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How to Write a Conclusion for Research Papers (with Examples)

The conclusion of a research paper is a crucial section that plays a significant role in the overall impact and effectiveness of your research paper. However, this is also the section that typically receives less attention compared to the introduction and the body of the paper. The conclusion serves to provide a concise summary of the key findings, their significance, their implications, and a sense of closure to the study. Discussing how can the findings be applied in real-world scenarios or inform policy, practice, or decision-making is especially valuable to practitioners and policymakers. The research paper conclusion also provides researchers with clear insights and valuable information for their own work, which they can then build on and contribute to the advancement of knowledge in the field.

The research paper conclusion should explain the significance of your findings within the broader context of your field. It restates how your results contribute to the existing body of knowledge and whether they confirm or challenge existing theories or hypotheses. Also, by identifying unanswered questions or areas requiring further investigation, your awareness of the broader research landscape can be demonstrated.

Remember to tailor the research paper conclusion to the specific needs and interests of your intended audience, which may include researchers, practitioners, policymakers, or a combination of these.

Table of Contents

What is a conclusion in a research paper, summarizing conclusion, editorial conclusion, externalizing conclusion, importance of a good research paper conclusion, how to write a conclusion for your research paper, research paper conclusion examples.

• How to write a research paper conclusion with Paperpal? 

Frequently Asked Questions

A conclusion in a research paper is the final section where you summarize and wrap up your research, presenting the key findings and insights derived from your study. The research paper conclusion is not the place to introduce new information or data that was not discussed in the main body of the paper. When working on how to conclude a research paper, remember to stick to summarizing and interpreting existing content. The research paper conclusion serves the following purposes: 1

• Warn readers of the possible consequences of not attending to the problem.
• Recommend specific course(s) of action.
• Restate key ideas to drive home the ultimate point of your research paper.
• Provide a “take-home” message that you want the readers to remember about your study.

Types of conclusions for research papers

In research papers, the conclusion provides closure to the reader. The type of research paper conclusion you choose depends on the nature of your study, your goals, and your target audience. I provide you with three common types of conclusions:

A summarizing conclusion is the most common type of conclusion in research papers. It involves summarizing the main points, reiterating the research question, and restating the significance of the findings. This common type of research paper conclusion is used across different disciplines.

An editorial conclusion is less common but can be used in research papers that are focused on proposing or advocating for a particular viewpoint or policy. It involves presenting a strong editorial or opinion based on the research findings and offering recommendations or calls to action.

An externalizing conclusion is a type of conclusion that extends the research beyond the scope of the paper by suggesting potential future research directions or discussing the broader implications of the findings. This type of conclusion is often used in more theoretical or exploratory research papers.

Align your conclusion’s tone with the rest of your research paper. Start Writing with Paperpal Now!  

The conclusion in a research paper serves several important purposes:

• Offers Implications and Recommendations : Your research paper conclusion is an excellent place to discuss the broader implications of your research and suggest potential areas for further study. It’s also an opportunity to offer practical recommendations based on your findings.
• Provides Closure : A good research paper conclusion provides a sense of closure to your paper. It should leave the reader with a feeling that they have reached the end of a well-structured and thought-provoking research project.
• Leaves a Lasting Impression : Writing a well-crafted research paper conclusion leaves a lasting impression on your readers. It’s your final opportunity to leave them with a new idea, a call to action, or a memorable quote.

Writing a strong conclusion for your research paper is essential to leave a lasting impression on your readers. Here’s a step-by-step process to help you create and know what to put in the conclusion of a research paper: 2

• Research Statement : Begin your research paper conclusion by restating your research statement. This reminds the reader of the main point you’ve been trying to prove throughout your paper. Keep it concise and clear.
• Key Points : Summarize the main arguments and key points you’ve made in your paper. Avoid introducing new information in the research paper conclusion. Instead, provide a concise overview of what you’ve discussed in the body of your paper.
• Address the Research Questions : If your research paper is based on specific research questions or hypotheses, briefly address whether you’ve answered them or achieved your research goals. Discuss the significance of your findings in this context.
• Significance : Highlight the importance of your research and its relevance in the broader context. Explain why your findings matter and how they contribute to the existing knowledge in your field.
• Implications : Explore the practical or theoretical implications of your research. How might your findings impact future research, policy, or real-world applications? Consider the “so what?” question.
• Future Research : Offer suggestions for future research in your area. What questions or aspects remain unanswered or warrant further investigation? This shows that your work opens the door for future exploration.
• Closing Thought : Conclude your research paper conclusion with a thought-provoking or memorable statement. This can leave a lasting impression on your readers and wrap up your paper effectively. Avoid introducing new information or arguments here.
• Proofread and Revise : Carefully proofread your conclusion for grammar, spelling, and clarity. Ensure that your ideas flow smoothly and that your conclusion is coherent and well-structured.

Write your research paper conclusion 2x faster with Paperpal. Try it now!

Remember that a well-crafted research paper conclusion is a reflection of the strength of your research and your ability to communicate its significance effectively. It should leave a lasting impression on your readers and tie together all the threads of your paper. Now you know how to start the conclusion of a research paper and what elements to include to make it impactful, let’s look at a research paper conclusion sample.

How to write a research paper conclusion with Paperpal?

A research paper conclusion is not just a summary of your study, but a synthesis of the key findings that ties the research together and places it in a broader context. A research paper conclusion should be concise, typically around one paragraph in length. However, some complex topics may require a longer conclusion to ensure the reader is left with a clear understanding of the study’s significance. Paperpal, an AI writing assistant trusted by over 800,000 academics globally, can help you write a well-structured conclusion for your research paper. 

• Sign Up or Log In: Create a new Paperpal account or login with your details.  
• Navigate to Features : Once logged in, head over to the features’ side navigation pane. Click on Templates and you’ll find a suite of generative AI features to help you write better, faster.  
• Generate an outline: Under Templates, select ‘Outlines’. Choose ‘Research article’ as your document type.  
• Select your section: Since you’re focusing on the conclusion, select this section when prompted.  
• Choose your field of study: Identifying your field of study allows Paperpal to provide more targeted suggestions, ensuring the relevance of your conclusion to your specific area of research. 
• Provide a brief description of your study: Enter details about your research topic and findings. This information helps Paperpal generate a tailored outline that aligns with your paper’s content. 
• Generate the conclusion outline: After entering all necessary details, click on ‘generate’. Paperpal will then create a structured outline for your conclusion, to help you start writing and build upon the outline.  
• Write your conclusion: Use the generated outline to build your conclusion. The outline serves as a guide, ensuring you cover all critical aspects of a strong conclusion, from summarizing key findings to highlighting the research’s implications. 
• Refine and enhance: Paperpal’s ‘Make Academic’ feature can be particularly useful in the final stages. Select any paragraph of your conclusion and use this feature to elevate the academic tone, ensuring your writing is aligned to the academic journal standards. 

By following these steps, Paperpal not only simplifies the process of writing a research paper conclusion but also ensures it is impactful, concise, and aligned with academic standards. Sign up with Paperpal today and write your research paper conclusion 2x faster .  

The research paper conclusion is a crucial part of your paper as it provides the final opportunity to leave a strong impression on your readers. In the research paper conclusion, summarize the main points of your research paper by restating your research statement, highlighting the most important findings, addressing the research questions or objectives, explaining the broader context of the study, discussing the significance of your findings, providing recommendations if applicable, and emphasizing the takeaway message. The main purpose of the conclusion is to remind the reader of the main point or argument of your paper and to provide a clear and concise summary of the key findings and their implications. All these elements should feature on your list of what to put in the conclusion of a research paper to create a strong final statement for your work.

A strong conclusion is a critical component of a research paper, as it provides an opportunity to wrap up your arguments, reiterate your main points, and leave a lasting impression on your readers. Here are the key elements of a strong research paper conclusion: 1. Conciseness : A research paper conclusion should be concise and to the point. It should not introduce new information or ideas that were not discussed in the body of the paper. 2. Summarization : The research paper conclusion should be comprehensive enough to give the reader a clear understanding of the research’s main contributions. 3 . Relevance : Ensure that the information included in the research paper conclusion is directly relevant to the research paper’s main topic and objectives; avoid unnecessary details. 4 . Connection to the Introduction : A well-structured research paper conclusion often revisits the key points made in the introduction and shows how the research has addressed the initial questions or objectives. 5. Emphasis : Highlight the significance and implications of your research. Why is your study important? What are the broader implications or applications of your findings? 6 . Call to Action : Include a call to action or a recommendation for future research or action based on your findings.

The length of a research paper conclusion can vary depending on several factors, including the overall length of the paper, the complexity of the research, and the specific journal requirements. While there is no strict rule for the length of a conclusion, but it’s generally advisable to keep it relatively short. A typical research paper conclusion might be around 5-10% of the paper’s total length. For example, if your paper is 10 pages long, the conclusion might be roughly half a page to one page in length.

In general, you do not need to include citations in the research paper conclusion. Citations are typically reserved for the body of the paper to support your arguments and provide evidence for your claims. However, there may be some exceptions to this rule: 1. If you are drawing a direct quote or paraphrasing a specific source in your research paper conclusion, you should include a citation to give proper credit to the original author. 2. If your conclusion refers to or discusses specific research, data, or sources that are crucial to the overall argument, citations can be included to reinforce your conclusion’s validity.

The conclusion of a research paper serves several important purposes: 1. Summarize the Key Points 2. Reinforce the Main Argument 3. Provide Closure 4. Offer Insights or Implications 5. Engage the Reader. 6. Reflect on Limitations

Remember that the primary purpose of the research paper conclusion is to leave a lasting impression on the reader, reinforcing the key points and providing closure to your research. It’s often the last part of the paper that the reader will see, so it should be strong and well-crafted.

• Makar, G., Foltz, C., Lendner, M., & Vaccaro, A. R. (2018). How to write effective discussion and conclusion sections. Clinical spine surgery, 31(8), 345-346.
• Bunton, D. (2005). The structure of PhD conclusion chapters.  Journal of English for academic purposes ,  4 (3), 207-224.

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Research Recommendations – Guiding policy-makers for evidence-based decision making

Research recommendations play a crucial role in guiding scholars and researchers toward fruitful avenues of exploration. In an era marked by rapid technological advancements and an ever-expanding knowledge base, refining the process of generating research recommendations becomes imperative.

But, what is a research recommendation?

Research recommendations are suggestions or advice provided to researchers to guide their study on a specific topic . They are typically given by experts in the field. Research recommendations are more action-oriented and provide specific guidance for decision-makers, unlike implications that are broader and focus on the broader significance and consequences of the research findings. However, both are crucial components of a research study.

Difference Between Research Recommendations and Implication

Although research recommendations and implications are distinct components of a research study, they are closely related. The differences between them are as follows:

Types of Research Recommendations

Recommendations in research can take various forms, which are as follows:

These recommendations aim to assist researchers in navigating the vast landscape of academic knowledge.

Let us dive deeper to know about its key components and the steps to write an impactful research recommendation.

Key Components of Research Recommendations

The key components of research recommendations include defining the research question or objective, specifying research methods, outlining data collection and analysis processes, presenting results and conclusions, addressing limitations, and suggesting areas for future research. Here are some characteristics of research recommendations:

Research recommendations offer various advantages and play a crucial role in ensuring that research findings contribute to positive outcomes in various fields. However, they also have few limitations which highlights the significance of a well-crafted research recommendation in offering the promised advantages.

The importance of research recommendations ranges in various fields, influencing policy-making, program development, product development, marketing strategies, medical practice, and scientific research. Their purpose is to transfer knowledge from researchers to practitioners, policymakers, or stakeholders, facilitating informed decision-making and improving outcomes in different domains.

How to Write Research Recommendations?

Research recommendations can be generated through various means, including algorithmic approaches, expert opinions, or collaborative filtering techniques. Here is a step-wise guide to build your understanding on the development of research recommendations.

1. Understand the Research Question:

Understand the research question and objectives before writing recommendations. Also, ensure that your recommendations are relevant and directly address the goals of the study.

2. Review Existing Literature:

Familiarize yourself with relevant existing literature to help you identify gaps , and offer informed recommendations that contribute to the existing body of research.

3. Consider Research Methods:

Evaluate the appropriateness of different research methods in addressing the research question. Also, consider the nature of the data, the study design, and the specific objectives.

4. Identify Data Collection Techniques:

Gather dataset from diverse authentic sources. Include information such as keywords, abstracts, authors, publication dates, and citation metrics to provide a rich foundation for analysis.

5. Propose Data Analysis Methods:

Suggest appropriate data analysis methods based on the type of data collected. Consider whether statistical analysis, qualitative analysis, or a mixed-methods approach is most suitable.

6. Consider Limitations and Ethical Considerations:

Acknowledge any limitations and potential ethical considerations of the study. Furthermore, address these limitations or mitigate ethical concerns to ensure responsible research.

7. Justify Recommendations:

Explain how your recommendation contributes to addressing the research question or objective. Provide a strong rationale to help researchers understand the importance of following your suggestions.

8. Summarize Recommendations:

Provide a concise summary at the end of the report to emphasize how following these recommendations will contribute to the overall success of the research project.

By following these steps, you can create research recommendations that are actionable and contribute meaningfully to the success of the research project.

Download now to unlock some tips to improve your journey of writing research recommendations.

Example of a Research Recommendation

Here is an example of a research recommendation based on a hypothetical research to improve your understanding.

Research Recommendation: Enhancing Student Learning through Integrated Learning Platforms

Background:

The research study investigated the impact of an integrated learning platform on student learning outcomes in high school mathematics classes. The findings revealed a statistically significant improvement in student performance and engagement when compared to traditional teaching methods.

Recommendation:

In light of the research findings, it is recommended that educational institutions consider adopting and integrating the identified learning platform into their mathematics curriculum. The following specific recommendations are provided:

• Implementation of the Integrated Learning Platform:

Schools are encouraged to adopt the integrated learning platform in mathematics classrooms, ensuring proper training for teachers on its effective utilization.

• Professional Development for Educators:

Develop and implement professional programs to train educators in the effective use of the integrated learning platform to address any challenges teachers may face during the transition.

• Monitoring and Evaluation:

Establish a monitoring and evaluation system to track the impact of the integrated learning platform on student performance over time.

• Resource Allocation:

Allocate sufficient resources, both financial and technical, to support the widespread implementation of the integrated learning platform.

By implementing these recommendations, educational institutions can harness the potential of the integrated learning platform and enhance student learning experiences and academic achievements in mathematics.

This example covers the components of a research recommendation, providing specific actions based on the research findings, identifying the target audience, and outlining practical steps for implementation.

Using AI in Research Recommendation Writing

Enhancing research recommendations is an ongoing endeavor that requires the integration of cutting-edge technologies, collaborative efforts, and ethical considerations. By embracing data-driven approaches and leveraging advanced technologies, the research community can create more effective and personalized recommendation systems. However, it is accompanied by several limitations. Therefore, it is essential to approach the use of AI in research with a critical mindset, and complement its capabilities with human expertise and judgment.

Here are some limitations of integrating AI in writing research recommendation and some ways on how to counter them.

1. Data Bias

AI systems rely heavily on data for training. If the training data is biased or incomplete, the AI model may produce biased results or recommendations.

How to tackle: Audit regularly the model’s performance to identify any discrepancies and adjust the training data and algorithms accordingly.

2. Lack of Understanding of Context:

AI models may struggle to understand the nuanced context of a particular research problem. They may misinterpret information, leading to inaccurate recommendations.

How to tackle: Use AI to characterize research articles and topics. Employ them to extract features like keywords, authorship patterns and content-based details.

3. Ethical Considerations:

AI models might stereotype certain concepts or generate recommendations that could have negative consequences for certain individuals or groups.

How to tackle: Incorporate user feedback mechanisms to reduce redundancies. Establish an ethics review process for AI models in research recommendation writing.

4. Lack of Creativity and Intuition:

AI may struggle with tasks that require a deep understanding of the underlying principles or the ability to think outside the box.

How to tackle: Hybrid approaches can be employed by integrating AI in data analysis and identifying patterns for accelerating the data interpretation process.

5. Interpretability:

Many AI models, especially complex deep learning models, lack transparency on how the model arrived at a particular recommendation.

How to tackle: Implement models like decision trees or linear models. Provide clear explanation of the model architecture, training process, and decision-making criteria.

6. Dynamic Nature of Research:

Research fields are dynamic, and new information is constantly emerging. AI models may struggle to keep up with the rapidly changing landscape and may not be able to adapt to new developments.

How to tackle: Establish a feedback loop for continuous improvement. Regularly update the recommendation system based on user feedback and emerging research trends.

The integration of AI in research recommendation writing holds great promise for advancing knowledge and streamlining the research process. However, navigating these concerns is pivotal in ensuring the responsible deployment of these technologies. Researchers need to understand the use of responsible use of AI in research and must be aware of the ethical considerations.

Exploring research recommendations plays a critical role in shaping the trajectory of scientific inquiry. It serves as a compass, guiding researchers toward more robust methodologies, collaborative endeavors, and innovative approaches. Embracing these suggestions not only enhances the quality of individual studies but also contributes to the collective advancement of human understanding.

Frequently Asked Questions

The purpose of recommendations in research is to provide practical and actionable suggestions based on the study's findings, guiding future actions, policies, or interventions in a specific field or context. Recommendations bridges the gap between research outcomes and their real-world application.

To make a research recommendation, analyze your findings, identify key insights, and propose specific, evidence-based actions. Include the relevance of the recommendations to the study's objectives and provide practical steps for implementation.

Begin a recommendation by succinctly summarizing the key findings of the research. Clearly state the purpose of the recommendation and its intended impact. Use a direct and actionable language to convey the suggested course of action.

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How To Write The Conclusion Chapter

The what, why & how explained simply (with examples).

By: Jenna Crossley (PhD Cand). Reviewed By: Dr. Eunice Rautenbach | September 2021

So, you’ve wrapped up your results and discussion chapters, and you’re finally on the home stretch – the conclusion chapter . In this post, we’ll discuss everything you need to know to craft a high-quality conclusion chapter for your dissertation or thesis project.

Overview: Dissertation Conclusion Chapter

• What the thesis/dissertation conclusion chapter is
• What to include in your conclusion chapter
• How to structure and write up your conclusion chapter
• A few tips  to help you ace the chapter

What exactly is the conclusion chapter?

The conclusion chapter is typically the final major chapter of a dissertation or thesis. As such, it serves as a concluding summary of your research findings and wraps up the document. While some publications such as journal articles and research reports combine the discussion and conclusion sections, these are typically separate chapters in a dissertation or thesis. As always, be sure to check what your university’s structural preference is before you start writing up these chapters.

So, what’s the difference between the discussion and the conclusion chapter?

Well, the two chapters are quite similar , as they both discuss the key findings of the study. However, the conclusion chapter is typically more general and high-level in nature. In your discussion chapter, you’ll typically discuss the intricate details of your study, but in your conclusion chapter, you’ll take a   broader perspective, reporting on the main research outcomes and how these addressed your research aim (or aims) .

A core function of the conclusion chapter is to synthesise all major points covered in your study and to tell the reader what they should take away from your work. Basically, you need to tell them what you found , why it’s valuable , how it can be applied , and what further research can be done.

Whatever you do, don’t just copy and paste what you’ve written in your discussion chapter! The conclusion chapter should not be a simple rehash of the discussion chapter. While the two chapters are similar, they have distinctly different functions.  

What should I include in the conclusion chapter?

To understand what needs to go into your conclusion chapter, it’s useful to understand what the chapter needs to achieve. In general, a good dissertation conclusion chapter should achieve the following:

• Summarise the key findings of the study
• Explicitly answer the research question(s) and address the research aims
• Inform the reader of the study’s main contributions
• Discuss any limitations or weaknesses of the study
• Present recommendations for future research

Therefore, your conclusion chapter needs to cover these core components. Importantly, you need to be careful not to include any new findings or data points. Your conclusion chapter should be based purely on data and analysis findings that you’ve already presented in the earlier chapters. If there’s a new point you want to introduce, you’ll need to go back to your results and discussion chapters to weave the foundation in there.

In many cases, readers will jump from the introduction chapter directly to the conclusions chapter to get a quick overview of the study’s purpose and key findings. Therefore, when you write up your conclusion chapter, it’s useful to assume that the reader hasn’t consumed the inner chapters of your dissertation or thesis. In other words, craft your conclusion chapter such that there’s a strong connection and smooth flow between the introduction and conclusion chapters, even though they’re on opposite ends of your document.

Need a helping hand?

How to write the conclusion chapter

Now that you have a clearer view of what the conclusion chapter is about, let’s break down the structure of this chapter so that you can get writing. Keep in mind that this is merely a typical structure – it’s not set in stone or universal. Some universities will prefer that you cover some of these points in the discussion chapter , or that you cover the points at different levels in different chapters.

Step 1: Craft a brief introduction section

As with all chapters in your dissertation or thesis, the conclusions chapter needs to start with a brief introduction. In this introductory section, you’ll want to tell the reader what they can expect to find in the chapter, and in what order . Here’s an example of what this might look like:

This chapter will conclude the study by summarising the key research findings in relation to the research aims and questions and discussing the value and contribution thereof. It will also review the limitations of the study and propose opportunities for future research.

Importantly, the objective here is just to give the reader a taste of what’s to come (a roadmap of sorts), not a summary of the chapter. So, keep it short and sweet – a paragraph or two should be ample.

Step 2: Discuss the overall findings in relation to the research aims

The next step in writing your conclusions chapter is to discuss the overall findings of your study , as they relate to the research aims and research questions . You would have likely covered similar ground in the discussion chapter, so it’s important to zoom out a little bit here and focus on the broader findings – specifically, how these help address the research aims .

In practical terms, it’s useful to start this section by reminding your reader of your research aims and research questions, so that the findings are well contextualised. In this section, phrases such as, “This study aimed to…” and “the results indicate that…” will likely come in handy. For example, you could say something like the following:

This study aimed to investigate the feeding habits of the naked mole-rat. The results indicate that naked mole rats feed on underground roots and tubers. Further findings show that these creatures eat only a part of the plant, leaving essential parts to ensure long-term food stability.

Be careful not to make overly bold claims here. Avoid claims such as “this study proves that” or “the findings disprove existing the existing theory”. It’s seldom the case that a single study can prove or disprove something. Typically, this is achieved by a broader body of research, not a single study – especially not a dissertation or thesis which will inherently have significant and limitations. We’ll discuss those limitations a little later.

Step 3: Discuss how your study contributes to the field

Next, you’ll need to discuss how your research has contributed to the field – both in terms of theory and practice . This involves talking about what you achieved in your study, highlighting why this is important and valuable, and how it can be used or applied.

In this section you’ll want to:

• Mention any research outputs created as a result of your study (e.g., articles, publications, etc.)
• Inform the reader on just how your research solves your research problem , and why that matters
• Reflect on gaps in the existing research and discuss how your study contributes towards addressing these gaps
• Discuss your study in relation to relevant theories . For example, does it confirm these theories or constructively challenge them?
• Discuss how your research findings can be applied in the real world . For example, what specific actions can practitioners take, based on your findings?

Be careful to strike a careful balance between being firm but humble in your arguments here. It’s unlikely that your one study will fundamentally change paradigms or shake up the discipline, so making claims to this effect will be frowned upon . At the same time though, you need to present your arguments with confidence, firmly asserting the contribution your research has made, however small that contribution may be. Simply put, you need to keep it balanced .

Step 4: Reflect on the limitations of your study

Now that you’ve pumped your research up, the next step is to critically reflect on the limitations and potential shortcomings of your study. You may have already covered this in the discussion chapter, depending on your university’s structural preferences, so be careful not to repeat yourself unnecessarily.

There are many potential limitations that can apply to any given study. Some common ones include:

• Sampling issues that reduce the generalisability of the findings (e.g., non-probability sampling )
• Insufficient sample size (e.g., not getting enough survey responses ) or limited data access
• Low-resolution data collection or analysis techniques
• Researcher bias or lack of experience
• Lack of access to research equipment
• Time constraints that limit the methodology (e.g. cross-sectional vs longitudinal time horizon)
• Budget constraints that limit various aspects of the study

Discussing the limitations of your research may feel self-defeating (no one wants to highlight their weaknesses, right), but it’s a critical component of high-quality research. It’s important to appreciate that all studies have limitations (even well-funded studies by expert researchers) – therefore acknowledging these limitations adds credibility to your research by showing that you understand the limitations of your research design .

That being said, keep an eye on your wording and make sure that you don’t undermine your research . It’s important to strike a balance between recognising the limitations, but also highlighting the value of your research despite those limitations. Show the reader that you understand the limitations, that these were justified given your constraints, and that you know how they can be improved upon – this will get you marks.

Next, you’ll need to make recommendations for future studies. This will largely be built on the limitations you just discussed. For example, if one of your study’s weaknesses was related to a specific data collection or analysis method, you can make a recommendation that future researchers undertake similar research using a more sophisticated method.

Another potential source of future research recommendations is any data points or analysis findings that were interesting or surprising , but not directly related to your study’s research aims and research questions. So, if you observed anything that “stood out” in your analysis, but you didn’t explore it in your discussion (due to a lack of relevance to your research aims), you can earmark that for further exploration in this section.

Essentially, this section is an opportunity to outline how other researchers can build on your study to take the research further and help develop the body of knowledge. So, think carefully about the new questions that your study has raised, and clearly outline these for future researchers to pick up on.

Step 6: Wrap up with a closing summary

Quick tips for a top-notch conclusion chapter

Now that we’ve covered the what , why and how of the conclusion chapter, here are some quick tips and suggestions to help you craft a rock-solid conclusion.

• Don’t ramble . The conclusion chapter usually consumes 5-7% of the total word count (although this will vary between universities), so you need to be concise. Edit this chapter thoroughly with a focus on brevity and clarity.
• Be very careful about the claims you make in terms of your study’s contribution. Nothing will make the marker’s eyes roll back faster than exaggerated or unfounded claims. Be humble but firm in your claim-making.
• Use clear and simple language that can be easily understood by an intelligent layman. Remember that not every reader will be an expert in your field, so it’s important to make your writing accessible. Bear in mind that no one knows your research better than you do, so it’s important to spell things out clearly for readers.

Hopefully, this post has given you some direction and confidence to take on the conclusion chapter of your dissertation or thesis with confidence. If you’re still feeling a little shaky and need a helping hand, consider booking a free initial consultation with a friendly Grad Coach to discuss how we can help you with hands-on, private coaching.

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Really you team are doing great!

Your guide on writing the concluding chapter of a research is really informative especially to the beginners who really do not know where to start. Im now ready to start. Keep it up guys

Really your team are doing great!

Very helpful guidelines, timely saved. Thanks so much for the tips.

This post was very helpful and informative. Thank you team.

A very enjoyable, understandable and crisp presentation on how to write a conclusion chapter. I thoroughly enjoyed it. Thanks Jenna.

This was a very helpful article which really gave me practical pointers for my concluding chapter. Keep doing what you are doing! It meant a lot to me to be able to have this guide. Thank you so much.

Nice content dealing with the conclusion chapter, it’s a relief after the streneous task of completing discussion part.Thanks for valuable guidance

Thanks for your guidance

I get all my doubts clarified regarding the conclusion chapter. It’s really amazing. Many thanks.

Very helpful tips. Thanks so much for the guidance

Thank you very much for this piece. It offers a very helpful starting point in writing the conclusion chapter of my thesis.

It’s awesome! Most useful and timely too. Thanks a million times

Bundle of thanks for your guidance. It was greatly helpful.

Wonderful, clear, practical guidance. So grateful to read this as I conclude my research. Thank you.

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• How to Write Discussions and Conclusions

The discussion section contains the results and outcomes of a study. An effective discussion informs readers what can be learned from your experiment and provides context for the results.

What makes an effective discussion?

When you’re ready to write your discussion, you’ve already introduced the purpose of your study and provided an in-depth description of the methodology. The discussion informs readers about the larger implications of your study based on the results. Highlighting these implications while not overstating the findings can be challenging, especially when you’re submitting to a journal that selects articles based on novelty or potential impact. Regardless of what journal you are submitting to, the discussion section always serves the same purpose: concluding what your study results actually mean.

A successful discussion section puts your findings in context. It should include:

• the results of your research,
• a discussion of related research, and
• a comparison between your results and initial hypothesis.

Tip: Not all journals share the same naming conventions.

You can apply the advice in this article to the conclusion, results or discussion sections of your manuscript.

Our Early Career Researcher community tells us that the conclusion is often considered the most difficult aspect of a manuscript to write. To help, this guide provides questions to ask yourself, a basic structure to model your discussion off of and examples from published manuscripts. 

Questions to ask yourself:

• Was my hypothesis correct?
• If my hypothesis is partially correct or entirely different, what can be learned from the results? 
• How do the conclusions reshape or add onto the existing knowledge in the field? What does previous research say about the topic? 
• Why are the results important or relevant to your audience? Do they add further evidence to a scientific consensus or disprove prior studies? 
• How can future research build on these observations? What are the key experiments that must be done? 
• What is the “take-home” message you want your reader to leave with?

How to structure a discussion

Trying to fit a complete discussion into a single paragraph can add unnecessary stress to the writing process. If possible, you’ll want to give yourself two or three paragraphs to give the reader a comprehensive understanding of your study as a whole. Here’s one way to structure an effective discussion:

Writing Tips

While the above sections can help you brainstorm and structure your discussion, there are many common mistakes that writers revert to when having difficulties with their paper. Writing a discussion can be a delicate balance between summarizing your results, providing proper context for your research and avoiding introducing new information. Remember that your paper should be both confident and honest about the results! 

• Read the journal’s guidelines on the discussion and conclusion sections. If possible, learn about the guidelines before writing the discussion to ensure you’re writing to meet their expectations. 
• Begin with a clear statement of the principal findings. This will reinforce the main take-away for the reader and set up the rest of the discussion. 
• Explain why the outcomes of your study are important to the reader. Discuss the implications of your findings realistically based on previous literature, highlighting both the strengths and limitations of the research. 
• State whether the results prove or disprove your hypothesis. If your hypothesis was disproved, what might be the reasons? 
• Introduce new or expanded ways to think about the research question. Indicate what next steps can be taken to further pursue any unresolved questions. 
• If dealing with a contemporary or ongoing problem, such as climate change, discuss possible consequences if the problem is avoided. 
• Be concise. Adding unnecessary detail can distract from the main findings. 

Don’t

• Rewrite your abstract. Statements with “we investigated” or “we studied” generally do not belong in the discussion. 
• Include new arguments or evidence not previously discussed. Necessary information and evidence should be introduced in the main body of the paper. 
• Apologize. Even if your research contains significant limitations, don’t undermine your authority by including statements that doubt your methodology or execution. 
• Shy away from speaking on limitations or negative results. Including limitations and negative results will give readers a complete understanding of the presented research. Potential limitations include sources of potential bias, threats to internal or external validity, barriers to implementing an intervention and other issues inherent to the study design. 
• Overstate the importance of your findings. Making grand statements about how a study will fully resolve large questions can lead readers to doubt the success of the research. 

Snippets of Effective Discussions:

Consumer-based actions to reduce plastic pollution in rivers: A multi-criteria decision analysis approach

Identifying reliable indicators of fitness in polar bears

• How to Write a Great Title
• How to Write an Abstract
• How to Write Your Methods
• How to Report Statistics
• How to Edit Your Work

The contents of the Peer Review Center are also available as a live, interactive training session, complete with slides, talking points, and activities. …

The contents of the Writing Center are also available as a live, interactive training session, complete with slides, talking points, and activities. …

There’s a lot to consider when deciding where to submit your work. Learn how to choose a journal that will help your study reach its audience, while reflecting your values as a researcher…

Writing the parts of scientific reports

22 Writing the conclusion & recommendations

There are probably some overlaps between the Conclusion and the Discussion section. Nevertheless, this section gives you the opportunity to highlight the most important points in your report, and is sometimes the only section read. Think about what your research/ study has achieved, and the most important findings and ideas you want the reader to know. As all studies have limitations also think about what you were not able to cover (this shows that you are able to evaluate your own work objectively).

Possible structure of this section:

Use present perfect to sum up/ evaluate:

This study has explored/ has attempted …

Use past tense to state what your aim was and to refer to actions you carried out:

• This study was intended to analyse …
• The aim of this study was to …

Use present tense to evaluate your study and to state the generalizations and implications that you draw from your findings.

• The results add to the knowledge of …
• These findings s uggest that …

You can either use present tense or past tense to summarize your results.

• The findings reveal …
• It was found that …

Achievements of this study (positive)

• This study provides evidence that …
• This work has contributed to a number of key issues in the field such as …

Limitations of the study (negative)

• Several limitations should be noted. First …

Combine positive and negative remarks to give a balanced assessment:

• Although this research is somewhat limited in scope, its findings can provide a basis for future studies.
• Despite the limitations, findings from the present study can help us understand …

Use more cautious language (modal verbs may, can, could)

• There are a number of possible extensions of this research …
• The findings suggest the possibility for future research on …
• These results may be important for future studies on …
• Examining a wider context could/ would lead …

Or indicate that future research is needed

• There is still a need for future research to determine …
• Further studies should be undertaken to discover…
• It would be worthwhile to investigate …

Academic Writing in a Swiss University Context Copyright © 2018 by Irene Dietrichs. All Rights Reserved.

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• How to Write Recommendations in Research | Examples & Tips

How to Write Recommendations in Research | Examples & Tips

Published on 15 September 2022 by Tegan George .

Recommendations in research are a crucial component of your discussion section and the conclusion of your thesis , dissertation , or research paper .

As you conduct your research and analyse the data you collected , perhaps there are ideas or results that don’t quite fit the scope of your research topic . Or, maybe your results suggest that there are further implications of your results or the causal relationships between previously-studied variables than covered in extant research.

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Table of contents

What should recommendations look like, building your research recommendation, how should your recommendations be written, recommendation in research example, frequently asked questions about recommendations.

Recommendations for future research should be:

• Concrete and specific
• Supported with a clear rationale
• Directly connected to your research

Overall, strive to highlight ways other researchers can reproduce or replicate your results to draw further conclusions, and suggest different directions that future research can take, if applicable.

Relatedly, when making these recommendations, avoid:

• Undermining your own work, but rather offer suggestions on how future studies can build upon it
• Suggesting recommendations actually needed to complete your argument, but rather ensure that your research stands alone on its own merits
• Using recommendations as a place for self-criticism, but rather as a natural extension point for your work

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There are many different ways to frame recommendations, but the easiest is perhaps to follow the formula of research question   conclusion  recommendation. Here’s an example.

Conclusion An important condition for controlling many social skills is mastering language. If children have a better command of language, they can express themselves better and are better able to understand their peers. Opportunities to practice social skills are thus dependent on the development of language skills.

As a rule of thumb, try to limit yourself to only the most relevant future recommendations: ones that stem directly from your work. While you can have multiple recommendations for each research conclusion, it is also acceptable to have one recommendation that is connected to more than one conclusion.

These recommendations should be targeted at your audience, specifically toward peers or colleagues in your field that work on similar topics to yours. They can flow directly from any limitations you found while conducting your work, offering concrete and actionable possibilities for how future research can build on anything that your own work was unable to address at the time of your writing.

See below for a full research recommendation example that you can use as a template to write your own.

The current study can be interpreted as a first step in the research on COPD speech characteristics. However, the results of this study should be treated with caution due to the small sample size and the lack of details regarding the participants’ characteristics.

Future research could further examine the differences in speech characteristics between exacerbated COPD patients, stable COPD patients, and healthy controls. It could also contribute to a deeper understanding of the acoustic measurements suitable for e-health measurements.

While it may be tempting to present new arguments or evidence in your thesis or disseration conclusion , especially if you have a particularly striking argument you’d like to finish your analysis with, you shouldn’t. Theses and dissertations follow a more formal structure than this.

All your findings and arguments should be presented in the body of the text (more specifically in the discussion section and results section .) The conclusion is meant to summarize and reflect on the evidence and arguments you have already presented, not introduce new ones.

The conclusion of your thesis or dissertation should include the following:

• A restatement of your research question
• A summary of your key arguments and/or results
• A short discussion of the implications of your research

For a stronger dissertation conclusion , avoid including:

• Generic concluding phrases (e.g. “In conclusion…”)
• Weak statements that undermine your argument (e.g. “There are good points on both sides of this issue.”)

Your conclusion should leave the reader with a strong, decisive impression of your work.

In a thesis or dissertation, the discussion is an in-depth exploration of the results, going into detail about the meaning of your findings and citing relevant sources to put them in context.

The conclusion is more shorter and more general: it concisely answers your main research question and makes recommendations based on your overall findings.

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George, T. (2022, September 15). How to Write Recommendations in Research | Examples & Tips. Scribbr. Retrieved 29 April 2024, from https://www.scribbr.co.uk/thesis-dissertation/research-recommendations/

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A Survey of Attitudes and Actions on Dual Use Research in the Life Sciences: A Collaborative Effort of the National Research Council and the American Association for the Advancement of Science (2009)

Chapter: 4 conclusions and recommendations.

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4 Conclusions and Recommendations INTRODUCTION The results of the survey provide some of the first empirical data about the perceptions of a sample of U.S. life scientists of the potential risks of misuse of legitimate scientific research for malicious purposes. The survey obtained information from a diverse group of academic, gov- ernment, and industry researchers. The survey data provide evidence about how the respondents perceive the sources of risk related to dual use research, the actions that some scientists are taking to reduce the risk of misuse of science, and the prospects for acceptance of various policy proposals aimed at reducing the risks of misuse of legitimate life science research. While useful, the results of the survey must be viewed with caution because of the low response rate and possible response bias. Scientists who may be involved in biodefense or select agent research, for example, may be more aware of the dual use dilemma and thus more likely to have responded to the survey. In addition, a few of the questions could have been interpreted in multiple ways. Despite the limitations, which are discussed in detail in Chapter 2, the committee believes that the data obtained in this study offer valuable insights and new information. Overall, the survey findings suggest that there is considerable support for models of oversight that rely on the responsible conduct of research and self-governance by the scientific community. The responses also sug- gest, however, that there is a critical need to clarify the scope of research activities of high concern and to determine the appropriate actions that 115

116 DUAL USE RESEARCH IN THE LIFE SCIENCES members of the life sciences community can take to reduce the risk of misuse of science for bioweapons development or bioterrorism. The rest of the chapter provides a summary of the survey findings. Following a brief summary of the perceptions of risks of the scientists who responded to the survey, three key areas of current and potential activities and policies are highlighted: actions that life scientists have already taken to address dual use concerns, mechanisms for the oversight of research, and issues related to education and outreach. The chapter closes with the committee’s recommendations for furthering education and outreach activities that are based on the findings of the survey and its own judg- ments and analysis. PERCEPTIONS OF RISK The findings suggest that, on average, the scientists who responded to the survey perceive a potential, but not overwhelming, risk of bioter- rorism and that the risk is greater outside the United States. On average, the respondents believed that there is a 51 percent chance that there will be an act of bioterrorism somewhere in the world in the next 5 years and a 35 percent chance that there will be an act of bioterrorism in the United States in the next 5 years. Three-quarters of the respondents believe that a preference for other means of attack is the primary reason why there have been only a few acts of bioterrorism to date; overwhelmingly, 87 percent of respondents said that they believe that terrorists are not deterred by the threat of being caught and punished. Fewer scientists considered a lack of knowledge (46 percent) or access to equipment (51 percent) or agents (36 percent) to be significant barriers. It may be that one’s perceived risk of such an attack is related to one’s support for taking measures to reduce the risks that life sciences research might be misused. With regard to the chance that the knowledge, tools, or techniques from dual use research will facilitate bioterrorism, the respondents per- ceive a 28 percent chance, on average, of such a bioterror attack within the next 5 years. Half of the respondents thought that if someone wanted to create a harmful biological agent, the Internet would be the most likely place to provide sufficient information for life scientists with college- level training. Other sources of information—articles in scientific journals (40 percent), personal communications (38 percent), and presentations at professional meetings (18 percent)—were considered relatively less likely sources, although on average 45 percent of respondents answered “Don’t Know” to these questions.

CONCLUSIONS AND RECOMMENDATIONS 117 ACTIONS TAKEN BY LIFE SCIENTISTS IN RESPONSE TO DUAL USE CONCERNS Although the responses to the survey indicate that bioterrorism prob- ably is not perceived to present a serious immediate risk to U.S. or global security, the survey results also indicate that there is already concern about dual use issues among some of the life scientists who responded. Fifteen percent of the respondents (260 individuals out of 1,744) indicated that they are so concerned about dual use research that they have taken actions, even in the absence of guidelines or mandatory regulations from the U.S. government. Some respondents reported that they had broken collaborations, not conducted some research projects, or not commu- nicated research results. The results indicate that more scientists have modified their research activities than some members of the committee expected on the basis of previous reports of manuscripts that have been modified or not published because of dual use concerns. Interestingly, many of the actions that the respondents reported tak- ing to mitigate concerns occurred before the publication stage; much of the behavior change occurred during the research design, collaboration, and early communication stages. Of particular interest and concern to the committee, a few respondents commented on their concerns about for- eigners as potential security risks, which may be reflected in the reported avoidance of some collaborations. The survey results suggest that: (1) some life scientists in the United States may be willing to consider self-governance aimed at the respon- sible scientific conduct for dual use research, and (2) some life scientists in the United States are already acting, even in the absence of govern- ment regulations and guidance, to protect against the perceived risk of misuse of dual use research. OVERSIGHT MECHANISMS With a proposed oversight framework for dual use research of concern proposed by NSABB in June 2007 now under consideration within the U.S. government, the survey was an opportunity to assess scientists’ atti- tudes toward specific policy options. Many of the respondents indicated that they believe that personal responsibility, including measures such as codes of conduct, could foster a positive culture within the scientific com- munity to evaluate the potential consequences of their research for public safety and national security. They also indicated that they believe that individual researchers, professional scientific societies, institutions, and scientific journals should be responsible for evaluating dual use potential of research and/or fostering the culture of scientific responsibility. A majority of those who responded to the survey favored self-gov-

118 DUAL USE RESEARCH IN THE LIFE SCIENCES ernance mechanisms for dealing with dual use research of concern, such as those proposed by the Fink report (NRC 2004a), rather than addi- tional mandatory government regulations. In addition to the low level of support for greater federal oversight (26 percent), the individual com- ments indicated a belief that increased government oversight of dual use research would be counterproductive by inhibiting the research needed to combat emerging infectious diseases and bioterrorism as well as being potentially harmful to the scientific enterprise more generally. The survey suggests that most of the respondents (82 percent) favor their professional societies’ prescribing a code of responsible conduct to help prevent misuse of life sciences research. However, many respondents (66 percent) did not know whether the societies to which they belonged already had codes that address dual use issues, and some of the societies most frequently cited do not in fact have a code. There was substantially less support (38 percent agree or strongly agree) for a Hippocratic-style oath. The results also indicate potential support for journals having bios- ecurity policies. Yet, most of the respondents did not know if any of the journals in which they have published or to which they have submitted manuscripts have those policies. Moreover, more than half of those who responded to the survey strongly disagreed or disagreed with restrictions on personal communication, altering or removing methods or findings from scientific publications, or limiting publication itself. The survey points to a likely preference for self-governance measures to provide oversight of dual use research. There was substantially less support for mandatory measures that might be imposed by regulation, although the results varied for different policy measures. The results indicate that there may be greater support for restrictions on access to biological agents (just under 50 percent of the respondents said they agree or strongly agree) and certifications of researchers (just over 40 percent of the respondents said they agree or strongly agree) than for any control of scientific knowledge generated from the research or through informa- tion exchange (only 20 to 30 percent of respondents supported these measures). Table 4-1 provides a list of the level of support for the various measures addressed in the survey. The survey results suggest there is support for: 1. Greater oversight that is not federally mandated, 2. Self-governance mechanisms as an approach for preventing misuse of life science research and knowledge, 3. Professional and scientific societies adopting codes of conduct that include dual use research as suggested in the Fink report (NRC 2004a), 4. Establishing and implementing policies for authors and reviewers

CONCLUSIONS AND RECOMMENDATIONS 119 TABLE 4-1  Summary of Results Regarding Support for Measures of Personal and Institutional Responsibility Strongly Agree or Agree Measures of Personal or Institutional Responsibility (or Respond Yes*) (%) Principal investigators should be responsible for the 87 initial evaluation of the dual use potential of their life sciences research. Principal investigators should be responsible for training 86 lab staff, students, and visiting scientists about dual use research. Should professional science societies have codes for the 82* responsible conduct of dual use life sciences research? University and college students should receive 68 educational lectures and materials on dual use life sciences research. Scientists should provide formal assurance to their 67 institution that they are assessing their work for dual use potential. Funding agencies should require grantees to attest on 60 grant applications that they have considered dual use implications of their proposed research. Should scientific journals have policies regarding 57* publication of dual use research? Institutions should provide mandatory training for 55 scientists regarding dual use life sciences research. Greater restrictions should be placed on access to specific 47 biological agents or toxins. Researchers conducting dual use research should be 42 certified. All grant proposals for life sciences research with dual 41 use potential should be reviewed by a researcher’s institution prior to submission for funding. Scientists conducting or managing research should take 38 an oath. Research findings should be classified based on their dual 28 use potential. Dual use research needs greater federal oversight. 26 Certain experimental methods or findings should be 22 altered or removed prior to publication or presentation. Certain biological equipment that is commonly used in 21 life science research should be licensed. There should be restrictions on disclosure of details 21 about the research or its findings through personal communication. There should be restrictions on publication of findings 21 based on their dual use potential. SOURCE: NRC/AAAS Survey of Life Scientists; data analysis by staff.

120 DUAL USE RESEARCH IN THE LIFE SCIENCES to consider the dual use potential of research manuscripts submitted to journals. The survey results suggest there is opposition to: 1. Mandatory government regulations to govern the conduct of dual use research and the communication of knowledge from that research; 2. Other mandatory oversight actions, such as oaths or licensing of scientists. Based on the survey results and its own analysis, the committee believes that a basis of support exists within the U.S. scientific commu- nity for measures that, taken together, could lead to the development of a system of self-governance for the oversight of key aspects of dual use research. EDUCATION AND OUTREACH A major reason for conducting the survey was to inform efforts for education and awareness-raising about dual use research by providing empirical data on the attitudes of a sample of the life sciences community. In general, the respondents to this survey would likely support educa- tional and outreach activities aimed at raising awareness of the dual use dilemma. The respondents indicated that they supported educational materials and lectures on dual use research for students. They also sup- ported mandatory training by institutions for practicing life scientists regarding dual use research of concern. The survey results also highlight the need to better define the scope of dual use research of concern. Fewer than half of the respondents who indicated that they were carrying out dual use research activities felt that their research fell into one of the seven categories of research of concern specified by the NSABB. The dual use experiments of concern as listed in the Fink report (NRC 2004a) and by the NSABB are all based on microbial research, but other relevant research, such as theoretical research, scenario development, or applied research (e.g., pharmaceutical formulations or neuroscience research) can be of dual use concern. In their individual comments, a number of respondents stressed the difficulties of defining dual use, as did participants in the focus groups used to develop the survey. Clearly a better understanding of the scope of dual use research of real concern would help any educational or outreach activities aimed at raising the awareness of life scientists so that appropriate actions can be taken.

CONCLUSIONS AND RECOMMENDATIONS 121 Based on the survey results and its own analysis, the committee believes that there is support for mandatory education and training about dual use issues, most likely as part of ethics and responsible conduct of research training. RECOMMENDATIONS The committee believes that the survey raises several hypotheses that merit further research about the views of life scientists about oversight policies and education and outreach efforts to address concerns about dual use issues in the life sciences. In particular, based on the survey results and its own deliberations, the committee offers the following recommendations: Oversight, Education, and Outreach 1. Explore how to continue and to expand the dialogue within the life sciences community about dual use research of concern. 2. Explore ways to provide guidance to the life sciences community about appropriate actions that can be taken to protect against the misuse of dual use research. 3. Seek to better define the scope of knowledge in the life sciences that may be at greatest risk for misuse and to provide the life sciences community with criteria for recognizing dual use research of concern. 4. Encourage journals that have biosecurity policies or plan to adopt them in the future and the professional and scientific societies that have or plan to develop codes of conduct to communicate those policies more effectively. Further Research 1. Examine the effectiveness of existing educational programs and how they can be enhanced and focused. 2. Seek to extend educational and awareness-raising efforts being conducted in the United States to the broad international scientific community. 3. Examine how education and outreach activities can be developed to guide the life science community’s response to concerns about dual use research so as to ensure that actions taken by the community are appro- priate and contribute to advancing scientific knowledge while protecting national security. 4. Conduct additional surveys, interviews, or focus groups of U.S. life scientists that better represent the full community, with higher response

122 DUAL USE RESEARCH IN THE LIFE SCIENCES rates than the current study was able to achieve, and the ability to assess potential bias, in order to gain  i.  a better understanding of the awareness of a broader range of U.S. life scientists about dual use research of concern and the measure that they would support to reduce the threat that research in the life sciences could be subverted to do harm;  ii.  a better understanding of the types of behavioral changes being made in response to dual use concerns to determine if actions by life scientists are contributing to national security or harming scientific research; such research is critical given the actions that the current survey suggests are being taken;  iii.  more detailed information about the types of changes scientists are making or scientists’ thoughts about dual use issues, experiments of concern, and select agents;  iv.  a better understanding of scientists’ experiences with educa- tion on this topic and their views about the content and delivery of educational and training materials. 5. Conduct additional surveys of life scientists outside the United States that would enable comparisons of attitudes toward dual use research of concern and inform educational and outreach programs so that they can be effective on a global scale. Such knowledge could also facilitate international discussions of potential measures to address dual use concerns.

The same technologies that fuel scientific advances also pose potential risks—that the knowledge, tools, and techniques gained through legitimate biotechnology research could be misused to create biological weapons or for bioterrorism. This is often called the dual use dilemma of the life sciences. Yet even research with the greatest potential for misuse may offer significant benefits. Determining how to constrain the danger without harming essential scientific research is critical for national security as well as prosperity and well-being.

This book discusses a 2007 survey of American Association for the Advancement of Science (AAAS) members in the life sciences about their knowledge of dual use issues and attitudes about their responsibilities to help mitigate the risks of misuse of their research.

Overall, the results suggest that there may be considerable support for approaches to oversight that rely on measures that are developed and implemented by the scientific community itself. The responses also suggest that there is a need to clarify the scope of research activities of concern and to provide guidance about what actions scientists can take to reduce the risk that their research will be misused by those with malicious intent.

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Burt J, Campbell J, Abel G, et al. Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience. Southampton (UK): NIHR Journals Library; 2017 Apr. (Programme Grants for Applied Research, No. 5.9.)

Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience.

Chapter 12 conclusions, implications for practice and recommendations for future research.

• Conclusions

In Chapter 1 we outlined how, following the introduction of a wide range of quality improvement strategies as part of an overarching ‘clinical governance’ strategy in the late 1990s, there had been step changes in the management of major chronic diseases in the NHS. However, the ways in which patients experienced health care had not been given such a priority and the need for a rebalancing was seen by increasing attention to patient experience in policy documents, the routine publication of patient experience data, benchmarking of hospitals in relation to patient experience and even an (ill-fated) attempt to attach payments to patients’ assessments of their GP ’s care.

There has therefore been widespread acceptance that good patient experience is an important outcome of care in its own right and our work 304 and that of others 305 has shown that patient experience is a domain of quality that is distinct from, but complementary to, the quality of clinical care. Although an increasing number of surveys have been developed to measure patient experience, there has been equally widespread acceptance that these measures have not been very effective at actually improving care. 45 This is the background to our programme of work. Entitled IMPROVE , we aimed to find better ways of both measuring and using information on patient experience that would lead to improvements in patient care in both in-hours and out-of-hours primary care settings.

In the introduction, we described a range of ways of obtaining patient feedback on their care, including surveys, focus groups and analysis of complaints. In this programme, we have focused on the use of patient surveys as they are the dominant method currently used in the UK. However, in Chapter 10 we describe an exploratory trial of RTF , which moves away from the paper-based questionnaires that still dominate the measurement of patient experience in the NHS.

This programme had seven aims, each of which was tied closely to one work package of research. These aims were to:

• understand how general practices respond to low patient survey scores, testing a range of approaches that could be used to improve patients’ experience of care
• estimate the extent to which aggregation of scores to practice level in the national study masks differences between individual doctors
• investigate how patients’ ratings on questions in the GP Patient Survey relate to actual behaviour by GPs in consultations
• understand better patients’ responses to questions on communication and seeing a doctor of their choice
• understand the reasons why minority ethnic groups, especially South Asian populations, give lower scores on patient surveys than the white British population
• carry out an exploratory RCT of an intervention to improve patient experience, using tools developed in earlier parts of the programme
• investigate how the results of the GP Patient Survey can be used to improve patients’ experience of out-of-hours care.

The aims of the programme did not change during the 5 years of our research, although some details of the research were modified as the work progressed (we have summarised any changes in each individual chapter). We presented the results of our research under three broad headings and also use these headings in this conclusions chapter, namely:

• understanding patient experience data (aims 3 and 4)
• understanding patient experience in minority ethnic groups (aim 5)
• using data on patient experience for quality improvement (aims 1, 2, 6 and 7).

Understanding patient experience data

Patient surveys are now widely used in many countries, yet still comparatively little is known about what experiences lead patients to respond in particular ways in these surveys. What drives them to tick particular boxes and how do those responses relate to the care that they have actually received? We approached this in two main studies, one in which we asked patients directly about how they chose certain items on the questionnaire while showing them a video of their consultation (see Chapter 2 ) and one in which we compared their responses with those of expert raters using two standard instruments for assessing videos of consultations (see Chapter 3 ). The results of these studies have important implications for the interpretation of survey data, particularly data focused on patient evaluations of specific encounters with health-care professionals.

The first study (see Chapter 2 ) showed that, although patients readily criticised their care when reviewing GP consultations on video, they had been reluctant to be critical when completing a questionnaire after the consultation. Reasons for this included the need to maintain a relationship with the GP (including uncertainty about how confidential survey results would be) and their gratitude for the care that they had received from the NHS in the past. In addition, perceived power asymmetries made people reluctant to criticise their doctor. Patients were also disinclined to be critical when completing a questionnaire if they had actually received the treatment that they wanted. Overall, we concluded that patients find that questionnaires administered at the point of care may be limited tools for being able to feed back concerns about primary care consultations.

The second study (see Chapter 3 ) reinforced our conclusion from Chapter 2 that patient evaluations of consultations in surveys may present an uncritical view of the actual consultations. In this study videotapes of GP –patient consultations were assessed by four independent clinical raters. The results were striking. When trained raters rated communication within a consultation to be of a high standard, patients did the same (with one single exception). However, when trained raters judged the communication during a consultation to be of a poor standard, patients’ assessments varied from poor to very good. This finding again points to the reluctance of patients to criticise their doctor in questionnaire surveys. In the previous study the ‘gold standard’ was the patient’s own account of the consultation and in this study the standard was that of a trained external GP rater.

We do not think that these results mean that patient surveys cannot be used to assess the quality of general practice care. However, they do point to clear limitations. One of the concerns that GPs have about surveys (see Chapters 7 and 8 ) is that they are selectively completed by critical or grumpy patients and that survey results will therefore give a negative and biased view of their care. The results of the two studies described here suggest that the opposite is the case. Patients’ reluctance to criticise their doctor means that survey responses using evaluative type of questions are likely to give an overly positive view of their doctor’s care. This is one reason why there has been a move towards using report items in some survey instruments (though we do not know whether or not these suffer from similar problems). Because of this tendency for patients to choose the most positive response options, we suggest that absolute scores should be treated with some caution, as they may present an overly optimistic view of their care. However, this does not mean that surveys cannot be used to look at relative scores: scores from a GP that are lower than those of his or her colleagues and from GPs in other practices are likely to indicate a problem, even though high scores from other doctors or practices may conceal deficiencies in care in those practices too.

We also looked at how GPs rated their own consultations. GPs completed a form immediately after each consultation, using the same scale as the patients. GPs were certainly more inclined to criticise themselves than the patients were to criticise the care that they had received. This is entirely consistent with the findings from our subsequent interviews with patients. However, we found absolutely no correlation between patient scores and GP scores. Neither did we find any correlation between GPs’ own scores and those of expert raters who reviewed the consultations on video. GPs are clearly using different parameters when assessing their own performance, but we were not able to investigate this in more detail in this study.

When we spoke to GPs about their survey results (see Chapters 7 and 8 ), through both focus groups and face-to-face interviews, they reported how, although positive about the concept of patient feedback, they struggled to engage with and make changes under the current approaches to measurement. They also commonly expressed concern that patients would be critical of their care if they did not get what they wanted (e.g. an antibiotic prescription). This concern was borne out to some extent by our results. In our analysis of the assessment of nurses (see Chapter 4 ), a strong predictor of survey scores was whether or not patients wanted to see a nurse when they first contacted the practice. If they had wanted to see a GP but saw a nurse, the scores given to those nurses were much lower. We have no reason to think that the nurses’ communication was worse in those consultations and the low scores may therefore indicate a more general dissatisfaction of patients because of not having their original expectations met.

It is important to understand that, in line with the overall aims of the programme, the work in these two chapters focused on the assessment of communication in the primary care consultation (such as giving the patient enough time and explaining tests and treatments). Our conclusion that survey scores have more value in assessing relative performance than absolute performance of doctors may or may not hold true for other aspects of practice performance commonly assessed in surveys, such as difficulty in getting appointments, getting through on the telephone and waiting times. Patients’ reasons for not wanting to criticise their doctor may be less important when they assess what they regard as management aspects of the practice.

A second aspect of care that we identified as part of our programme of work relates to patients’ ability to see a GP of their choice. Although most of our research focused on communication, the results that we report in Chapter 4 have some important findings in relation to patient choice. 142 The results show that most patients have a particular GP who they prefer to see. It is sometimes suggested that this matters only for some population groups (e.g. not young people) but we found that this is not the case. Even among those aged 18–24 years, > 50% of respondents to the GP Patient Survey have a particular doctor who they prefer to see, rising to > 80% in those aged > 75 years. Disturbingly, a large percentage of people who have such a preference are unable to see the doctor of their choice. This percentage has risen from 30% to 40% from 2010 to 2015. One possible impact of this change comes from our analysis of data from patients who saw a nurse when they had originally wanted to see a doctor; they expressed considerable dissatisfaction with their subsequent consultation with the nurse. However, these data do not reflect what would have happened if patients had seen another doctor, just not the one of their choice.

Overall, patients express more negative opinions about choice of doctor than in any other part of the GP Patient Survey, something that may in part have got worse as a result of government policies to improve access. There is a clear tension between the ability of practices to provide rapid access and the ability of practices to provide continuity of care and data from our studies suggest that patients’ inability to see a doctor of their choice is a significant quality issue for the NHS.

Understanding patient experience in minority ethnic groups

In this part of our research, we focused our main work on survey responses from minority ethnic groups and on South Asian groups in particular. The general interest in minority ethnic groups is because they tend to report worse experiences using surveys in most countries studied, including in the UK. Our research on out-of-hours care in this programme ( see Chapter 11 ) replicated this result, with Asian and mixed ethnic groups reporting worse experiences than the white majority.

Our specific focus in the major strand of this research was on South Asian respondents because of the size of this group in England and the consistently low scores generated by this group in English surveys across both primary and secondary care settings. We focused on questionnaires competed in English; although the GP Patient Survey is available in 15 languages, a tiny minority of surveys are completed in languages other than English (typically < 0.2% of returns).

A number of potential explanations have been suggested for the lower ratings given by South Asian and other minority ethnic groups. Broadly, these relate to whether these groups of patients (1) receive lower-quality care or (2) receive the same care but rate this more negatively. 75 For example, such respondents might rate the same care more negatively if they have higher expectations or because they interpret the survey items and response options in different ways (such as being culturally less likely to check extreme options).

The last of these options was potentially the simplest to explore. Taking advantage of the large numbers of respondents available in the GP Patient Survey to examine the responses of South Asian groups using item response theory and allowing for a wide range of other sociodemographic characteristics (see Chapter 5 , Workstream 3 ), we found no evidence that South Asian respondents used the scales in a different way from white British respondents. Although these results do not provide conclusive evidence of equivalence in the way in which different respondents use the survey scales, they increase the likelihood that the worse experience reported by South Asian respondents reflects either differences in expectations or genuinely worse care. Our previous work 75 suggested that, for one aspect of care (waiting times), South Asian respondents might have higher expectations of care, implying that their lower scores on surveys might not be associated with worse care. We were able to advance our understanding of this complex issue considerably as a result of the research in this programme.

First, we showed that South Asian respondents to the GP Patient Survey tend to be registered in practices with generally low scores. This explained about half of the difference in reported experience between South Asian and white British patients (see Chapter 5 , Workstream 1 ) and identified that some practice effects were related to the ethnicity of the doctor (with minority ethnic doctors receiving lower scores for doctor–patient communication; see Chapter 5 , Workstream 4 ). However, these practice effects did not account for the low scores among South Asian patients, even though the differences were reduced when practices offered consultations in a South Asian language 172 (PhD project allied to our programme). Next, we showed that, far from being uniform across all population groups, the lower scores from South Asian patients were much more marked among older female respondents. It was therefore important in our subsequent work to ensure that these patients were represented in our research (see Chapter 5 , Workstream 2 ).

In video elicitation interviews with South Asian patients (see Chapter 2 ), we identified the same issues driving evaluations of communication in South Asian as in white British patients: their relationship with their GP (and others within the practice), their expectations of the consultation and a reluctance to criticise their doctor’s performance. The finding that South Asian patients are assessing broadly similar issues when completing questionnaires therefore still leaves unanswered the question of why scores from South Asian patients are low.

The final and most original part of this work provides insight into this (see Chapter 6 ). Here, we filmed 16 simulated consultations based on transcripts of real consultations using various combinations of white and Asian doctors and patients, with half scripted to be ‘good’ and half scripted to be ‘poor’. We showed three randomly sampled videos to each of 1120 people (half of whom were white British and half of whom were Pakistani, equally split between those aged < 55 years and those aged ≥ 55 years) and asked them to score the consultations using the communication items from the GP Patient Survey.

If the low scores reported by South Asian patients in real-life settings were the result of higher expectations on their part, then we would expect them to give lower scores in the experimental vignette situation. However, quite the reverse happened. When viewing the same consultations, South Asian respondents gave scores that were higher, indeed much higher when adjusted for sociodemographic characteristics, than those of the white British respondents. This suggests that the low scores given by South Asian patients in surveys such as the GP Patient Survey reflect care that is genuinely worse, and possibly much worse, than that experienced by their white British counterparts. This is consistent with the only previous study of this type in which predominantly written consultations were shown to people from different ethnic groups in the USA, with the conclusion being that differences in ratings were more likely to represent differences in care than differences in expectations or scale use. 81

There is a clear practice implication of this result: low scores from South Asian patients should be investigated as possible indicators of poor care. This is relevant to all settings, not just primary care.

Using data on patient experience for quality improvement

The results that we have discussed so far indicate that the results of patient experience surveys such as the GP Patient Survey can identify areas where there are important gaps in care that the NHS provides, such as patients being able to see a doctor of their choice. However, although patients tend to give very high scores for doctor–patient communication, these conceal significant negative experiences that patients describe when shown, and which independent observers can see in, recorded primary care consultations. These issues extend to minority ethnic patients and our research suggests that the negative scores that South Asian patients record (compared with those of white British patients) do represent genuine problems with care. This therefore brings us to the important issue of how data from patient surveys can be used to improve care.

Current national approaches to measuring patient experience, including communication, rely on practice-level assessments of care. In Chapter 9 , we outline the results of a patient experience survey that we conducted across 25 general practices, asking patients specifically about their experience of a particular consultation with a named GP . We found that practice-level scores for communication mask considerable variation between GPs within each practice, notably for those practices receiving poorer communication scores overall. Such ‘poorly performing’ practices, which may be identified as such through the national GP Patient Survey, may in fact contain GPs with communication skills ranging from very poor to very good. This has important implications for the use of national survey data to identify primary care practices and practitioners in need of improvement.

In Chapters 7 and 8 we describe the two studies in which we sought the views of GPs and practice staff on survey results, seeking to understand how they could better be used as quality improvement tools. Chapter 7 describes focus groups with practice staff following feedback of practice-level scores for patient experience and Chapter 8 describes interviews with GPs after we had conducted a survey in which they received individual feedback from surveys returned by patients whom they had seen in the surgery. In Chapter 11 , we describe how out-of-hours providers use data from patient surveys.

Broadly, staff in different primary care settings neither believed nor trusted patient surveys. Concerns were expressed about the validity and reliability of surveys (some practices have very low rates of response) and about the likely representativeness of those who responded. Some practice groups mentioned recent negative experiences with pay linked to survey scores as part of the QOF (a technicality of the payment schedule meant that payments could be reduced even though practice performance had improved). There was also a view expressed that some patients had unreasonable expectations: staff worked as hard as they could and could not be expected to respond to all patients’ ‘wants’. Some practices did describe improvements that they had made as a result of survey results. Those that were easiest to engage with related to practices’ office functions such as appointment systems and telephone answering systems. Addressing an individual doctor’s performance (e.g. communication skills) was much more difficult. Out-of-hours service staff were also concerned that service users did not understand the complex care pathways within urgent care settings and that this might lead to unrealistic expectations of what individual services were expected to deliver. Staff viewed surveys as necessary, but not sufficient. Clear preferences for more qualitative feedback to supplement survey scores were expressed as this provided more actionable data on which to mount quality improvement initiatives.

The doctors who we interviewed expressed markedly ambivalent views in discussing feedback from surveys. Although they had a number of concerns about individual doctor surveys (credibility, reliability, concerns about patient motivation), they also expressed positive views about the importance of patient feedback in monitoring and improving services.

These results led us to consider how patient feedback might be obtained in a way that would engage doctors more actively with patient survey results to stimulate quality improvement. We conducted a preliminary evaluation of RTF , using touch screens that patients could use to leave feedback following a primary care consultation. RTF was selected to address some of the problems identified by our research, such as providing practice feedback on a much more regular basis (e.g. fortnightly) and allowing practices the opportunity to add questions of their own to the RTF survey to increase the relevance of the results to their service.

As RTF has not been widely used, an exploratory RCT and qualitative study were conducted to answer questions about the feasibility of using RTF in real-world general practice, estimate likely response rates, obtain patient and staff views on providing feedback in this way and estimate the costs to a practice of introducing RTF. We also included facilitated feedback in one arm of the exploratory trial.

In the exploratory trial, only 2.5% of consulting patients left any RFT without prompting; however, if encouraged to leave RTF by staff, as many as 60% of patients did so. Encouragement was rare, with such encouragement provided in only 5% of > 1100 patient–staff interactions that we observed in reception areas. Of patients who used a touch screen to leave RTF, 86% found it easy to use and were positive about it as a feedback method. Lack of awareness of the screens and lack of time were the most common reasons given for not providing feedback.

Staff were broadly positive about using RTF and practices valued the ability to include their own questions in the survey. Practices that had open communication between staff members tended to be more positive about using patient feedback. Practice staff identified clear benefits from having a facilitated session for discussion of patient feedback and having protected time to discuss the results.

Had practices not been taking part in a research study, the cost of RTF to practices would have been substantial at > £1000 for the 12 weeks, with the bulk of the cost relating to provision of the equipment and analysis and feedback of the data collected from the touch screens.

Although the absolute number of patients providing RTF to each practice (> 100) was comparable to the number of respondents per practice in the national GP Patient Survey, we do now know how the considerably lower response rate in our RTF study (2.5%) would have affected the outcome of the patient experience surveys (it was not part of our study design to find this out). We do not know how representative or valuable the views of a small proportion of patients who respond are, just as we do not know how representative are the views of the very small numbers of patients providing the narrative feedback that is recorded on NHS Choices.

Considering these results together, we have been able to identify some clear learning to take forward into a future clinical trial examining the potential utility and effectiveness of RTF in informing service delivery in primary care.

• Implications for practice

The work that we have carried out over the 5 years of the programme grant has clear implications for practice. We summarise these here.

The importance of patient experience

Our research supports the continuing emphasis on obtaining patient experience feedback as an important means of informing NHS care. Although continuing effort should be invested in refining the most effective and meaningful mechanism to capture high-quality patient feedback, the key challenge is to provide primary care staff with the support and means to enable them to act on patient feedback.

The need for action on the quality of care for minority ethnic groups

There has been much speculation whether the lower scores reported by minority ethnic groups on numerous patient experience surveys are ‘real’, reflecting poorer quality of care, or are an artefact of the questionnaires used or higher expectations of care. We have now conducted a series of studies to progressively examine this issue to understand with greater certainty the major drivers of reported variations in care. Examinations of survey responses, interviews with patients and an innovative experimental vignette study combine to strongly suggest that it is the former: patients from South Asian backgrounds experience considerably poorer communication with GPs than their white British counterparts. It is of concern that survey results may be dismissed as artefactual when, in fact, they are likely to point to real areas of concern. Effort should be invested to ensure that lower scores from such groups on patient experience surveys in both primary care and secondary care are investigated as markers of poorer quality of care.

Patients give overly positive responses when rating their care

Our results show the difficulty that patients have in feeding back negative experiences in questionnaire surveys. This suggests that there is more work to be done in improving patient experience than might be suggested by the high scores that are commonly seen in patient surveys. However, patients’ reluctance to criticise a doctor or provider with whom they have to maintain an ongoing relationship will not be addressed simply by changing the survey method. Efforts should be made to ensure that providers and managers understand that absolute scores paint an optimistic picture of patients’ true views.

Surveys are not sufficient to fully capture patient feedback

Across primary and out-of-hours care settings, staff view patient surveys as necessary, but not sufficient. Alternative methods for gaining more qualitative feedback were commonly used to supplement survey scores, with free text often viewed as providing more actionable data than responses to standard survey questions. Taken alongside our findings on patients’ reluctance to criticise doctors through surveys and staff challenges to the credibility of surveys, we suggest that additional approaches are therefore needed to better capture aspects of patient experience that can be used to improve the quality of care.

The need for valid, reliable individual-level feedback for doctors

Despite the comments above, we have shown that there is substantial variation in performance within practices for aspects of care related to individual doctors (e.g. doctor–patient communication). Reporting patient experience at practice level masks this variation and makes it more difficult for doctors to relate to feedback. However, we have also shown that, if a practice has overall high scores for doctor–patient communication, it is very unlikely that such a practice contains a low-scoring doctor. In contrast, when a practice is low scoring, individual doctors may be high or low scoring. Therefore, if there are additional requirements for individual-level surveys, they could be focused on practices with low overall scores. Additionally, robust mechanisms are required to help practices, particularly lower-scoring practices, identify and support individual doctors whose patient feedback identifies areas of potential improvement.

We note that, at present, data are provided at practice level for the GP Patient Survey, scores are produced at practice level for the Friends and Family Test and GPs have to provide individual-level surveys to meet GMC requirements for revalidation. This results in considerable overlap and duplication and adds to the sense that these are ‘boxes to be ticked’ rather than sources of information that are valuable for improving care.

Patient surveys need to become more meaningful to staff

Our research shows that primary care staff in different settings are ambivalent about the value of patient surveys. Although believing in general about the importance of issues such as doctor–patient communication, they use every opportunity to challenge the credibility and reliability of scores produced by national surveys. This is not helped by their recent experiences, for example of a poorly conceived attempt to tie financial incentives to patient reports of waiting times to get an appointment 306 and the imposition of the Friends and Family Test, which is even regarded by NHS England as being of limited value for comparing health-care organisations. 60

On the whole, practices found it easier to engage with items on surveys that related to practice management (e.g. availability of appointments, ability to get through on the telephone) than to items that related to issues around communication between patients and clinical staff. Staff viewed surveys as necessary, but not sufficient, and expressed a clear preference for qualitative feedback to supplement survey scores as this provided more actionable data on which to mount quality improvement initiatives.

Immediacy of feedback, regularity of feedback and having some control over the questions asked were all aspects of our experiment with RTF that were valued by practices and had the potential to make feedback more useful. However, a number of important questions remain before RTF could be recommended as a replacement for postal questionnaires. We outline these in the next section on research recommendations.

The value of surveys in monitoring national trends

Despite some reservations about the value of national surveys as vehicles for stimulating quality improvement in general practices and out-of-hours services, they can be important for monitoring national trends. For example, the GP Patient Survey is the only source of data which demonstrates that, year on year, from 2010 to 2015, patients report that they have had increasing difficulty in seeing a doctor of their choice. Indeed, for out-of-hours services the GP Patient Survey is the only way to monitor such trends as individual services use very different tools and approaches, precluding comparisons. Additionally, patient feedback – particularly in secondary care – is used for organisational risk assessment and regulatory monitoring. However, when national surveys are used to monitor trends in care it is important that the questions stay the same. In contrast to questions in the GP Patient Survey related to whether or not patients are able to see a doctor of their choice, questions in the survey on access have undergone major changes, making it difficult to follow long-term trends. However, it should be noted that much smaller sample sizes are required to monitor national trends and comparable national surveys often include tens of thousands of participants rather than millions. Our work on out-of-hours care suggests some ways in which the current questions in the GP Patient Survey could be improved.

Development of surveys in out-of-hours care

Our work on the use of patient experience surveys in out-of-hours care highlights a number of areas requiring consideration. National quality requirements (NQR5) state that all out-of-hours services must audit patient experience but provide no information on how to do this. 307 In the absence of clear guidance on tools and approaches, many services are taking different tacks to both collect and act on patient feedback. As well as being inefficient in approach, with little consistency or shared learning, this also precludes national comparisons being made between providers. We suggest that NQR5 should be reviewed and tightened to avoid the duplication of effort occurring in different services.

Second, out-of-hours items from the GP Patient Survey are now being used for the purposes of CQC and National Audit Office monitoring of out-of-hours care. Our research in this area commenced prior to the launch of the CQC and providers knew little about the GP Patient Survey and expressed concern about the relevance of the out-of-hours items. Our research suggests that, subject to minor amendments, the GP Patient Survey is suitable for this kind of national monitoring of out-of-hours care; indeed, it is the only current approach suitable for monitoring, given the variation in approaches to patient feedback currently taken by service providers. However, although the GP Patient Survey enables the use of benchmarking, it is not sufficiently detailed to support quality improvement and as such is unlikely to replace the in-house methods and tools being used by providers. We also note that current presentations of GP Patient Survey data for out-of-hours care are at ‘commissioner’ level; as providers often cover more than one commissioner level, such analyses may not highlight problems occurring at the larger organisational level. Finally, to look at the performance of different out-of-hours providers on key patient experience measures, it is important that NHS England maintains a list of such providers to ensure oversight, which it currently does not.

Overall, large-scale postal surveys are likely to remain the dominant approach for gathering patient feedback for the time being, although refinements to this approach as well as the development of other modes are required to address the weaknesses that we have identified. We are aware that providers are experimenting with a wide range of other approaches, one of which ( RTF ) has been part of our research. Other methods include interviews and focus groups, online feedback, analysis of complaints, practice participation groups and social media. In the following section, we outline recommendations for research and identify the criteria that any new methods will need to meet to become useful quality improvement tools.

• Recommendations for research

The world of patient feedback is becoming increasingly diverse and complex, with standard patient survey approaches being supplemented by the use of tablets, kiosks, online feedback, including that provided by the NHS and by commercial organisations, analysis of complaints, the use of interviews and focus groups and practice participation groups. In addition, social media may come to play an important part in how patients choose their doctor and how they feed back on their experiences. Some of these new approaches are being evaluated in terms of their ability to provide more detailed information on what is needed to improve services, for example using patient narratives 308 and through the analysis of internet-based feedback. 309 , 310 However, despite the plethora of approaches to gathering patient feedback, our research demonstrates that there is a major deficit in taking action as a result of such feedback. Enabling and supporting providers to engage with and plan changes may require complex whole-system approaches, and our knowledge of what is most effective in this area is currently sparse.

Research is therefore needed into how gathering and acting on patient feedback may be best supported, across five key areas:

• How patient experience can be captured so that it more effectively identifies areas of performance that could be improved – this should include investigation of diverse methods of obtaining patient feedback to support patients to highlight poor care when necessary. An additional important area of work is how some of the issues highlighted within this report, such as patients’ reluctance to criticise, apply to different approaches to assessing patient experience using either rating-type or report-type questionnaire items.
• The system, practitioner and patient factors that influence poorer reported experiences of care in South Asian patient groups and how these may be addressed – this should include a particular focus on the impact of cross-cultural consultations.
• How information from patients can be fed back to clinicians and services in a way that appears credible to them – this should include evaluations of approaches to increase the plausibility of patient surveys, such as greater use of benchmarking and innovative ways of presenting and interpreting findings, as well as assessment of varying, tailored ways of presenting feedback to the different health-care professionals who might receive feedback on their care. Of additional relevance here is how clinicians are encouraged to reflect on their own performance and others’ assessments of this, with the aim of understanding where and how gaps in evaluations may occur.
• How services can be organised and managed in such a way that patient feedback is seen as a positive opportunity for improving services.
• What interventions are most effective in improving care when deficiencies in care are identified – the area where there is the greatest gap here is in doctor–patient communication, with our results showing that clinicians have great difficulty in even discussing deficiencies among their colleagues and that few effective interventions exist.

Our finding in the research on out-of-hours care that commercial providers had lower ratings for patient experience than services provided by the NHS is consistent with previous work suggesting that practices working under Alternative Provider Medical Services contracts, which are sometimes provided by the private sector, may provide worse care. 311 However, the circumstances in which commercial providers gain contracts for primary care services may be very different from those in other areas. The way in which the primary care workforce is configured is changing rapidly, with an increase in the proportion of salaried GPs, the development of GP federations and super-practices and an increase in the number of large-scale provider groups (owned both by commercial companies and by GPs). It is important that these changes should be monitored so that we understand their impact on quality of care.

Included under terms of UK Non-commercial Government License .

• Cite this Page Burt J, Campbell J, Abel G, et al. Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience. Southampton (UK): NIHR Journals Library; 2017 Apr. (Programme Grants for Applied Research, No. 5.9.) Chapter 12, Conclusions, implications for practice and recommendations for future research.
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