Blending critical realist and emancipatory practice development methodologies: making critical realism work in nursing research

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

“Come together”: a thematic analysis of experiences with belonging

Purpose

The purpose of this paper is to explore, describe and interpret two research questions: How do persons with co-occurring mental health and substance abuse problems, living in supportive housing, experience belonging? How do residential support staff experience promoting a sense of belonging for persons with co-occurring mental health and substance abuse problems, living in a supportive housing?

Design/methodology/approach

Individual semi-structured interviews were conducted with five persons with co-occurring mental health and substance abuse problems living in supportive housing in a Norwegian district. In addition, one semi-structured focus group was conducted with nine residential support staff. All interviews were transcribed verbatim and analyzed using thematic analysis.

Findings

Analysis resulted in three main themes: “I do not go to sleep in my pajamas”, “Do I have a choice?” and “Be kind to each other”.

Research limitations/implications

More research on how inclusive practices that are commonly described in guidelines actually affect the experience of residents and residential support staff is needed.

Practical implications

Practices that incorporate a communal and contextual understanding when assigning supportive housing are warranted.

Originality/value

By paying attention to the components of social recovery, this paper provides a nuanced understanding of how persons with co-occurring mental health and substance abuse problems, living in supportive housing, experience belonging. In addition, residential support staffs’ experiences with promoting a sense of belonging for this group are explored.

Personality, Work-Life Balance, Hardiness, and Vocation: A Typology of Nurses and Nursing Values in a Special Sample of English Hospital Nurses

This initial report of a longitudinal study of 192 English hospital nurses measured Nursing Values (the 6Cs of nursing); Personality, Self-Esteem and Depression; Burnout Potential; Work-Life Balance Stress; “Hardy Personality”; and Intention to Leave Nursing. Correlational, component, and cluster analysis identified four groups: “The Soldiers” (N = 79), with medium scores on most measures, who bravely “soldier on” in their nursing roles, in the face of numerous financial cuts to the National Health Service, and worsening nurse–patient ratios; “Cheerful Professionals” (N = 54), coping successfully with nursing roles, and a variety of challenges, in upwardly mobile careers; “High Achievers” (N = 39), senior nurses with strong profiles of a “hardy personality”, and commitment to fundamental nursing values; and “Highly Stressed, Potential Leavers” (N = 20), with indicators of significant psychological distress, and difficulty in coping with nursing role challenges. We have initiated a program of co-counselling and social support for this distressed group, by nurses who are coping more successfully with multiple challenges. We discuss the role of nurse educators in fostering nursing values, developing and supporting a “hardy personality” and emotional resilience in recruits to nursing. This study is framed within the disciplinary approach of Critical Realism, which identifies the value basis for research and dialogue in developing strategies for social change. The importance of this research is that: (a) it is part of the new thrust in nursing research, applying Critical Realist theory and methodology to research on nursing stress; (b) it has established, through network sampling, a group of nurses who can be supportive of each other in their stressful careers; (c) it establishes the reliability and potential validity of a measure of core nursing values; (d) it is among the first studies in research on nursing stress, to use the humanizing methodology of moving from data analysis (description of “things”), to describing a typology of nursing stress and career progress (description of individuals).

Developing allied health leaders to enhance person-centred healthcare

PURPOSE

The purpose of this paper is to present findings from a mixed methods study investigating leadership development of allied health practitioners within a large public healthcare organization in Australia.

DESIGN/METHODOLOGY/APPROACH

The South Eastern Sydney Local Health District Allied Health Leadership Development Program was undertaken with an allied health cohort ( n=16) between May 2014 and March 2015 and comprised all-day workshops, action learning sets and individual coaching. Using experiential learning, the program tested whether practice development methods and action learning approaches developed the leadership skills of participants compared with a control group ( n=17). Descriptive statistics were collected to evaluate participant and program outcomes. Leadership, workplace culture and engagement measures were analyzed as part of the study.

FINDINGS

The Allied Health Leadership Development Program received high ratings by participants. They reported enhanced skills in leading self and others through mechanisms such as critical reflection and facilitation, and greater confidence managing change and with engaging staff, colleagues and patients in decision making, affecting the quality and safety of healthcare. Statistically significant differences were found with transformational leadership elements, leadership outcomes, and measures of workplace culture and engagement after program completion for intervention group participants, compared with the control group.

RESEARCH LIMITATIONS/IMPLICATIONS

Results provide new empirical evidence about the effectiveness of using practice development for allied health leadership development.

PRACTICAL IMPLICATIONS

This low-cost leadership program can be replicated by other organizations.

ORIGINALITY/VALUE

Outcomes from an Allied Health Leadership Development Program have not been previously reported in the literature.

Facilitating transition from children's to adult services for young adults with life-limiting conditions (TASYL): Programme theory developed from a mixed methods realist evaluation

BACKGROUND

Improvements in care and treatment have led to more young adults with life-limiting conditions living beyond childhood, necessitating a transition from children's to adult services. Given the lack of evidence on interventions to promote transition, it is important that those creating and evaluating interventions develop a theoretical understanding of how such complex interventions may work.

OBJECTIVES

To develop theory about the interventions, and organisational and human factors that help or hinder a successful transition from children's to adult services, drawing on the experience, knowledge, and insights of young adults with life-limiting conditions, their parents/carers, and service providers.

DESIGN

A realist evaluation using mixed methods with four phases of data collection in the island of Ireland. Phase one: a questionnaire survey of statutory and non-statutory organisations providing health, social and educational services to young adults making the transition from children's to adult services in Northern Ireland and one Health Services Executive area in the Republic of Ireland. Phase two: interviews with eight young adults. Phase three: two focus groups with a total of ten parents/carers. Phase four: interviews with 17 service providers. Data were analysed seeking to explain the impact of services and interventions, and to identify organisational and human factors thought to influence the quality, safety and continuity of care.

RESULTS

Eight interventions were identified as facilitating transition from children's to adult services. The inter-relationships between these interventions supported two complementary models for successful transition. One focused on fostering a sense of confidence among adult service providers to manage the complex care of the young adult, and empowering providers to make the necessary preparations in terms of facilities and staff training. The other focused on the young adults, with service providers collaborating to develop an autonomous young adult, whilst actively involving parents/carers. These models interact in that a knowledgeable, confident young adult who is growing in decision-making abilities is best placed to take advantage of services - but only if those services are properly resourced and run by staff with appropriate skills. No single intervention or stakeholder group can guarantee a successful transition. Rather, service providers could work with young adults and their parents/carers to consider desired outcomes, and the range of interventions, in light of the organisational and human resources available in their context. This would allow them to supplement the organisational context where necessary and select interventions that are more likely to deliver outcomes in that context.

Moments of speaking and silencing: Nurses share their experiences of manual handling in healthcare

Nursing care involves complex patient handling tasks, resulting in high musculoskeletal injury rates. Epidemiological studies from the 1980s estimated a lifetime prevalence of lower back injuries for nurses between 35 and 80%. National and international studies continue to mirror these findings. Despite the development of programs intended to reduce manual handling injuries, sustainable solutions remain elusive. This paper reports on a study of nurses speaking about their perspectives on current manual handling practices. Qualitative research conducted in 2012 investigated nurses' perceptions and experiences relating to manual handling in the healthcare context and their participation in injury prevention programs. There were two research methods: semi-structured interviews and researcher reflective journaling. The research was framed in critical emancipatory methodology. Thirteen nurses from two Australian states participated in the study. Thematic analysis revealed an overarching theme of 'power relations' with a subcategory of '(mis)power' that comprised two subthemes, these being 'how to practice' and 'voicing practice issues'. Specifically, this paper explores nurses verbalising their views in the workplace and responses which left them feeling silenced, punished and disillusioned. The findings suggest that the sociopolitical context within which nurses practice impacts upon their ability to voice concerns or ideas related to manual handling. Inclusion of nurses in the manual handling dialogue may generate an expanded understanding of, and the potential to transform, manual handling practices in healthcare environments.

Developing nursing and midwifery research priorities: a Health Service Executive (HSE) North West study

AIM

The primary purpose of this study was to identify research priorities for nurses and midwives across the Health Service Executive (HSE) North West region. The rationale for the study was underlined during meetings of HSE North West Directors of Nursing and Midwifery in January 2011. It was agreed that a more strategic approach to generating synergy among nursing and midwifery research, evaluation, and evidence-based practice should be developed through the Nursing and Midwifery Planning and Development Unit.

METHODS

The research design was founded upon collaborative processes for consensus building that included the Delphi technique and nominal group technique. The study sample included a panel of experts. Data were collected between March 2011 and December 2011.

FINDINGS

Findings from this study validate the efficacy of the research methodology in enabling the effective identification of priority areas for research. These include: (a) an evaluation of the impact of postgraduate nursing and midwifery education programs focusing upon patient, professional, and organizational outcomes; (b) development and evaluation of an effective culture of nurse- and midwife-led audit across all services within a Regional Health Trust in Ireland; (c) an examination of the efficacy of approaches to clinical supervision within the context of the Irish health system; (d) an evaluation of the impact of an Advanced Nurse Practitioner role in supporting the effective management of long-term conditions within the context of Regional Health Trust primary care settings in Ireland; and (e) Supporting and developing an ethical framework for nursing and midwifery research within a Regional Health Trust in Ireland.

LINKING EVIDENCE TO ACTION

It is anticipated that future work, outlined within this paper, will lead to important improvements in patient care and outcomes. Furthermore, this study provides evidence that a strong nursing and midwifery research agenda can be established upon genuine collaborations and partnerships across varying levels of research knowledge and skills, but with a shared purpose and shared values.