease classification, measures of risk and methods of standardization is perfectly sound one wonders if any practitioners, medical or nursing, would make such calculations. However, a clear understanding of these issues is helpful when evaluating epidemiologicai research papers. Of more interest, since it may be applied in research more generally, is the discussion in chapter four of bias, validity and repeatability. Chapter five covers the planning and conduct of surveys and offers much sound practical as well as theoretical advice, e.g. avoiding the temptation to use statistical packages without prior consultation with a statistician. By necessity, discussion of the topics is limited and readers would do well to seek further information/advice if they intend to conduct a survey. Two quibbles: 9
9
Firstly, the table discussing confidence limits is not particularly self-explanatory, especially for those with limited statistical skills. Secondly, some advice concerning how data from open ended questions should be handled for analysis would be welcome.
The next four chapters contain concise descriptions of the principal epidemiological studies, including those perhaps most familiar to nurses: case-control, cohort and experimental designs. The latter is particularly pertinent since the current NHS R & D budget focuses much of its efforts on issues of effectiveness, with RCTs being perceived as the design of choice. A greater use of simple diagrams might have conveyed the essence of these different approaches to the novice epidemiologist.
the issues; however, choice and responsibility could have been explored. The reviewer believes this would have added to the depth of the chapters and represented the reality of the clinical environment, where anaesthetists work not in isolation but in partnership with women, midwives and obstetricians.
Wendy Jessiman Lecturer Practitioners in Action Judith Lathlean Butterworth Heinemann, 1997 ISBN: 0 7506 2449 3, Price: s 15.99 This book reports a 4-year research study of lecturer practitioners (LPs). Nationally, the number of LPs is steadily rising. The premise is that the practitioner who works in the clinical as well as the educational setting, is ideally placed to bridge the theory-practice gap. The main piece of research underpinning this book is a small scale, in depth qualitative study of LPs, which was triangulated with interviews with colleagues and students of the LPs, and a postal survey of all LPs in post at the time. The aim of the book is to describe what it is like to be a lecturer practitioner, and this it achieves. Thorough accounts are given of the way in which the lives of six LPs are organized. The strength of the book lies in its intricate detail. I would recommend it to LPs who are interested in how colleagues in a similar position organize their work, or to anyone who is in the process of conducting or writing up a piece of qualitative research. The book reads very much like a thesis. A review of the literature explores the background to the development of the LR and a methods chapter describes in detail the principles and processes of data collection. The middle section of the book contains descriptive accounts of 'being a lecturer practitioner', 'lecturer practitioners and student learning' and 'theory and practice' ('findings' Chapters 4, 5 and 6 respectively). Chapter 7, the final findings chapter, is rather more analytical in its exploration of the viability of the role of the LP. Particularly interesting were the interview data from the colleagues and students of the LPs. The LPs were able to explain the process of being an LP, but it was the accounts of their colleagues and students that began to illustrate their achievements. Chapter 8, entitled 'conclusions and beyond', presents a short discussion of the implications of the findings. Although Lathlean suggests that the reader might skip or skim the methods chapter, for the research minded it is essential reading; not least because such detailed accounts of qualitative methods are all too infrequent. In the 'findings' chapters Lathlean describes in great detail the ways in which the LPs organized their work and, to an extent, analysis of the data is left to the reader. Any difficulty experienced in following these detailed descriptions is offset by a thorough explanation of why the study was carried out and presented in this
49
way, which is found in the philosophy of Lathlean as 'ethnographer'. The accounts of the LPs are presented unadorned in her attempt neither to influence the data during collection, nor in the reporting. What is missing in Lathlean's approach, however, is an analysis of the data throughout the findings by, for example, drawing parallels with other literature, or setting the data in a policy context or, for the readership of this journal, relating it to the concepts of evidence-based practice and clinical effectiveness. This is the main weakness of the book, which gives it the impression of being rather out of date. This may in part be because the data were collected between 1989 and 1994, and a lot has happened in the world of the LP since then, yet I would contend that Lathlean could have made links with current contextual issues. I was left wondering whether the employment of LPs can help to bridge the theory-practice gap, and contribute to clinically effective practice. I was unclear about what the LPs in the study even meant by 'theory': was this sociological or psychological theory perhaps, or were they also talking about research evidence? The emphasis by the LPs on organizational issues at the expense of the application of research to practice may be rather discouraging to the readers of this journal. But Lathlean was reporting a small study and her findings might not reflect current duaI roles in the health service. It is clear that the role of the LP is an important topic for further research and this book starts that process.
Jane Griffiths Interpreting Official Statistics R. Levitas,W. Guy (eds) Routledge, 1996 ISBN 0 415 10836 5, Price s 13.99 The title of this book does little to inspire the reader; however, I would suggest perseverance as the contents of the book are essential reading for anyone undertaking nursing research or health services research at either undergraduate or postgraduate level. It is also useful reading for health professionals in public health and primary care taking forward current health policy, as it covers national statistics on health, poverty, unemployment and crime as well as the social divisions of class, gender, ethnicity and disability. The book is well written and affordable. It is edited by Ruth Levitas and WitI Guy and comprises 10 chapters with eight of the contributing authors all coming from the sociology department of the University of Bristol. The book contains detailed analyses of key official data sets, such as Households Below Average Income, Administrative and Survey Measures of Unemployment and Crime, General Household Survey, Population Census Data on Ethnicity, Data Sources on Women and Work, The Relationship
51}
Clinical EffectJveness in Nursing
Between Class and Health, and Safety at Work, the Disability and the Labour Force Survey. As well as analyses, the book also covers ways in, which information has been suppressed, manipulated or misinterpreted since 1979. The first chapter sets the book in context and covers the growth of official statistics and the 1980 Rayner Review of the Government Statistical Service within the UK. This review led to cuts in the service resulting in problems with the reliability of official statistics quoted by government ministers and loss of public confidence in official data. In 1996 the Central Statistical Office (CSO) and the Office of Population Censuses and Surveys (OPCS) were merged to form the Office for National Statistics (ONS) with its Director being Registrar General for England and Wales as well as the Director of the CSO and Head of OPCS. The second chapter deals with poverty and details how government manipulation of the statistics can paint a positive picture when the reality is somewhat different. The thresholds for poverty (sometimes also termed inequality) are selectively arbitrary within and between countries and between governments. It is argued that new scientific criteria and alternative definitions and measures of poverty are required in order to be able to measure trends and accurately reflect this aspect of social inequality. In Chapter 3 it is recognized that unemployment figures and the claimant count are politically sensitive and are grossly underestimated. The claimant count is described as one of the worst official statistics there is although the unemployment figures have been able to reflect contradictory trends within the previous 15 years. The Labour Force Survey has provided alternative information which lends itself to useful secondary analysis although caution should prevail as the definitions used reflect the interests of the state monitoring the labour market. Social class is covered in Chapter 4 which informs us about the historical context of social class measurement, which reflects status based upon productive and unproductive labour. This social grading is economic in its basis and does not include culture, status, power or esteem and has been mainly used for social stratification. Prior to 1991 The Registrar General's Classification of Occupations used for the basis of social class considered the economic head of household as being male. Women did not feature, which means the information and trends associated with women were not available in official statistics that governments used to base their policies. Technical modifications, particularly since 1971, have meant that some occupational groups have been lost and some have been added, rendering comparisons of populations on the basis of social class over time meaningless. As social class cannot measure the dynamics of social change, what we are really measuring is stratum or
hierarchical systems at one point in time. This absence of women from official statistics has helped forge the emerging body of knowledge on women's studies, feminism andxelated research. The absence of information on women or their views has led to official statistics being questioned and alternative research methods, predominantly qualitative methods, have been used to obtain their views and describe the context of important issues for women such as work, health, caring, and disability. For social scientists in general, the book also describes how the recognition of the limitations of quantitative data and statistics has contributed to the use of qualitative research methods for providing information on the contexts of health, poverty, unemployment and crime as well as class, gender, ethnicity and disability for populations and sub groups within populations. In Chapter 5 the issue of health and measuring health is covered. At present, official statistics deal mainly with mortality and better methods are required to measure morbidity and health, which are sensitive to cultural and behavioural differences, so that health services can be planned and targeted and population changes in health improvement may be evaluated over time. Chapter 6 looks at the monitoring of safety and accident rates in British Manufacturing and Chapter 7 goes on to look at working women in relation to part time work (which has been the main growth area in the last decade), ethnicity, social class, working mothers and the information available from official data sets. The Labour Force Survey provides important information on women and demonstrates the inequalities between men and women as well as the inequalities between women themselves. Chapter 8 covers ethnicity and related social inequalities which are difficult to assess as it was only in the 1991 Census that a measure of independent group had been included. As the book points out, many people from black and ethnic minorities did not make a return and it is too early to say what the effects of racial disadvantage and social inequalities are. Disability is covered in Chapter 9, which contends that disability is a social construct and the preponderance of a medical model definition has meant that data (claimed to be made on an oppressive theory) have been collected on (in)ability rather than addressing how society disables impaired people. The present government may do well to reflect on this. There is evidence that disability causes poverty. Finally, in Chapter 10 crimes and victimisation are covered where it contends that crime and deviance are behaviours people wish to hide, by stealth and disguise, and so they are difficult to measure. Unreported crime is difficult to record and can be captured from regular crime surveys. Evidence was cited that property crime drops when economic indicators improve while violent crime becomes worse.
Book reviews
Each chapter provides a useful introduction and conclusion and the main introduction to the book sets the context of social science and social statistics. This is an excellent book, which I highly recommend.
Brenda Roe The New Dictionary of Medical Ethics M. Boyd, R Higgs,A.J. Pinching (eds) BMJ Publishing, 1997 ISBN: 0 7279 1001 9, Price: s 19.95 As straight-forward textbooks on ethics are no longer selling well, dictionaries on ethics have become popular. Perhaps the realization that ethics cannot be taught like anatomy, and that wider access is needed by many more people than would read a textbook has made this form of book attractive. The original Dictionary of Medical Ethics was published in 1977, and the present editors (a different editorial team and a different publisher) have deliberately taken a different format and approach while building on the original text. With around 700 entries, the New Dictionary of Medical Ethics is an impressive work, as is the list of contributors. The contributors are only listed by name, not by job, so it is a question of picking out the names recognized rather than identifying professions. Inevitably, I first turned to the entries on nursing. 'nursing education' is a long entry compared to some others. Sadly, I found this entry to have a negative ring about it, detailing what used to happen and not mentioning Project 2000. On the other hand, the entry under 'nursing' is excellent and to the point. The cross-references given under 'nursing' are an interesting insight into some other entries in the book: 'accountability'; 'care'; 'codes'; 'competence to practice'; 'duty of care'; 'guidelines'; 'healthcare systems'; 'health education'; 'holistic'; 'incompetent professionals'; 'misconduct'; 'multidisciplinary teams'; 'nurse education'; 'professionalism'; 'quality assurance'; and 'statutory bodies'. Other entries which are intriguing to find in such a volume are 'humour', 'jester', 'parsimony', and 'heartsink patients'. The concluding sentence under this last title is: 'Difficult patients' are usually the creation of 'difficult professionals'. The entries are written in a very easy, sometimes snappy, style that is refreshing. There is no verbiage. Indeed, many of the entries are very short and certainly to the point. This is much to be commended and actually makes this book almost compulsive reading. This dictionary is unlikely to be bought by individual nurses unless they are studying the subject of ethics. But, libraries should have several copies because any nurse involved in academic study will benefit from concise definitions of so many subjects that touch on nursing, professional caring, and ethics.
VerenaTschudin
5
Epidemiology for the Uninitiated D. Coggan, G. Rose D.J.P. Barker BMJ Publishing Group, 1997 ISBN 0 7279 I 102 3, Price: s The fourth edition of this popular text provides a concise and relatively accessible introduction, or aide memoire, to epidemiology. In the words of its authors it is 'an ABC of the epidemiological approach, its terminology and methods'. The first chapter introduces central underlying concepts such as epidemiology's focus on populations, the importance of careful population definition and the use of comparisons among groups. Most of the explanations are clear, but for the totally uniniated it might have been helpful to define, at this stage, rather than later such terms as false positive and bias. Additionally, an opportunity was lost to just briefly indicate the range of epidemiological approaches, i.e. traditional, clinical, social, and lay, which readers may encounter. Measures of disease frequency and the comparison of disease rates are covered in the second and third chapters. A clear explanation of the difference between prevalence and incidence is provided and this would be useful to many nurses who may erroneously use these concepts interchangeably. Although the discussion of disease classification, measures of risk and methods of standardization is perfectly sound one wonders if any practitioners, medical or nursing, would make such calculations. However, a clear understanding of these issues is helpful when evaluating epidemiologicai research papers. Of more interest, since it may be applied in research more generally, is the discussion in chapter four of bias, validity and repeatability. Chapter five covers the planning and conduct of surveys and offers much sound practical as well as theoretical advice, e.g. avoiding the temptation to use statistical packages without prior consultation with a statistician. By necessity, discussion of the topics is limited and readers would do well to seek further information/advice if they intend to conduct a survey. Two quibbles: 9
9
Firstly, the table discussing confidence limits is not particularly self-explanatory, especially for those with limited statistical skills. Secondly, some advice concerning how data from open ended questions should be handled for analysis would be welcome.
The next four chapters contain concise descriptions of the principal epidemiological studies, including those perhaps most familiar to nurses: case-control, cohort and experimental designs. The latter is particularly pertinent since the current NHS R & D budget focuses much of its efforts on issues of effectiveness, with RCTs being perceived as the design of choice. A greater use of simple diagrams might have conveyed the essence of these different approaches to the novice epidemiologist.