Developing practice and staff: enabling improvement in care delivery through participatory action research

Developing New Methods for Person-Centred Approaches to Adjudicate Context-Mechanism-Outcome Configurations in Realist Evaluation

Realist evaluation provides a general method of evaluating the application of interventions including policy, legislation, projects, and new processes in social settings such as law enforcement, healthcare and education. Realist evaluation focuses on what about interventions works, for whom, and in what circumstances, and there is a growing body of work using realist evaluation to analyse interventions in healthcare organizations, including those using Lean Six Sigma improvement methodologies. Whilst realist evaluation facilitates the analysis of interventions using both qualitative and quantitative research, there is little guidance given on methods of data collection and analysis. The purpose of this study is to address this lack of guidance through detailing the use of innovative person-centred methods of data collection and analysis in a realist evaluation that enabled us to understand the contribution of Lean Six Sigma to person-centred care and cultures. This use of person-centred principles in the adjudication of identified program theories has informed novel methods of collecting and analysing data in realist evaluation that facilitate a person-centred approach to working with research participants and a way of making the implicit explicit when adjudicating program theory.

An integrative literature review of the implementation of advance care planning in hospital settings

AIMS AND OBJECTIVES

To identify and synthesise existing literature about action research in the implementation of advance care planning in a hospital setting.

BACKGROUND

Despite the proven added value of advance care planning, there is a lack of wide integration of this concept. There are several obstacles known for the implementation but it remains unclear how these can be overcome. Action research is described in the literature as a plausible way to overcome obstacles to the implementation of quality enhancing projects.

DESIGN

An integrative literature review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) and reported in accordance with the PRISMA statement.

METHODS

We searched databases MEDLINE, EMBASE, CINAHL and Web of Science to identify executed action research for the implementation of advance care planning programs within a hospital setting, from January 2005 until November 2019. Studies were assessed for comprehensiveness and were supplemented by studies in reference lists of included articles. A quality appraisal and a thematic synthesis were performed on all included studies.

RESULTS

Five studies met inclusion criteria. Interventions focused on both nurses, physicians and hospitalised patients. Interventions targeted three different themes: identifying at-risk patients, adapting documentation to the local context and using communication improvement tools.

CONCLUSIONS

A Supportive and Palliative Care Indicators Tool is proposed to identify patients in need of advance care planning to work more efficiently. Furthermore, adapting documentation and instruments to a specific care context are shown to make advance care planning more effective. Communication challenges can be addressed by promoting communication skills and increase stakeholder self-confidence.

Perception of nurse managers’ care coordination practices among nurses at the unit level

Introduction

Nursing practice demands coordination of activities within and across units to enable quality delivery of healthcare services. Nurse managers are best positioned to ensure effective care coordination at the operational level in the hospitals. The purpose of this study was to examine the care coordination practices of nurse managers at the unit level.

Methods

A quantitative exploratory descriptive approach using a cross-sectional survey design was used to collect data from 522 nurses in 19 hospitals in the Greater Accra region of Ghana. Descriptive and regression analyses were performed to describe the sample and to predict the behaviour of nurse managers. The systems model was used as a conceptual framework for the survey. Data collection was from October 2015 to March 2016.

Results

The response rate for collection of data was 95.7%. Nurse managers exhibited an acceptable level of care coordination practices. Nurse managers’ characteristics together predicted the care coordination practices at the unit (R2=0.111, p < 0.001). The unit, unit workload, experience as a nurse manager, and work duration with nurses were the significant predictors in the regression model.

Discussion

Care coordination is needed at the unit level to prevent conflict, overlapping, and constant interdepartmental friction which enables nurses to take a broad overview of coordinated care instead of myopic observation and reflection in the unit. Nurse managers are best positioned to coordinate care due to their vast professional knowledge and experience. Effective communication, good interpersonal relationship, and good listening skills are essential coordination practices critical to the efficiency of the unit.

A systematic mixed studies review on Organizational Participatory Research: towards operational guidance

BACKGROUND

Organizational Participatory Research (OPR) seeks organizational learning and/or practice improvement. Previous systematic literature reviews described some OPR processes and outcomes, but the link between these processes and outcomes is unknown. We sought to identify and sequence the key processes of OPR taking place with and within healthcare organizations and the main outcomes to which they contribute, and to define ideal-types of OPR.

METHODS

This article reports a participatory systematic mixed studies review with qualitative synthesis A specialized health librarian searched MEDLINE, CINAHL, Embase Classic + Embase, PsycINFO, the Cochrane Library, Social Work Abstracts and Business Source Complete, together with grey literature data bases were searched from inception to November 29, 2012. This search was updated using forward citation tracking up to June 2014. Reporting quality was appraised and unclear articles were excluded. Included studies clearly reported OPR where the main research related decisions were co-constructed among the academic and healthcare organization partners. Included studies were distilled into summaries of their OPR processes and outcomes, which were subsequently analysed using deductive and inductive thematic analysis. All summaries were analysed; that is, data analysis continued beyond saturation.

RESULTS

Eighty-three studies were included from the 8873 records retrieved. Eight key OPR processes were identified. Four follow the phases of research: 1) form a work group and hold meetings, 2) collectively determine research objectives, 3) collectively analyse data, and 4) collectively interpret results and decide how to use them. Four are present throughout OPR: 1) communication, 2) relationships; 3) commitment; 4) collective reflection. These processes contribute to extra benefits at the individual and organizational levels. Four ideal-types of OPR were defined. Basic OPR consists of OPR processes leading to achieving the study objectives. This ideal-type and may be combined with any of the following three ideal-types: OPR resulting in random additional benefits for the individuals or organization involved, OPR spreading to other sectors of the organization and beyond, or OPR leading to subsequent initiatives. These results are illustrated with a novel conceptual model.

CONCLUSION

The model provides operational guidance to help OPR stakeholders collaboratively address organizational issues and achieve desired outcomes and more.

REVIEW REGISTRATION

As per PROSPERO inclusion criteria, this review is not registered.

Organizational participatory research: a systematic mixed studies review exposing its extra benefits and the key factors associated with them

BACKGROUND

In health, organizational participatory research (OPR) refers to health organization members participating in research decisions, with university researchers, throughout a study. This non-academic partner contribution to the research may take the form of consultation or co-construction. A drawback of OPR is that it requires more time from all those involved, compared to non-participatory research approaches; thus, understanding the added value of OPR, if any, is important. Thus, we sought to assess whether the OPR approach leads to benefits beyond what could be achieved through traditional research.

METHODS

We identified, selected, and appraised OPR health literature, and at each stage, two team members independently reviewed and coded the literature. We used quantitative content analysis to transform textual data into reliable numerical codes and conducted a logistic regression to test the hypothesis that a co-construction type OPR study yields extra benefits with a greater likelihood than consultation-type OPR studies.

RESULTS

From 8873 abstracts and 992 full text papers, we distilled a sample of 107 OPR studies. We found no difference between the type of organization members' participation and the likelihood of exhibiting an extra benefit. However, the likelihood of an OPR study exhibiting at least one extra benefit is quadrupled when the impetus for the study comes from the organization, rather than the university researcher(s), or the organization and the university researcher(s) together (OR = 4.11, CI = 1.12-14.01). We also defined five types of extra benefits.

CONCLUSIONS

This review describes the types of extra benefits OPR can yield and suggests these benefits may occur if the organization initiates the OPR. Further, this review exposes a need for OPR authors to more clearly describe the type of non-academic partner participation in key research decisions throughout the study. Detailed descriptions will benefit others conducting OPR and allow for a re-examination of the relationship between participation and extra benefits in future reviews.

The content, format and timing of a preparation for childhood hospitalization booklet: An action research project

The experience of childhood hospitalization may be improved by appropriate preparation. As part of a larger project to improve preparation practices for children and their families, a group of health-care professionals investigated the content, format and timing of a pre-existing preparation booklet for a particular procedure. This article analyses the evaluation of the preparation booklet that led to a finding that collaboration among health-care professionals enables improved practice and shared professional power and responsibility.

Empowering Change Agents in Hierarchical Organizations: Participatory Action Research in Prisons

Participatory action research (PAR) approaches harness collaborative partnerships to stimulate change in defined communities. The purpose of this article is to illustrate key methodological strategies used in the application of PAR methods in the particularly challenging environment of a hierarchical organization. A study designed to promote sustainable, insider-generated system-level changes in the provision of end-of-life (EOL) care in the restrictive setting of six state prisons is used as an exemplar of the application of three cardinal principles of PAR. First, development of a collaborative network with active partnership between outsider academic researchers and insider co-researchers began with careful attention to understanding the culture and processes of prisons and gaining the support of organizational leadership, using qualitative data gathering and trust-building. During the implementation phase, promoting co-ownership of change in EOL care through the co-construction of knowledge and systems to enhance sustainable change required carefully-orchestrated strategies to maximize the collaborative spirit of the project. Co-researchers were empowered to examine their worlds and capture opportunities for change using new leadership skills role-modeled by the research team. Third, their local knowledge of the barriers inherent in the contextual reality of prisons was translated into achievable system change by production of a toolkit of formalized and well-rehearsed change strategies that collaborative teams were empowered to enact within their hierarchical prison environment. © 2016 Wiley Periodicals, Inc.

Implementing action research in hospital settings: a systematic review

Purpose

– Health care organizations and hospitals in particular are highly resistant to change. The reasons for this are rooted in professional role behaviors, hierarchical structures and the influence of hidden curricula that inform organizational culture. Action research (AR) has been identified as a promising bottom-up approach that has the potential to address the significant barriers to change. However, to date no systematic review of the field in health care exists. The paper aims to discuss these issues.

Design/methodology/approach

– A systematic review of the literature was conducted. Studies were reviewed with regard to the four stages of AR; problem identification, planning, implementation and evaluation.

Findings

– Only 19 studies were identified that fit the inclusion criteria. Results revealed significant heterogeneity with regard to theoretical background, methodology employed and evaluation methods used.

Research limitations/implications

– Only studies published and written in the English language were included.

Practical implications

– The field of AR interventions would benefit from a theoretical framework that has the ability to guide the methodology and evaluation processes.

Originality/value

– This is the first systematic review of AR in hospitals.

Effect of guided self-determination youth intervention integrated into outpatient visits versus treatment as usual on glycemic control and life skills: a randomized clinical trial in adolescents with type 1 diabetes

BACKGROUND

Providing care for adolescents with type 1 diabetes is complex, demanding, and often unsuccessful. Guided self-determination (GSD) is a life skills approach that has been proven effective in caring for adults with type 1 diabetes. To improve care, GSD was revised for adolescents, their parents, and interdisciplinary healthcare providers (HCP) to create GSD-Youth (GSD-Y). We evaluated the impact of GSD-Y after it was integrated into pediatric outpatient visits versus treatment-as-usual, focusing on glycemic control and the development of life skills in adolescents with type 1 diabetes.

METHODS

Seventy-one adolescents (mean age: 15 years, mean duration of diabetes: 5.7 years, mean HbA1c: 77 mmol/mol (9.1%), upon entering the study) from two pediatric departments were randomized into a GSD-Y group (n = 37, GSD-Y was provided during individual outpatient sessions) versus a treatment-as-usual group (n = 34). The primary outcome was the HbA1c measurement. The secondary outcomes were life skills development (assessed by self-reported psychometric scales), self-monitored blood glucose levels, and hypo- and hyperglycemic episodes. The analysis followed an intention-to-treat basis.

RESULTS

Fifty-seven adolescents (80%) completed the trial, and 53 (75%) completed a six-month post-treatment follow-up. No significant effect of GSD-Y on the HbA1c could be detected in a mixed-model analysis after adjusting for the baseline HbA1c levels and the identity of the HCP (P = 0.85). GSD-Y significantly reduced the amotivation for diabetes self-management after adjusting for the baseline value (P = 0.001). Compared with the control group, the trial completion was prolonged in the GSD-Y group (P <0.001), requiring more visits (P = 0.05) with a higher rate of non-attendance (P = 0.01). GSD-Y parents participated in fewer of the adolescents' visits (P = 0.05) compared with control parents.

CONCLUSIONS

Compared with treatment-as-usual, GSD-Y did not improve HbA1c levels, but it did decrease adolescents' amotivation for diabetes self-management.

TRIAL REGISTRATION

ISRCTN 54243636, registered on 10 January 2010. Life skills for adolescents with type 1 diabetes and their parents.

Examining professionals' and parents' views of using transanal irrigation with children: Understanding their experiences to develop a shared health resource for education and practise

Irrigation as a bowel management approach has been reportedly used with children for more than 20 years. Parents managing their child's chronic bowel problem have previously been shown to have increased emotional stress. The aim of this study was to explore professionals' (n = 24) understanding and parents' (n = 18) experiences of using transanal irrigation with children at home as a mid to longer term bowel management approach. This study was underpinned by action research methodology and used mixed methods determined by an action research group of parents, professionals, researchers, a voluntary sector worker, commercial representative and independent observer. Data informed the study outcome which was the development and evaluation of a shared health resource to support professionals in their holistic approach when prescribing transanal irrigation and guide parents in the areas of education, management, problem solving, support and goal setting. The resource includes constructed case studies from parents of their experiences to inform choice and decision-making between parents and professionals. The shared health resource provides an approach to initiating and evaluating transanal irrigation and is available in a paper format from key Internet sites across hospital, community and voluntary services.

An action research study to explore the nature of the nurse consultant role in the care of children and young people

AIMS AND OBJECTIVES

An action research study was undertaken to explore the development of the nurse consultant role when caring for children and young people.

BACKGROUND

Five nurse consultants in different areas of specialist care in a tertiary paediatric hospital undertook the study when implementing the new role of nurse consultant into the hospital.

METHODS

Action research meetings took place over a year. The nurse consultants then collated and analysed data using thematic analysis during the second year. A research fellow facilitated meetings, carried out participant observation, and coordinated the action research project.

RESULTS

Data analysis revealed 22 subthemes grouped into four overarching themes: shaping the role; shaping child-centred care through consultancy; taking responsibility for practice; and leadership. These roles and their ease and complexity within the nurse consultant role are examined in further detail in this paper. Balancing the four key components in a newly developing role was initially complex and required support. Over time the nurse consultants developed the necessary skills to perform fully in all areas. A major challenge was developing the research role, a key function of the nurse consultant role. By the end of the study, all nurse consultants were actively embarking upon their own research either in preparation for or as part of Doctoral studies.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

While there are many similarities with nurse consultants in adult practice, one major difference was the nurse consultant role in supporting families when caring for children and young people. This meant having a three-way communication style: with the family, the child/young person, and other healthcare professionals. This communication style was observed by the research fellow in participant observation of the nurse consultants undertaking clinical care and is described further in the analysis of the role.

Using genograms to understand pediatric practices' readiness for change to prevent abuse and neglect

A novel use of genograms in primary care practice is to identify processes and relationships among physicians and staff prior to implementing practice change. The authors hypothesized that the genogram would inform researchers and practice staff, participating in a child maltreatment prevention study, how practice members function in a practice. They describe the use of genograms and show how the genogram results are associated with intervention uptake. Researchers constructed genograms, collected baseline surveys, and conducted postintervention interviews with physicians. Data were analyzed to determine processes associated with intervention uptake. While survey results supported the relationships and conflicts observed in the genograms, the genogram provided more multilevel information that reflected practices' abilities to implement change. By providing a snapshot of the relationship and organizational dynamics within a practice, genograms can assess culture for practice change. Genograms describe organizational dynamics and are useful tools to use prior to initiating new programs.