researcher bias concerns in qualitative research

How to Avoid Bias in Qualitative Research

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Research bias occurs when researchers try to influence the results of their work, in order to get the outcome they want. Often, researchers may not be aware they are doing this. Whether they are aware or not, such behavior clearly severely affects the impartiality of a study and greatly reduces the value of the results.

The Issues in Qualitative Research

Recently, I discussed the problem of bias with a researcher friend.

“I heard that research bias is a bigger problem for qualitative research than quantitative research.”

“Why is that?”

“Qualitative research relies more on the experience and judgment of the researcher. Also, the type of data collected is subjective and unique to the person or situation. So it is much harder to avoid bias than in quantitative research.”

“Are there ways to avoid bias ?”

“A good start is to recognize that bias exists in all research. We can then try to predict what type of bias we might have in our study, and try to avoid it as much as possible.”

Types of Bias in Research

“Are there different types of bias to watch out for?”

• There’s design bias , where the researcher does not consider bias in the design of the study. Factors like sample size , the range of participants, for example – all of these can cause bias.
• Next there’s also selection or sampling bias . For example, you might omit people of certain ages or ethnicities from your study. This is called omission bias. The other type, inclusive bias, is when you select a sample just because it is convenient. For example, if the people you select for your study are all college students, they are likely to share many characteristics.”

“Are there more?”

“Yes, there are lots of different types of bias.

• There’s procedural bias , where the way you carry out a study affects the results. For example, if you give people only a short time to answer questions, their responses will be rushed.
• There’s also measurement bias that can happen if the equipment you are using is faulty, or you are not using it correctly.”

“That’s a lot to think about.”

“I can think of three more.

• There’s interviewer bias , which is very hard to avoid. This is when an interviewer subconsciously influences the responses of the interviewee. Their body language might indicate their opinion, for example.
• Furthermore, there’s response bias , where someone tries to give the answers they think are “correct.”
• Finally, there’s reporting bias . This is often outside the researcher’s control. It means that research with positive, or exciting, results is far more likely to be reported, so can seem more critical.”

How to Avoid Bias in Research

“With so many types of bias, how can it be avoided?”

“There are a number of things the researcher can do to avoid bias.

• Read the guidelines : Check the guidelines of your institution or sponsor and make sure you follow them.
• Think about our objectives : Plan your study early. Be clear about what you want to achieve, and how. This will help to avoid bias when you start collecting data.”

“And next?”

• Maintain records : Keep detailed records. This reduces the chance of making mistakes.
• Be honest when reporting : Make sure you include all your results in your report. Even the results that don’t seem important. Finally, be honest about the limitations of your study in your report.”

Avoiding Participant Bias

“That explains what researchers can do. But what about participant bias?”

“Try asking indirect questions. People might change their answers to direct questions to make a good impression. But if you ask them what a friend or colleague might think, you might get a more honest response.”

“Are open-ended questions useful?”

“Yes. They allow information to flow more freely, by not forcing a limited set of answers. But even these should be used with caution . You should try to be impartial about all parts of the study, and avoid implying that there is a right answer. It might help to ask people to rate their responses on a scale of 1-5, for example, rather than agree/disagree.”

Reducing Researcher Bias

“All researchers should try to avoid confirmation bias. This is when you interpret your data in a way that supports your hypothesis. Secondly, you should make sure to analyze all your data, even if it doesn’t seem useful. Finally, always get an independent person to check your work, ideally several times during your study.”

Identifying and avoiding research bias in qualitative research is clearly tricky, with many different factors to consider. However, it is also vital. Biased research has little value; it is a waste of researchers’ valuable time and resources.

Learn even more about bias here . How did you overcome bias in your research? Share your experiences and thoughts in the comment section below.

Can you please tell me who is the author of this article: How to Avoid Bias in Qualitative Research Last updated May 3, 2019

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The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada

• Samina Idrees 1 ,
• Gillian Young 1 ,
• Brian Dunne 2 ,
• Donnie Antony 2 ,
• Leslie Meredith 1 &
• Maria Mathews 1  

BMC Health Services Research volume  24 , Article number:  680 ( 2024 ) Cite this article

Metrics details

Person-centred planning refers to a model of care in which programs and services are developed in collaboration with persons receiving care (i.e., persons-supported) and tailored to their unique needs and goals. In recent decades, governments around the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery. Although regional mandates provide a framework for directing care, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. This study aims to address a gap in the literature by describing how person-centred care plans are implemented in community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Ontario, Canada. We asked participants about their organization’s approach to developing and updating person-centred care plans, including relevant supports and barriers. We analyzed the data thematically using a pragmatic, qualitative, descriptive approach.

We interviewed administrators from 12 community-care organizations. We identified three overarching categories or processes related to organizational characteristics and person-centred planning: (1) organizational context, (2) organizational culture, and (3) the design and delivery of person-centred care plans. The context of care and the types of services offered by the organization were directly informed by the needs and characteristics of the population served. The culture of the organization (e.g., their values, attitudes and beliefs surrounding persons-supported) was a key influence in the development and implementation of person-centred care plans. Participants described the person-centred planning process as being iterative and collaborative, involving initial and continued consultations with persons-supported and their close family and friends, while also citing implementation challenges in cases where persons had difficulty communicating, and in cases where they preferred not to have a formal plan in place.

Conclusions

The person-centred planning process is largely informed by organizational context and culture. There are ongoing challenges in the implementation of person-centred care plans, highlighting a gap between policy and practice and suggesting a need for comprehensive guidance and enhanced adaptability in current regulations. Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Peer Review reports

The community-care sector facilitates the coordination and administration of in-home and community-based health and social services. Community-care services include supports for independent living, residential services, complex medical care, and community-participation services to support personal and professional goals (e.g., education, employment, and recreation-based supports) [ 1 ]. There is substantial heterogeneity in the clinical and demographic characteristics of the community-care population, including individuals with physical and developmental disabilities, and complex medical needs [ 2 ]. We refer to the individuals served by these organizations as ‘persons-supported’ in line with person-first language conventions [ 3 , 4 ].

In recent decades, governments across the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery [ 5 , 6 , 7 , 8 ]. Person-centred care encompasses a broad framework designed to direct care delivery, as opposed to a singular standardized process. In the context of community-care, person-centred planning refers to a model of care provision in which programs and services are developed in collaboration with persons-supported and tailored to their unique needs and desired outcomes [ 9 , 10 ].

In Ontario, Canada, community-care services are funded by the Ministry of Health (MOH) and the Ministry of Children, Community and Social Services (MCCSS). Service agreements between these ministries and individual agencies can be complex and contingent on different factors including compliance with a number of regulatory items and policies [ 7 , 11 ]. MOH provides funding for health-based services including in-home physiotherapy, respiratory therapy, and personal support services, among several others. MOH funds Home and Community Care Support Services (HCCSS), a network of organizations responsible for coordinating the delivery of in-home and community-based care in the province. MCCSS funds social service agencies including those providing community participation and residential support for people with intellectual and developmental disabilities (IDDs).

Several tools and resources have been developed to aid organizations in providing person-centred care and organizations may differ in their use of these tools and their specific approach. Although regional mandates provide a framework for directing care delivery, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. In addition, as noted by a recent scoping review, there is limited literature on the implementation process and impact of person-centred planning on individual outcomes [ 12 ]. Using a pragmatic, qualitative, descriptive approach [ 13 ], we outline how community-care organizations enact a person-centred approach to care and the factors that shape their enactment. By describing existing practices in the context of the community-care sector, we aim to provide insight on how to optimize care delivery to improve outcomes and inform current policy. This study is part of a larger, multi-methods project examining the implementation of person-centred care plans in the community-care sector. This project encompasses qualitative interviews with representatives from different community-care organizations, as well as staff and persons-supported at a partner community-care organization. This paper focuses on analyzing data from interviews with representatives from different community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Southwestern Ontario (roughly the Ontario Health West Region) between October 2022 and January 2023. We included community-care organizations funded by MOH or MCCSS. We excluded organizations that did not provide services in Southwestern Ontario. We identified eligible organizations and participants by searching online databases, including community resource lists, as well as through consultation with members of the research team.

We used maximum variation sampling [ 14 ], to recruit participants from organizations with a wide range of characteristics including location (i.e., urban, rural), organization type (i.e., for-profit, not-for-profit), and types of services provided (e.g., residential, recreation, transportation, etc.) We contacted eligible organizations via email, providing them with study information and inviting them to participate. We recruited until the data reached saturation, defined as the point at which there was sufficient data to enable rigorous analysis [ 14 , 15 ].

In each interview, we asked participants about their organization’s approach to developing and updating individual service agreements or person-centred care plans, and the supports and barriers (e.g., organizational, funding, staffing, etc.) that facilitate or hinder the implementation of these plans (Supplementary Material 1 : Interview Guide). We also collected information on relevant participant and organizational characteristics, including participant gender, position, years of experience, organization location, type (i.e., for-profit, not-for-profit), services offered, years in operation, and client load. The interviews were approximately one hour in length and conducted virtually via Zoom (Zoom Video Communications Inc.) or by telephone. The interviews were audio-recorded and transcribed verbatim. Interviewer field notes were also used in data analysis.

We analyzed the data thematically [ 16 ]. The coding process followed a collaborative and multi-step approach. Initially, three members of the research team independently reviewed and coded a selection of transcripts to identify key ideas and patterns in the data, and form a preliminary coding template. We then met to consolidate individual coding efforts. We compared coding of each transcript, resolving conflicts through discussion and consensus. In coding subsequent transcripts and through a series of meetings, we worked together to finalize the codebook to reflect more analytic codes. We used the finalized template to code all interview transcripts in NVivo (QSR International), a software designed to facilitate qualitative data analysis. We refined the codebook on an as-needed basis by incorporating novel insights gleaned from the coding of additional transcripts, reflecting the iterative nature of the analysis.

We increased the robustness of our methodology by pre-testing interview questions, documenting interview and transcription protocols, using experienced interviewers, and confirming meaning with participants in interviews [ 14 , 15 , 16 ]. We kept detailed records of interviews, field notes, and drafts of the coding template. We made efforts to identify negative cases and provided rich descriptions and illustrative quotes [ 17 ]. We included individuals directly involved in the administration of community-care services on our research team. These individuals provided important context and feedback at each stage of the research process.

This study was approved by the research ethics board at Western University. We obtained informed consent from participants prior to the onset of interviews. We maintained confidentiality through secure storage of interview data (e.g., audio recordings), password-protection of sensitive documents, and the de-identification of transcripts.

Positionality

The authors represent a multidisciplinary team of researchers, clinicians, and community-care leaders. The community-care leaders and clinicians on our team provided key practical expertise to inform the development of interview questions and the analysis of study findings.

We interviewed administrators across 12 community-care organizations in Southwestern Ontario. The sample included representatives from seven organizations that received funding from MCCSS, three organizations that received funding from MOH, and two organizations that received funding from both MCCSS and MOH (Table  1 ). Eleven organizations were not-for-profit, one was a for-profit agency. The organizations provided care in rural ( n =  3), urban ( n =  4), or both rural and urban populations ( n =  5). Seven of the 12 participants were women, nine had been working with their organization for more than 11 years, and all had been working in the community-care sector for more than 12 years (Table  2 ).

We identified three key categories or processes relating to organizational characteristics and their impact on the design and delivery of person-centred care plans: (1) organizational context, (2) organizational culture, and (3) the development and implementation of person-centred care plans.

Organizational context

Organizational context refers to the characteristics of persons-supported, and the nature of services provided. Organizational context accounts for the considerable heterogeneity across organizations in the community-care sector and their approach to person-centred care plans.

Populations served

The majority of organizations included in the study supported individuals with IDDs: “all of the people have been identified as having a developmental disability. That’s part of the eligibility criteria for any funded developmental service in Ontario.” [P10]. Participants described how eligibility was ascertained through the referral process: “ the DSO [Developmental Services Ontario] figures all of that out and then refers them to us .” [P08]. These descriptions highlighted a common access point for publicly-funded adult developmental services in the province. Accordingly, these organizations were primarily funded by MCCSS. Other organizations focused on medically complex individuals including those with acquired brain injuries or those unable to access out-patient services due to physical disabilities: “the typical reason for referral is going to be around a physical impairment… But, with this medically complex population, you’re often seeing comorbidities where there may be some cognitive impairment, early dementia.” [P04]. In these organizations, eligibility and referral were usually coordinated by HCCSS. These insights highlighted the diverse characteristics of community-care populations, emphasizing the need to consider both physical and cognitive health challenges in care provision approaches.

Services offered

The characteristics of persons-supported informed the context of care and the type of services offered by the organization. The different dimensions of services offered within this sector include social and medical care, short and long-term care provision, in-home and community-care, and full and part-time care.

Nature of care: social vs. medical

Many organizations serving individuals with IDDs employed a holistic, psychosocial model of care, designed to support all areas of an individual’s life including supports for independent-living, and community-based education, employment, and recreation services to support personal and professional goals: “we support people in their homes, so residential supports. We also support people in the community, to be a part of the community, participate in the community and also to work in the community.” [P06]. These descriptions reflect a comprehensive approach to care, aiming to address needs within and beyond residential settings to promote active participation within the broader community. In contrast, some organizations followed a biomedical model of care, designed to support specific health needs: “We provide all five therapies… physiotherapy, occupational therapy, speech, social work, and nutrition. In some locations we provide visiting nursing, at some locations shift nursing. We have some clinic-nursing… and we provide personal support and home-making services in a number of locations as well.” [P04]. These organizations adopted a more clinically-focused approach to care. In either instance, the care model and the nature of services offered were largely determined by an organization’s mandate including which gaps they aimed to fill within the community. Many organizations described providing a mixture of social and medical care for individuals with complex needs. However, the implementation of care plans could be impacted by the lack of integration between social and medical care sectors, as some participants spoke to the importance of “[integrating] all of the different healthcare sector services… [including] acute care and public health and home and community care and primary care, and mental health and addictions.” [P04].

Duration of care: short-term vs. long-term

The duration of care also varied based on the needs of persons-supported. Organizations serving individuals with IDDs usually offered support across the lifespan: “We support adults with developmental disabilities and we support them from 18 [years] up until the end of their life.” [P06]. Some organizations provided temporary supports aimed at addressing specific health needs: “For therapies – these are all short-term interventions and typically they’re very specific and focused on certain goals. And so, you may get a referral for physiotherapy that is authorized for three visits or five visits” [P04], or crisis situations (e.g., homelessness): “Our services are then brought in to help provide some level of support, guidance, stabilization resource, and once essentially sustainability and positive outcomes are achieved—then our services are immediately withdrawn.” [P12]. One organization employed a model of care with two service streams, an initial rehabilitation stream that was intended to be short-term and an ongoing service stream for individuals requiring continuing support.

In-home vs. community-based care

Many organizations provided in-home care and community-based supports, where residential supports were designed to help individuals lead independent lives, and community-based supports encouraged participation in community activities to further inclusion and address personal and professional goals. One participant spoke about the range of services offered in the home and community:

“There’s probably two big categories of [services we offer]: community support services—so that includes things like adult day programs, assisted living, meals on wheels, transportation, friendly visiting … and things like blood pressure clinics, exercise programs… and then on the other side we do home care services. In the home care basket, we provide personal support, and we also provide social work support.” [P05].

Likewise, another participant spoke in further detail on the types of services that allow individuals to live independently within their homes, or in community-based residential settings (e.g., long-term care facilities):

“We provide accommodation supports to about 100 people living in our community—which means that we will provide support to them in their own homes. So, anywhere from an hour a week to 24 hours a day. And that service can include things from personal care to home management to money management, cooking, cleaning, and being out and about in communities—so community participation. We also provide supports for about 50 people living in long-term care facilities and that is all community participation support. So, minus the last 2 and a half years because of the pandemic, what that means is that a person living in a long-term care facility with a developmental disability can have our support to get out and about for 2 or 3 hours a week, on average.” [P10].

Full-time vs. part-time support

The person-supported’s needs also determined whether they would receive care within their homes and if they would be supported on a full-time (i.e., 24 h a day, 7 days a week) or part-time basis:

“ It really does range from that intensive 24- hour/7 day a week support, which we actually do provide that level of intense support in the family home, if that’s needed. And then, all the way through to just occasional advocacy support and phone check-in.” [P01].

Organizational Culture

Organizational culture was described as a key influence in the development and implementation of person-centred care plans. The culture of the organization includes their perceptions, attitudes and beliefs surrounding persons-supported; their model of care provision; as well as their willingness to evolve and adapt service provision to optimize care delivery.

Perceptions, attitudes, and beliefs regarding persons-supported

Participants described their organization’s view of persons-supported, with many organizations adopting an inclusionary framework where persons-supported were afforded the same rights and dignities as others in the community. This organizational philosophy was described as being deeply intertwined with an organization’s approach to personalizing programs and services:

“…an organization needs to be able to listen to the people who are receiving the service… and support them, to learn more, figure out, articulate, whatever it is, the service or the supports that they need in order to get and move forward with their life.” [P10].

The focus on the person-supported, their needs, likes, and dislikes, was echoed across organizations, with an emphasis on the impact of “culture and trying to embed for each person who delivers service the importance of understanding the individual.” [P05]. Participants also described their organization’s approach to allowing persons-supported to take risks, make mistakes, and live life on their own terms:

“You have to go and venture out and take some [risks]… We try to exercise that philosophy - people with disabilities should have the same rights and responsibilities as other people in the community. Whether that’s birthing or education, getting a job, having a house they can be proud of, accessing community supports, whether that be [a] library or community centre, or service club, whatever that is.” [P03].

Model of care provision

The model of care provision was heavily influenced by the organization’s values and philosophy. Several organizations employed a flexible model of care where supports were developed around the needs, preferences, and desired outcomes of the person-supported:

“…if we don’t offer [the program they want], we certainly build it. Honestly, most of our programs were either created or built by someone coming to us [and] saying ‘I want to do this with my life,’ or …‘my son would like to do art.’” [P02].

Although there were similarities in models across the different organizations, one participant noted that flexibility can be limited in the congregate care setting as staff must tend to the needs of a group as opposed to an individual:

“Our typical plan of operation outside of the congregate setting is we design services around the needs of the person. We don’t ask them to fit into what we need, we build services for what they need. Within the congregate care setting, we have a specific set of rules and regulations for safety and well-being of the other people that are here.” [P11].

Evolving service orientation

In organizations serving individuals with IDDs, many described shifting from program-based services to more individualized and community-based supports: “The goal was always to get people involved in their community and build in some of those natural supports … [we] are looking to support people in their own communities based on their individual plans.” [P07]. One participant described this model as a person-directed approach as opposed to person-centred, citing the limitations of program-based services in meeting individual needs:

“[Persons-supported] couldn’t [do] what they wanted because they were part of a bigger group. We would listen to the bigger group, but if one person didn’t want to go bowling … we couldn’t support them because everybody had to go bowling.” [P06].

The focus on individualized support could potentially lead to increased inclusion for persons-supported in their communities:

“… people go to Tim Horton’s, and if they go every day at 9 they probably, eventually will meet other people that go at 9 o’clock and maybe strike up a conversation and get to know somebody and join a table … and meet people in the community.” [P02].

By creating routines centred on individual preferences, the person-supported becomes a part of a community with shared interests and values.

Person-centred care plans

Community-care organizations enacted a person-centred approach by creating person-centred care plans for each person-supported. Although all participants said their organization provided person-centred services, there was considerable variation in the specific processes for developing, implementing, and updating care plans.

Developing a person-centred care plan

The development of a care plan includes assessment, consultation, and prioritization. The initial development of the care plan usually involved an assessment of an individual’s needs and goals. Participants described agency-specific assessment processes that often incorporated information from service referrals: “ In addition to the material we get from the DSO [Disability Services Ontario] we facilitate the delivery of an intake package specifically for our services. And that intake package helps to further understand the nature and needs of an individual.” [P12]. Agency-specific assessment processes differed by the nature of services provided and the characteristics of the population. However, most organizations included assessments of “not only physical functioning capabilities, but also cognitive.” [P01]. Assessment also included an appraisal of the suitability of the organization’s services. In instances where persons-supported were seeking residential placements or independent-living support, organizations assessed their ability to carry out the activities of daily living:

“[Our internal assessment] is an overview of all areas of their life. From, ‘do they need assistance with baking, cooking, groceries, cleaning, laundry? Is there going to be day program opportunities included in that residential request for placement? What the medical needs are?’” [P02].

In contrast, the person-supported’s community-based activities were primarily informed by their interests and desired outcomes: “We talk about what kinds of goals they want to work on. What kind of outcomes we’re looking for…” [P06].

The development of the care plan also included a consultation phase, involving conversations with the person-supported, their family members, and potentially external care providers: “We would use the application information, we’d use the supports intensity scale, but we’d also spend time with the person and their connections, their family and friends, in their home to figure out what are the kinds of things that this person needs assistance with.” [P10]. Participants described the person-supported’s view as taking precedence in these meetings: “We definitely include the family or [alternate] decision-maker in that plan, but the person-supported ultimately has the final stamp of approval.” [P08]. Many participants also acknowledged the difficulty of identifying and incorporating the person-supported’s view in cases where opinions clash and the person-supported has difficulty communicating and/or is non-verbal: “Some of the people we support are very good at expressing what they want. Some people are not. Some of our staff are really strong in expressing what they support. …And some of the family members are very strong. So you have to be very careful that the [person-supported] is not being lost in the middle of it.” [P06].

Participants also noted that some persons-supported preferred not to have a care plan:

“Some of the people say ‘I hate [the plans] I don’t want to do them’…. we look at it in a different way then. We’ll use graphic art, we’ll use video, we’ll think outside the box to get them to somehow—because at the end of the day when we’re audited by MCCSS every [person-supported] either has to have [a plan]… or there has to be [an approval of] why it wasn’t completed.” [P02].

Plan development may also include a prioritization process, particularly in cases where resources are limited. A person-supported’s goals could be prioritized using different schemas. One participant noted that “the support coordinator takes the cue from the person-supported - … what they’ve identified as ‘have to have’ and ‘nice to have’. … because the ‘have to haves’ are prioritized.” [P09]. Likewise, the person-supported’s preference could also be identified through “[an] exercise, called ‘what’s important for and what’s important to .’” [P06]. This model, based on a Helen Sanderson approach [ 18 ], was described as being helpful in highlighting what is important to the person-supported, as opposed to what others (i.e., friends, family, staff, etc.) feel is important for them.

Several organizations updated care plans throughout the year, to document progress towards goals, adapt to changing needs and plan for future goals: “We revisit the plan periodically through the year. And if they say the goal is done, we may set another goal.” [P06]. Organizations may also change plans to adapt to the person-supported’s changing health status or personal capacity.

Implementing a person-centred care plan

The implementation of care plans differed based on the nature of services provided by the organization. The delivery of health-based or personal support services often involved matching the length and intensity of care with the individual’s needs and capacity:

“Sometimes that is a long time, sometimes it’s a short time, sometimes it’s an intervention that’s needed for a bit, and then the person is able to function.” [P05].

In contrast, the delivery of community-based services involved matching activities and staff by interests: “[if] a person-supported wants to go out and be involved in the music community, then we pull the staff pool in and match them up according to interest.” [P06].

Broad personal goals were broken down into smaller, specific activities. For example, one participant described their organization’s plan in helping a person-supported achieve his professional goal of securing employment:

“[The person-supported] said ‘Okay, I want a job.’ So for three weeks he was matched up with a facilitator. They came up with an action plan in terms of how to get a job, what kind of job he’s looking for, where he wants to go, where he wants to apply, how to conduct an interview. And after three weeks he got a job.” [P09].

Organizations that provided residential services focused on developing independent-living skills. One participant described their organization’s plan to empowering persons-supported by allowing them to make their own financial decisions:

“If one month they’re looking after their own finances, and they’ve overspent. Well, maybe we help them out with a grocery card or something and say ‘okay, next month how are you going to do this?’ [The person-supported may say], ‘well, maybe I’ll put so much money aside each week rather than doing a big grocery shop the first week and not having enough money left at the end of the month.’” [P03].

The participant noted that “a tremendous amount of learning [happens] when a person is allowed to [take] risks and make their own decisions.” [P03].

Likewise, participants representing organizations that provided residential services described tailoring care to the persons-supported’s sleeping schedule and daily routine:

“We develop a plan and tweak it as we go. With [the person-supported] coming to the home, what worked well was, we found that he wanted to sleep in, so we adjusted the [staff] time. We took a look at his [medication] times in the morning… and [changed] his [medication] times. We found that he wanted to sleep [until] later in the day, so he would get up at 10 o’clock, so then instead of having breakfast, lunch, and supper he would just have a bigger brunch. Just really tailoring the plan around the person-supported, and it’s worked out well.” [P08].

These examples highlight how organizational context and culture influence how organizations operationalize person-centred care plans; the same individual may experience different approaches to care and engage in different activities depending on the organization they receive services from.

In this paper, we described key elements of the person-centred planning process across different community-care organizations in Southwestern Ontario. We also identified that the context and culture of an organization play a central role in informing the process by which services are personalized to an individual’s needs. These findings shed light on the diversity of factors that influence the implementation of person-centred care plans and the degree to which organizations are able to address medical and social needs in an integrated fashion. They also inform future evaluations of person and system-related outcomes of person-centred planning.

There are regulations around individualizing services delivered by community-care organizations, whereby care providers must allow persons-supported to participate in the development and evaluation of their care plans. HCCSS or MOH-funded services are largely focused on in-home rehabilitation or medical care. In contrast, MCCSS-funded organizations often focus on developing independent living skills or promoting community participation, thus highlighting the role of the funding agency in determining organizational context as well as the nature of services and personalization of care plans.

We also identified organizational culture as a key influence in the person-centred planning process. In previous reports, organizational culture, and specifically the way in which staff perceive and view persons-supported and their decision-making capabilities can impact the effective delivery of person-centred care [ 19 ]. Staff support, including their commitment to persons-supported and the person-centred process, has been regarded as one of the most powerful predictors of positive outcomes and goal attainment in the developmental services sector [ 20 , 21 ]. Moreover, in order to be successful, commitment to this process should extend across all levels of the organization, be fully integrated into organizational service delivery, and be reflected in organizational philosophy, values and views of persons-supported [ 22 , 23 , 24 ].

MCCSS mandates that agencies serving individuals with IDDs develop an individual service plan (ISP) for each person-supported, one “that address[es] the person’s goals, preferences and needs.” [ 7 ]. We reference ISPs as person-centred care plans, as is in line with the view of participants in interviews. There are a series of checklists designed to measure compliance with these policies, and the process is iterative, with mandated annual reviews of care plans and active participation by the person-supported [ 25 ]. In our study, the agencies funded by MCCSS adhered to the general framework outlined by these regulations and informed service delivery accordingly. However, participants also described areas for improvement with respect to the implementation of these policies in practice. These policies, while well-intentioned, may imply a one-size-fits-all approach and appear more as an administrative exercise as opposed to a meaningful endeavor designed to optimize care. Participants spoke about individuals who preferred not to have an ISP, and how that in and of itself is a person-centred approach, respecting the person’s wishes. Additionally, we heard about how the goal-setting process may not be realistic as it can be perceived as unnatural to have goals at each point in one’s life. Moreover, participants noted challenges in implementing person-centred care in shared residential settings (e.g., group homes) or in cases where persons-supported had difficulty communicating.

Prior research indicates that individuals living in semi-independent settings fare better across several quality-of-life measures relative to individuals living in group homes, including decreased social dissatisfaction, increased community participation, increased participation in activities of daily living, and increased empowerment [ 26 ]. Furthermore, a recent study by İsvan et al. (2023) found that individuals living in the community (e.g., own home, family home, or foster home) exhibit greater autonomy in making everyday and life decisions, and greater satisfaction with their inclusion in the community [ 27 ]. These findings may be indicative of a reduced focus on person-centred care plan development and implementation in congregate care settings, where limited staff capacity can make it difficult to tend to the needs of everyone in the home. However, poor outcomes may also be explained by potentially more complex health challenges or more severe disability in persons-supported living in congregate care settings. The challenges described in our study are consistent with calls to improve the quality of care provided in residential group home settings [ 28 , 29 ].

In line with our findings, previous literature also describes challenges in implementing person-centred planning for individuals who have difficulty communicating or are non-verbal [ 19 , 30 , 31 , 32 ]. Communication has also been identified as a barrier to patient-centred care for adults with IDDs in healthcare settings [ 33 , 34 ]. Other reports have identified a need for increased training and awareness of diverse communication styles (including careful observation of non-verbal cues) to aid staff in including persons-supported in the development of care plans [ 35 , 36 , 37 ]. Importantly, these methods take substantial time which is often limited, and compounded by staffing shortages that are widespread across the sector [ 38 ]. Similar barriers were identified in interviews with staff and persons-supported at a partner community-care agency within our larger project [ 39 ]; other papers from the project examine strategies used by the organization to overcome these barriers.

Limitations

The findings from this study should be interpreted in the context of the following limitations. There is a risk for social desirability bias, whereby participants may feel pressure to present their care plan process in a more positive light due to societal norms and expectations [ 40 ]. Additionally, the experiences and views of community-care organizations may vary by region and organization type (i.e., for-profit vs. not-for-profit). In this study, we limited participation to agencies providing services in Southwestern Ontario and we were only able to interview one for-profit agency, despite concerted recruitment efforts. Consequently, we may not have fully captured how financial pressures, or different contextual and cultural components of an organization impact their implementation of care plans.

The person-centred planning process in community-care organizations is largely informed by the characteristics of the population served and the nature of services offered (i.e., organizational context). This process usually involves initial and continued consultations with persons-supported to tailor plans to their specific needs and desired outcomes. There are ongoing challenges in the implementation of person-centred planning, including a need for increased adaptability and clarity in current regulations. In some areas, there may be benefit to incorporating nuance in the application of policies (e.g., in cases where a person-supported does not want to have a formal plan in place). In other areas, it may be helpful to have increased guidance on how to optimize care delivery to improve outcomes (e.g., in cases where a person-supported has difficulty communicating, or is residing in a group home). Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Data availability

The datasets generated and analyzed in the current study are not publicly available to maintain participant confidentiality, however access may be granted by the corresponding author upon reasonable request.

Abbreviations

Acquired Brain Injury

Disability Services Ontario

Home and Community Care Support Services

Intellectual and Developmental Disabilities

Individual Service Plan

Ministry of Children, Community and Social Services

Ministry of Health

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Acknowledgements

The authors thank Ruth Armstrong, from PHSS - Medical & Complex Care in Community, for her valuable feedback and support throughout the research process.

This research was funded by the Canadian Institutes of Health Research. The funding agency had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

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S.I. conducted the interviews, developed the coding template, coded the data, thematically analyzed the data, and prepared the manuscript. G.Y. helped develop the coding template, and reviewed and approved the final manuscript. B.D. and D.A. helped conceptualize the study, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. L.M. coordinated research activities, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. M.M. conceptualized the study, supervised its implementation, and was a major contributor in reviewing and editing the manuscript. All authors have read and approved the final manuscript.

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Correspondence to Maria Mathews .

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Idrees, S., Young, G., Dunne, B. et al. The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada. BMC Health Serv Res 24 , 680 (2024). https://doi.org/10.1186/s12913-024-11089-7

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Identifying and Avoiding Bias in Research

This narrative review provides an overview on the topic of bias as part of Plastic and Reconstructive Surgery 's series of articles on evidence-based medicine. Bias can occur in the planning, data collection, analysis, and publication phases of research. Understanding research bias allows readers to critically and independently review the scientific literature and avoid treatments which are suboptimal or potentially harmful. A thorough understanding of bias and how it affects study results is essential for the practice of evidence-based medicine.

The British Medical Journal recently called evidence-based medicine (EBM) one of the fifteen most important milestones since the journal's inception 1 . The concept of EBM was created in the early 1980's as clinical practice became more data-driven and literature based 1 , 2 . EBM is now an essential part of medical school curriculum 3 . For plastic surgeons, the ability to practice EBM is limited. Too frequently, published research in plastic surgery demonstrates poor methodologic quality, although a gradual trend toward higher level study designs has been noted over the past ten years 4 , 5 . In order for EBM to be an effective tool, plastic surgeons must critically interpret study results and must also evaluate the rigor of study design and identify study biases. As the leadership of Plastic and Reconstructive Surgery seeks to provide higher quality science to enhance patient safety and outcomes, a discussion of the topic of bias is essential for the journal's readers. In this paper, we will define bias and identify potential sources of bias which occur during study design, study implementation, and during data analysis and publication. We will also make recommendations on avoiding bias before, during, and after a clinical trial.

I. Definition and scope of bias

Bias is defined as any tendency which prevents unprejudiced consideration of a question 6 . In research, bias occurs when “systematic error [is] introduced into sampling or testing by selecting or encouraging one outcome or answer over others” 7 . Bias can occur at any phase of research, including study design or data collection, as well as in the process of data analysis and publication ( Figure 1 ). Bias is not a dichotomous variable. Interpretation of bias cannot be limited to a simple inquisition: is bias present or not? Instead, reviewers of the literature must consider the degree to which bias was prevented by proper study design and implementation. As some degree of bias is nearly always present in a published study, readers must also consider how bias might influence a study's conclusions 8 . Table 1 provides a summary of different types of bias, when they occur, and how they might be avoided.

Major Sources of Bias in Clinical Research

Tips to avoid different types of bias during a trial.

Chance and confounding can be quantified and/or eliminated through proper study design and data analysis. However, only the most rigorously conducted trials can completely exclude bias as an alternate explanation for an association. Unlike random error, which results from sampling variability and which decreases as sample size increases, bias is independent of both sample size and statistical significance. Bias can cause estimates of association to be either larger or smaller than the true association. In extreme cases, bias can cause a perceived association which is directly opposite of the true association. For example, prior to 1998, multiple observational studies demonstrated that hormone replacement therapy (HRT) decreased risk of heart disease among post-menopausal women 8 , 9 . However, more recent studies, rigorously designed to minimize bias, have found the opposite effect (i.e., an increased risk of heart disease with HRT) 10 , 11 .

II. Pre-trial bias

Sources of pre-trial bias include errors in study design and in patient recruitment. These errors can cause fatal flaws in the data which cannot be compensated during data analysis. In this section, we will discuss the importance of clearly defining both risk and outcome, the necessity of standardized protocols for data collection, and the concepts of selection and channeling bias.

Bias during study design

The definition of risk and outcome should be clearly defined prior to study implementation. Subjective measures, such as the Baker grade of capsular contracture, can have high inter-rater variability and the arbitrary cutoffs may make distinguishing between groups difficult 12 . This can inflate the observed variance seen with statistical analysis, making a statistically significant result less likely. Objective, validated risk stratification models such as those published by Caprini 13 and Davison 14 for venous thromboembolism, or standardized outcomes measures such as the Breast-Q 15 should have lower inter-rater variability and are more appropriate for use. When risk or exposure is retrospectively identified via medical chart review, it is prudent to crossreference data sources for confirmation. For example, a chart reviewer should confirm a patient-reported history of sacral pressure ulcer closure with physical exam findings and by review of an operative report; this will decrease discrepancies when compared to using a single data source.

Data collection methods may include questionnaires, structured interviews, physical exam, laboratory or imaging data, or medical chart review. Standardized protocols for data collection, including training of study personnel, can minimize inter-observer variability when multiple individuals are gathering and entering data. Blinding of study personnel to the patient's exposure and outcome status, or if not possible, having different examiners measure the outcome than those who evaluated the exposure, can also decrease bias. Due to the presence of scars, patients and those directly examining them cannot be blinded to whether or not an operation was received. For comparisons of functional or aesthetic outcomes in surgical procedures, an independent examiner can be blinded to the type of surgery performed. For example, a hand surgery study comparing lag screw versus plate and screw fixation of metacarpal fractures could standardize the surgical approach (and thus the surgical scar) and have functional outcomes assessed by a blinded examiner who had not viewed the operative notes or x-rays. Blinded examiners can also review imaging and confirm diagnoses without examining patients 16 , 17 .

Selection bias

Selection bias may occur during identification of the study population. The ideal study population is clearly defined, accessible, reliable, and at increased risk to develop the outcome of interest. When a study population is identified, selection bias occurs when the criteria used to recruit and enroll patients into separate study cohorts are inherently different. This can be a particular problem with case-control and retrospective cohort studies where exposure and outcome have already occurred at the time individuals are selected for study inclusion 18 . Prospective studies (particularly randomized, controlled trials) where the outcome is unknown at time of enrollment are less prone to selection bias.

Channeling bias

Channeling bias occurs when patient prognostic factors or degree of illness dictates the study cohort into which patients are placed. This bias is more likely in non-randomized trials when patient assignment to groups is performed by medical personnel. Channeling bias is commonly seen in pharmaceutical trials comparing old and new drugs to one another 19 . In surgical studies, channeling bias can occur if one intervention carries a greater inherent risk 20 . For example, hand surgeons managing fractures may be more aggressive with operative intervention in young, healthy individuals with low perioperative risk. Similarly, surgeons might tolerate imperfect reduction in the elderly, a group at higher risk for perioperative complications and with decreased need for perfect hand function. Thus, a selection bias exists for operative intervention in young patients. Now imagine a retrospective study of operative versus non-operative management of hand fractures. In this study, young patients would be channeled into the operative study cohort and the elderly would be channeled into the nonoperative study cohort.

III. Bias during the clinical trial

Information bias is a blanket classification of error in which bias occurs in the measurement of an exposure or outcome. Thus, the information obtained and recorded from patients in different study groups is unequal in some way 18 . Many subtypes of information bias can occur, including interviewer bias, chronology bias, recall bias, patient loss to follow-up, bias from misclassification of patients, and performance bias.

Interviewer bias

Interviewer bias refers to a systematic difference between how information is solicited, recorded, or interpreted 18 , 21 . Interviewer bias is more likely when disease status is known to interviewer. An example of this would be a patient with Buerger's disease enrolled in a case control study which attempts to retrospectively identify risk factors. If the interviewer is aware that the patient has Buerger's disease, he/she may probe for risk factors, such as smoking, more extensively (“Are you sure you've never smoked? Never? Not even once?”) than in control patients. Interviewer bias can be minimized or eliminated if the interviewer is blinded to the outcome of interest or if the outcome of interest has not yet occurred, as in a prospective trial.

Chronology bias

Chronology bias occurs when historic controls are used as a comparison group for patients undergoing an intervention. Secular trends within the medical system could affect how disease is diagnosed, how treatments are administered, or how preferred outcome measures are obtained 20 . Each of these differences could act as a source of inequality between the historic controls and intervention groups. For example, many microsurgeons currently use preoperative imaging to guide perforator flap dissection. Imaging has been shown to significantly reduce operative time 40 . A retrospective study of flap dissection time might conclude that dissection time decreases as surgeon experience improves. More likely, the use of preoperative imaging caused a notable reduction in dissection time. Thus, chronology bias is present. Chronology bias can be minimized by conducting prospective cohort or randomized control trials, or by using historic controls from only the very recent past.

Recall bias

Recall bias refers to the phenomenon in which the outcomes of treatment (good or bad) may color subjects' recollections of events prior to or during the treatment process. One common example is the perceived association between autism and the MMR vaccine. This vaccine is given to children during a prominent period of language and social development. As a result, parents of children with autism are more likely to recall immunization administration during this developmental regression, and a causal relationship may be perceived 22 . Recall bias is most likely when exposure and disease status are both known at time of study, and can also be problematic when patient interviews (or subjective assessments) are used as a primary data sources. When patient-report data are used, some investigators recommend that the trial design masks the intent of questions in structured interviews or surveys and/or uses only validated scales for data acquisition 23 .

Transfer bias

In almost all clinical studies, subjects are lost to follow-up. In these instances, investigators must consider whether these patients are fundamentally different than those retained in the study. Researchers must also consider how to treat patients lost to follow-up in their analysis. Well designed trials usually have protocols in place to attempt telephone or mail contact for patients who miss clinic appointments. Transfer bias can occur when study cohorts have unequal losses to follow-up. This is particularly relevant in surgical trials when study cohorts are expected to require different follow-up regimens. Consider a study evaluating outcomes in inferior pedicle Wise pattern versus vertical scar breast reductions. Because the Wise pattern patients often have fewer contour problems in the immediate postoperative period, they may be less likely to return for long-term follow-up. By contrast, patient concerns over resolving skin redundancies in the vertical reduction group may make these individuals more likely to return for postoperative evaluations by their surgeons. Some authors suggest that patient loss to follow-up can be minimized by offering convenient office hours, personalized patient contact via phone or email, and physician visits to the patient's home 20 , 24 .

Bias from misclassification of exposure or outcome

Misclassification of exposure can occur if the exposure itself is poorly defined or if proxies of exposure are utilized. For example, this might occur in a study evaluating efficacy of becaplermin (Regranex, Systagenix Wound Management) versus saline dressings for management of diabetic foot ulcers. Significantly different results might be obtained if the becaplermin cohort of patients included those prescribed the medication, rather than patients directly observed to be applying the medication. Similarly, misclassification of outcome can occur if non-objective measures are used. For example, clinical signs and symptoms are notoriously unreliable indicators of venous thromboembolism. Patients are accurately diagnosed by physical exam less than 50% of the time 25 . Thus, using Homan's sign (calf pain elicited by extreme dorsi-flexion) or pleuritic chest pain as study measures for deep venous thrombosis or pulmonary embolus would be inappropriate. Venous thromboembolism is appropriately diagnosed using objective tests with high sensitivity and specificity, such as duplex ultrasound or spiral CT scan 26 - 28 .

Performance bias

In surgical trials, performance bias may complicate efforts to establish a cause-effect relationship between procedures and outcomes. As plastic surgeons, we are all aware that surgery is rarely standardized and that technical variability occurs between surgeons and among a single surgeon's cases. Variations by surgeon commonly occur in surgical plan, flow of operation, and technical maneuvers used to achieve the desired result. The surgeon's experience may have a significant effect on the outcome. To minimize or avoid performance bias, investigators can consider cluster stratification of patients, in which all patients having an operation by one surgeon or at one hospital are placed into the same study group, as opposed to placing individual patients into groups. This will minimize performance variability within groups and decrease performance bias. Cluster stratification of patients may allow surgeons to perform only the surgery with which they are most comfortable or experienced, providing a more valid assessment of the procedures being evaluated. If the operation in question has a steep learning curve, cluster stratification may make generalization of study results to the everyday plastic surgeon difficult.

IV. Bias after a trial

Bias after a trial's conclusion can occur during data analysis or publication. In this section, we will discuss citation bias, evaluate the role of confounding in data analysis, and provide a brief discussion of internal and external validity.

Citation bias

Citation bias refers to the fact that researchers and trial sponsors may be unwilling to publish unfavorable results, believing that such findings may negatively reflect on their personal abilities or on the efficacy of their product. Thus, positive results are more likely to be submitted for publication than negative results. Additionally, existing inequalities in the medical literature may sway clinicians' opinions of the expected trial results before or during a trial. In recognition of citation bias, the International Committee of Medical Journal Editors(ICMJE) released a consensus statement in 2004 29 which required all randomized control trials to be pre-registered with an approved clinical trials registry. In 2007, a second consensus statement 30 required that all prospective trials not deemed purely observational be registered with a central clinical trials registry prior to patient enrollment. ICMJE member journals will not publish studies which are not registered in advance with one of five accepted registries. Despite these measures, citation bias has not been completely eliminated. While centralized documentation provides medical researchers with information about unpublished trials, investigators may be left to only speculate as to the results of these studies.

Confounding

Confounding occurs when an observed association is due to three factors: the exposure, the outcome of interest, and a third factor which is independently associated with both the outcome of interest and the exposure 18 . Examples of confounders include observed associations between coffee drinking and heart attack (confounded by smoking) and the association between income and health status (confounded by access to care). Pre-trial study design is the preferred method to control for confounding. Prior to the study, matching patients for demographics (such as age or gender) and risk factors (such as body mass index or smoking) can create similar cohorts among identified confounders. However, the effect of unmeasured or unknown confounders may only be controlled by true randomization in a study with a large sample size. After a study's conclusion, identified confounders can be controlled by analyzing for an association between exposure and outcome only in cohorts similar for the identified confounding factor. For example, in a study comparing outcomes for various breast reconstruction options, the results might be confounded by the timing of the reconstruction (i.e., immediate versus delayed procedures). In other words, procedure type and timing may have both have significant and independent effects on breast reconstruction outcomes. One approach to this confounding would be to compare outcomes by procedure type separately for immediate and delayed reconstruction patients. This maneuver is commonly termed a “stratified” analysis. Stratified analyses are limited if multiple confounders are present or if sample size is small. Multi-variable regression analysis can also be used to control for identified confounders during data analysis. The role of unidentified confounders cannot be controlled using statistical analysis.

Internal vs. External Validity

Internal validity refers to the reliability or accuracy of the study results. A study's internal validity reflects the author's and reviewer's confidence that study design, implementation, and data analysis have minimized or eliminated bias and that the findings are representative of the true association between exposure and outcome. When evaluating studies, careful review of study methodology for sources of bias discussed above enables the reader to evaluate internal validity. Studies with high internal validity are often explanatory trials, those designed to test efficacy of a specific intervention under idealized conditions in a highly selected population. However, high internal validity often comes at the expense of ability to be generalized. For example, although supra-microsurgery techniques, defined as anastamosis of vessels less than 0.5mm-0.8mm in diameter, have been shown to be technically possible in high volume microsurgery centers 31 - 33 (high internal validity), it is unlikely that the majority of plastic surgeons could perform this operation with an acceptable rate of flap loss.

External validity of research design deals with the degree to which findings are able to be generalized to other groups or populations. In contrast with explanatory trials, pragmatic trials are designed to assess the benefits of interventions under real clinical conditions. These studies usually include study populations generated using minimal exclusion criteria, making them very similar to the general population. While pragmatic trials have high external validity, loose inclusion criteria may compromise the study's internal validity. When reviewing scientific literature, readers should assess whether the research methods preclude generalization of the study's findings to other patient populations. In making this decision, readers must consider differences between the source population (population from which the study population originated) and the study population (those included in the study). Additionally, it is important to distinguish limited ability to be generalized due to a selective patient population from true bias 8 .

When designing trials, achieving balance between internal and external validity is difficult. An ideal trial design would randomize patients and blind those collecting and analyzing data (high internal validity), while keeping exclusion criteria to a minimum, thus making study and source populations closely related and allowing generalization of results (high external validity) 34 . For those evaluating the literature, objective models exist to quantify both external and internal validity. Conceptual models to assess a study's ability to be generalized have been developed 35 . Additionally, qualitative checklists can be used to assess the external validity of clinical trials. These can be utilized by investigators to improve study design and also by those reading published studies 36 .

The importance of internal validity is reflected in the existing concept of “levels of evidence” 5 , where more rigorously designed trials produce higher levels of evidence. Such high-level studies can be evaluated using the Jadad scoring system, an established, rigorous means of assessing the methodological quality and internal validity of clinical trials 37 . Even so-called “gold-standard” RCT's can be undermined by poor study design. Like all studies, RCT's must be rigorously evaluated. Descriptions of study methods should include details on the randomization process, method(s) of blinding, treatment of incomplete outcome data, funding source(s), and include data on statistically insignificant outcomes 38 . Authors who provide incomplete trial information can create additional bias after a trial ends; readers are not able to evaluate the trial's internal and external validity 20 . The CONSORT statement 39 provides a concise 22-point checklist for authors reporting the results of RCT's. Manuscripts that conform to the CONSORT checklist will provide adequate information for readers to understand the study's methodology. As a result, readers can make independent judgments on the trial's internal and external validity.

Bias can occur in the planning, data collection, analysis, and publication phases of research. Understanding research bias allows readers to critically and independently review the scientific literature and avoid treatments which are suboptimal or potentially harmful. A thorough understanding of bias and how it affects study results is essential for the practice of evidence-based medicine.

Acknowledgments

Dr. Pannucci receives salary support from the NIH T32 grant program (T32 GM-08616).

Meeting disclosure:

This work was has not been previously presented.

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

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