A Realist Review Protocol into the Contexts and Mechanisms That Enable the Inclusion of Environmental Sustainability Outcomes in the Design of Lean Healthcare Improvement Interventions

Healthcare makes a significant contribution to the social, economic and environmental benefits of communities. It is correspondingly a significant employer and consumer of both energy and consumables, often at high costs. Lean, a quality improvement methodology focuses on the elimination of non-value add (NVA) activities (steps that do not add value from the perspective of the customer) to improve the flow of people, information or goods. Increasingly, Lean thinking is evolving from its initial focus on eliminating NVA to a more holistic approach that encompasses sustainability. However, little work has been undertaken intentionally, including environmental sustainability outcomes in Lean healthcare interventions. Realist review methodology facilitates an understanding of the extent to which an intervention works, for whom, in what context, why and how, and has proven useful in research relating to Lean interventions in healthcare settings. This protocol provides details for a realist review that will enable an understanding of the specific contexts in which certain mechanisms are activated that enable the inclusion of environmental sustainability outcomes in the design of Lean healthcare improvement interventions.

A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice

Quality measurement initiatives promote quality improvement in healthcare but can be challenging to implement effectively. This paper presents a Rapid Realist Review (RRR) of published literature on Quality Care-Process Metrics (QCP-M) implementation in nursing and midwifery practice. An RRR informed by RAMESES II standards was conducted as an efficient means to synthesize evidence using an expert panel. The review involved research question development, quality appraisal, data extraction, and evidence synthesis. Six program theories summarised below identify the key characteristics that promote positive outcomes in QCP-M implementation. Program Theory 1: Focuses on the evidence base and accessibility of the QCP-M and their ease of use by nurses and midwives working in busy and complex care environments. Program Theory 2: Examines the influence of external factors on QCP-M implementation. Program Theory 3: Relates to existing cultures and systems within clinical sites. Program Theory 4: Relates to nurses’ and midwives’ knowledge and beliefs. Program Theory 5: Builds on the staff theme of Programme Theory four, extending the culture of organizational learning, and highlights the meaningful engagement of nurses and midwives in the implementation process as a key characteristic of success. Program Theory 6: Relates to patient needs. The results provide nursing and midwifery policymakers and professionals with evidence-based program theory that can be translated into action-orientated strategies to help guide successful QCP-M implementation.

Quality care process metrics (QCP-Ms) in nursing and midwifery care processes: a rapid realist review (RRR) protocol

Background: In 2018, the Office of the Nursing and Midwifery Services Director (ONMSD) completed phase one of work which culminated in the development and launch of seven research reports with defined suites of quality care process metrics (QCP-Ms) and respective indicators for the practice areas - acute care, midwifery, children's, public health nursing, older persons, mental health and intellectual disability nursing in Ireland. This paper presents a rapid realist review protocol that will systematically review the literature that examines QCP-Ms in practice; what worked, or did not work for whom, in what contexts, to what extent, how and why? Methods : The review will explore if there are benefits of using the QCP-Ms and what are the contexts in which these mechanisms are triggered. The essence of this rapid realist review is to ascertain how a change in context generates a particular mechanism that produces specific outcomes. A number of steps will occur including locating existing theories on implementation of quality care metrics, searching the evidence, selecting relevant documents, data extraction, validation of findings, synthesising and refining programme theory. This strategy may help to describe potential consequences resulting from changes in context and their interactions with mechanisms. Initial theories will be refined throughout the process by the local reference panel, comprised of eight key intervention stakeholders, knowledge users such as healthcare professionals and an expert panel. Ethical approval is not required for this rapid realist review. Conclusion: It is anticipated that the final programme theory will help to explain how QCP-Ms work in practice; for whom, why and in what circumstances. Findings of this review could help to give insights into the use of a rapid realist review as a framework and how nursing and midwifery QCP-Ms have been implemented previously.

Quality care metrics (QC-M) in nursing and midwifery care processes: a rapid realist review (RRR) protocol

Background: In 2018, the Office of the Nursing and Midwifery Services Director (ONMSD) completed phase one of work which culminated in the development and launch of seven research reports with defined suites of quality care process metrics (QC-Ms) and respective indicators for the practice areas - acute care, midwifery, children's, public health nursing, older persons, mental health and intellectual disability nursing in Ireland. This paper presents a rapid realist review protocol that will systematically review the literature that examines QC-M in practice; what worked, or did not work for whom, in what contexts, to what extent, how and why? Methods : The review will explore if there are benefits of using the QC-Ms and what are the contexts in which these mechanisms are triggered. The essence of this rapid realist review is to ascertain how a change in context generates a particular mechanism that produces specific outcomes. A number of steps will occur including locating existing theories on implementation of quality care metrics, searching the evidence, selecting relevant documents, data extraction, validation of findings, synthesising and refining programme theory. This strategy may help to describe potential consequences resulting from changes in context and their interactions with mechanisms. Initial theories will be refined throughout the process by the local reference panel, comprised of eight key intervention stakeholders, knowledge users such as healthcare professionals and an expert panel. Ethical approval is not required for this rapid realist review. Conclusion: It is anticipated that the final programme theory will help to explain how QC-Ms work in practice; for whom, why and in what circumstances. Findings of this review could help to give insights into realism as a framework and how nursing and midwifery QC-Ms have been implemented previously.

Navigating the Tower of Babel: The Epistemological Shift of Bioinspired Innovation

The disparity between disciplinary approaches to bioinspired innovation has created a cultural divide that is stifling to the overall advancement of the approach for sustainable societies. This paper aims to advance the effectiveness of bioinspired innovation processes for positive benefits through interdisciplinary communication by exploring the epistemological assumptions in various fields that contribute to the discipline. We propose that there is a shift in epistemological assumptions within bioinspired innovation processes at the points where biological models derived from reductionist approaches are interpreted as socially-constructed design principles, which are then realized in practical settings wrought with complexity and multiplicity. This epistemological shift from one position to another frequently leaves practitioners with erroneous assumptions due to a naturalistic fallacy. Drawing on examples in biology, we provide three recommendations to improve the clarity of the dialogue amongst interdisciplinary teams. (1) The deliberate articulation of epistemological perspectives amongst team members. (2) The application of a gradient orientation towards sustainability instead of a dichotomous orientation. (3) Ongoing dialogue and further research to develop novel epistemological approaches towards the topic. Adopting these recommendations could further advance the effectiveness of bioinspired innovation processes to positively impact social and ecological systems.

‘I always have fun at work’: How ‘remarkable workers’ employ agency and control in order to enjoy themselves

Organisations and associated management practices are generally considered responsible for promoting employees' enjoyment of work. Our study, on the other hand, seeks to examine the capacity of individual workers to regulate their own experience of fun. We interviewed eight ‘remarkable’ workers who claimed to always (or nearly always) have fun at work. We utilised a critical realist approach in the analysis that enabled the consideration of both structure and agency in the experience of workplace fun. A key research finding was that participants possessed a strong sense of control over their own happiness at work, demonstrated in four ways: (1) a priority placed on fun, (2) a sense of responsibility for fun, (3) a positive orientation to the world and (4) a sense of mastery and challenge in work tasks. Research findings may inspire both individual workers and organisations to adopt an agentic outlook in the workplace, implementing strategies that enhance employee control.

Boardthink: Exploring the discourses and mind-sets of directors

In a context of institutionalized regulation and academic framing determined by agency theory, we note paradoxes in board governance literature and practice. These paradoxes concern boards’ conflicting roles of monitoring/control, and innovation/strategy-making. We explore directors’ mind-sets about governance on which their resolution of paradoxes and their decisions and actions will be based. We do this by applying discourse analysis to the transcripts of 60 semistructured interviews conducted with New Zealand directors who described and evaluated their experience of board governance. We identify and discuss their various discourses, which we label discourses of conformance, of deliberation, of enterprise and of bounded innovation. We note the homogeneity of discourses across different organization types, the dominance of conformance, the nonresolution of paradoxes, and the likely effects in inhibiting board strategy-making and contribution to innovation. We recommend attention by boards to their mind-sets and processes, and the development of generativity.

Co-constructing a Sense of Community at Work: The Emergence of Community in Coworking Spaces

As more individuals are working remotely, many feel increasingly isolated and socially adrift. To address this challenge, many independent workers are choosing to work in coworking spaces – shared spaces where individuals do their own work but in the presence of others with the express purpose of being part of a community. In this qualitative, single case study, we analyze how members of a coworking space work together to co-construct a sense of community through their day-to-day interactions in the space. We apply a relational constructionist lens to unpack the processes of ‘community work’ as an interactive, agentic process. We identify three types of collective actions, or interacts, that contribute to a sense of community: endorsing, encountering, and engaging. These interacts represent different forms of community work that members interactively accomplish to maintain a desired community experience. The rapidly growing coworking movement offers insights, as uncovered in this study, on how to integrate a sense of community into the world of work.

The Gentle Art of Retroduction: Critical Realism, Cultural Political Economy and Critical Grounded Theory

This article, first, proposes critical grounded theory (CGT) as a way to develop systematically an array of methods and theoretical propositions into a coherent critical methodology for organization studies (and beyond). Second, it demonstrates CGT’s usefulness through a case study of competing recovery projects from the Icelandic financial crisis. CGT is developed in engagement with the emerging paradigm of cultural political economy (CPE) and its preferred method of critical discourse analysis (CDA). CPE analyses the evolution of ‘economic imaginaries’ in both their structural/material and semiotic/discursive dimensions. This requires a critical realist, multi-dimensional research strategy which emphasizes ethnographic methods and substantial theoretical and historical work. The proposed methodology of CGT enables a retroductive research process that combines deductive theoretical deskwork with inductive fieldwork enabled by grounded theory tools to analyse organizational process, stability and change.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Foucault beyond Fairclough: From Transcendental to Immanent Critique in Organization Studies

This article presents the case that while Foucault’s ideas have been the subject of much debate, the distinctive transformative potentials of his immanent thought have tended to have been overlooked in the field to date. In making this case, critical realism provides an important counter-example, as a transcendental orientation to critical practice with significant influence in contemporary organization studies. In drawing out the difference between these contrasting orientations to critique, Norman Fairclough’s critical discourse analytic (CDA) framework is evaluated here as an approach to organization studies that took early inspiration from Foucault’s work, while having looked towards critical realist ideas in recent years. Fairclough’s writings on discourse and university ‘marketization’ provide a useful empirical focus to explore the distinctive styles of problem-posing that follow from these different critical orientations; contrasting the distanced normativity of critical realist-informed transcendentalism with the situated, transformative potentials of Foucault’s immanent thought. Through these investigations, the article offers a reappraisal of existing lines of debate on Foucault and critical realism in organization studies, and of the value of Foucault’s ideas to the field more broadly.

Can Sociological Paradigms Still Inform Organizational Analysis? A Paradigm Model for Post-Paradigm Times

The Burrell and Morgan model for classifying organization theory is revisited through meta-theoretical analysis of the major intellectual movement to emerge in recent decades, post-structuralism and more broadly postmodernism. Proposing a retrospective paradigm for this movement, we suggest that its research can be characterized as ontologically relativist, epistemologically relationist and methodologically reflexive; this also represents research that can be termed deconstructionist in its view of human nature. When this paradigm is explored further, in terms of Burrell and Morgan’s assumptions for the ‘nature of society’, two analytical domains emerge – normative post-structural and critical post-structural. Assessing the types of research developed within them, and focusing on actor-network theory in particular, we describe how post-structural and postmodern thinking can be classified within, rather than outside, or after, the Burrell and Morgan model. Consequently we demonstrate not only that organizational knowledge stands on meta-theoretical grounds, but also how recent intellectual developments rest on a qualitatively different set of meta-theoretical assumptions than established traditions of agency and structure.

‘Evidence Based Management’, or ‘Evidence Oriented Organizing’? A critical realist perspective

Recent years have witnessed a surge of interest in what has been described as Evidence Based Management (henceforth, EBM). Its proponents assert that management practice should be based on a better appreciation of ‘what works’, as determined by the research evidence. This has attracted a varied critique, which suggests that the evidence base on most management issues is uncertain, and constrained by the interests of powerful organizational actors. EBM is depicted as an effort to marginalize more critical perspectives within the field. This article adopts a different approach. Drawing on a critical realist epistemology, it suggests that while research evidence is rarely conclusive it can aspire towards the progressive displacement of ignorance by knowledge. While some advocates of EBM would accept this, it is argued that such acceptance is more rhetorical than substantive, and is undermined by a standpoint which systematically downplays the power saturated organizational contexts in which evidence is assembled and employed in decision making. The key tenets of critical realism as applied to EBM are therefore considered. Critical realism acknowledges epistemological relativism, yet also accepts the need to construct robust causal explanations for social phenomena. Recognizing that organizations are co-created and co-defined by multiple actors, rather than only by managers, it is argued that we should replace the concept of ‘Evidence Based Management’ with the notion of ‘Evidence Oriented Organizing’.