Assessing the outcomes of participatory research: protocol for identifying, selecting, appraising and synthesizing the literature for realist review

<p>Abstract</p> <p>Background</p> <p>Participatory Research (PR) entails the co-governance of research by academic researchers and end-users. End-users are those who are affected by issues under study (<it>e.g.</it>, community groups or populations affected by illness), or those positioned to act on the knowledge generated by research (<it>e.g.</it>, clinicians, community leaders, health managers, patients, and policy makers). Systematic reviews assessing the generalizable benefits of PR must address: the diversity of research topics, methods, and intervention designs that involve a PR approach; varying degrees of end-user involvement in research co-governance, both within and between projects; and the complexity of outcomes arising from long-term partnerships.</p> <p>Methods</p> <p>We addressed the above mentioned challenges by adapting realist review methodology to PR assessment, specifically by developing inductively-driven identification, selection, appraisal, and synthesis procedures. This approach allowed us to address the non-uniformity and complexity of the PR literature. Each stage of the review involved two independent reviewers and followed a reproducible, systematic coding and retention procedure. Retained studies were completed participatory health interventions, demonstrated high levels of participation by non-academic stakeholders (<it>i.e.</it>, excluding studies in which end-users were not involved in co-governing throughout the stages of research) and contained detailed descriptions of the participatory process and context. Retained sets are being mapped and analyzed using realist review methods.</p> <p>Results</p> <p>The librarian-guided search string yielded 7,167 citations. A total of 594 citations were retained after the identification process. Eighty-three papers remained after selection. Principle Investigators (PIs) were contacted to solicit all companion papers. Twenty-three sets of papers (23 PR studies), comprising 276 publications, passed appraisal and are being synthesized using realist review methods.</p> <p>Discussion</p> <p>The systematic and stage-based procedure addressed challenges to PR assessment and generated our robust understanding of complex and heterogeneous PR practices. To date, realist reviews have focussed on evaluations of relatively uniform interventions. In contrast our PR search yielded a wide diversity of partnerships and research topics. We therefore developed tools to achieve conceptual clarity on the PR field, as a beneficial precursor to our theoretically-driven synthesis using realist methods. Findings from the ongoing review will be provided in forthcoming publications.</p

Revising the formal, retrieving the hidden: undergraduate curricular reform in medicine and the scientific, institutional, and social transformation of the clinical training environment

In 2004, members of the McGill University Faculty of Medicine began implementing a new curriculum for undergraduate medical education entitled, Physicianship: The Physician as Professional and Healer. The initiative underscores the idea that physician training entails cultivating not only scientific knowledge and technical skill, but a mindset guided by intrinsic principles of doctoring. Although the McGill case exemplifies a wide-spread paradigm shift in medical teaching, there is a dearth of analysis concerning the degree of congruency between the objectives of formal undergraduate curricular revision and the so-called ‘hidden curriculum’ of the hospital training environment. With Physicianship as a point of departure, this dissertation maps evolutionary patterns in clinical medicine and, using qualitative methods, analyzes the perspectives of twenty physician-educators on curricular reform and the transforming clinical training environment. Physicians interviewed were generally supportive of the new curricular initiative. Concerns were raised, however, that many recent changes within the teaching hospital environment interfere with students’ cultivation of professional and healer attributes. These changes were organized into three main themes: scientific, institutional, and social. Physicians expressed concern that what is often considered beneficial for patients is often detrimental for medical training. For example, increased use of diagnostic technologies has improved patient care but reduces opportunities for trainees’ clinical skill development. Concern was raised that the concept of selfless service has been undermined through recent shift-work regulations and a culture gap between older and younger generation physicians. Alternatively, some perceived new policies of the clinical environment to be more conducive to physicians’ self-care and quality of life. Younger trainees were often described as more competent in managing medical information, more open to diversity, more candid about their needs, and more apt to challenge dogmatic or ethically substandard practices. The complexity of the transforming clinical environment is used to justify a rationale for developing the concept of Phronesis (practical wisdom) as a pedagogical framework. The concepts of ‘acuity of perception’ and ‘mastery of emotion’ are grounded in the data and analyzed for the development of Phronesis, to advance the field of medical education and support curricular initiatives such as the Physicianship program

Quantitative Methods in Participatory Research : Being sensitive to issues of scientific validity, community safety, and the academic-community relationship

In this paper, we suggest that participatory research (PR) is neither a research methodology, nor uniquely associated with qualitative methods, but rather an approach to research through which stakeholders can implement quantitative, qualitative or mixed methods study designs. By illustrating three partnerships retained in our recent systematic review of PR, we highlight issues involved in partnered quantitative research. Examples demonstrate that commitment to dialogue and consensus building among partnership stakeholders is key to ensuring that methods generate scientifically valid research without creating community harm, loss of reputation, stigma or without generating feelings of denial, betrayal and exclusion.Nous suggérons que la Recherche Participative (RP) n’est pas une méthodologie et n’est pas associée uniquement à des méthodes qualitatives. La RP est plutôt une approche de recherche où les acteurs peuvent utiliser des méthodes quantitatives, qualitatives ou mixtes. Afin d’illustrer certains aspects des méthodes quantitatives en RP, nous présentons trois projets inclus dans notre revue systématique de la littérature en RP. Ces exemples montrent que s’engager dans un processus de dialogue et de consensus est crucial afin d’assurer que les méthodes de recherche employées soient valides, mais pas aux dépens des membres des communautés (par ex., stigmatisation)

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review

Background: nurses, midwives and paramedics are the largest collective group of clinical staff in the NHS and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves. Aim: to improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions. Methods: realist synthesis methodology consistent with RAMESES reporting guidelines. Data sources First round database searching in MEDLINE ALL (via Ovid), CINAHL (via EBSCO) and HMIC (via Ovid), was undertaken between February-March 2021, followed by supplementary searching strategies (e.g., hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied. Results: we built on 7 key reports and included 75 papers in the first round (26 Nursing, 26 Midwifery, 23 Paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 Context Mechanism and Outcome configurations (CMOcs). The key findings identified that: 1) Interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; 2) It is difficult to promote staff psychological wellness where there is a blame culture; 3) The needs of the system often override staff wellbeing at work (‘serve &amp; sacrifice’); 4) There are unintended personal costs of upholding and implementing values at work; and 5) It is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors. Conclusions: our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological wellbeing. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to: 1) rebalance the working environment to enable healthcare professionals to recover and thrive; 2) invest in multi-level systems approaches to promoting staff psychological wellbeing; and use an organisational diagnostic framework such as the NHS England and NHS Improvement Health and Wellbeing framework to self-assess and implement a systems approach to staff wellbeing. Future work Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with frontline staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs. Limitations The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder / expert suggestions to augment our sample

Care Under Pressure 2: a realist review examining causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics

Background: health service delivery requires healthy, motivated staff but there is a high and increasing incidence of psychological ill-health, exacerbated further by the COVID-19 pandemic. Nurses, midwives and paramedics are the largest collective group of clinical staff in the UK’s National Health Service and have some of the highest prevalence of psychological ill-health. Existing professional development and support is often profession-specific, and empirical evidence tends to focus on individual discrete interventions, which risk simplifying the causes and solutions to psychological ill-health.Therefore, building on our previous work with doctors (Carrieri et al BMC Med 2020), this study asked:1. Why is psychological ill-health in healthcare professionals still a huge and growing problem?2. Why despite having interventions (some of which have an ‘evidence-base’) does the problem persist?3. How we can optimise existing interventions, as well as innovating new ones?Method: realist synthesis methodology was employed, following RAMESES reporting guidelines. First round database searching in MEDLINE ALL (via Ovid), CINAHL (via EBSCO) and HMIC (via Ovid), was undertaken February-March 2021, followed by more specific supplementary searching strategies (e.g., hand searching, expert solicitation of key papers). Subsequent database searches (December 2021) targeted COVID-19- specific literature and literature reviews. We developed novel approaches to characterise the state of education and practice for the three professions, manage the different-sized literatures, and co-produce the analysis.Throughout the project, we worked closely with a stakeholder group comprising nurses, midwives, paramedics, representatives of patients and the public, educators, managers and policy makers. Via narrative and interactive activities, they provided insights into the nature, structure and stressors of their daily work, and we shared developing literature-based insights which they refined and shaped.Results: we included 75 papers in the first round (26 Nursing, 26 Midwifery, 23 Paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature (aspects of work that are incompatible and affect psychological ill-health) and identified five key findings, supported by 26 Context Mechanism and Outcome configurations (CMOcs). We learned that: interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; it is difficult to promote staff psychological wellness where there is a blame culture; the needs of the system often override staff wellbeing at work (‘serve &amp; sacrifice’); there are unintended personal costs of upholding and implementing values at work; and it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors.Overall, we found more similarities than differences between professions in causes of psychological ill-health, and very few profession-specific interventions. In most cases it was the service architecture (organisational features, context and working practices) that increased risk rather than the profession itself. Staff appear particularly at risk when newly qualified, exposed to trauma, or under investigation. Individual characteristics including ethnicity, sexual orientation and/or gender identify, and disability require greater attention.Implications: through identifying tensions in the literature, we have learned that healthcare as a provider and employer is a balancing act, with different considerations needing to be held in productive tension, such as the needs of staff and the needs of patients. Healthcare organisations need to urgently rebalance the working environment to enable healthcare professionals to recover and thrive. This will involve a focus on staff essential needs in order of priority and a commitment to reduce stigma and counter blame cultures, through long-term plans and investment. For the future, we need to identify and nurture future compassionate leaders and invest in multi-level systems approaches to promoting staff psychological wellbeing

Care under pressure 2: examining causes and solutions to psychological ill-health for nurses, midwives &amp; paramedics

Introduction: health service delivery requires healthy, motivated staff. Nurses, midwives and paramedics are the largest collective group of clinical staff in the UK’s NHS but have some of the highest prevalence of psychological ill-health. Building on previous work with doctors (Carrieri et al. 2020), this study explored why psychological ill health in healthcare professionals is a growing problem and how we might change this.Methods: realist synthesis methodology (Wong et al. 2014) involved two rounds of database searching in MEDLINE, CINAHL and HMIC (the second round targetting COVID-19-specific literature and literature reviews) and supplementary searches. Novel methodological approaches were developed to accommodate different-sizedliteratures between professions. We worked closely with a stakeholder group comprising nurses, midwives, paramedics, patients and public representatives, educators, managers and policy makers.Results: we included 75 papers in the first round (26 Nursing, 26 Midwifery, 23 Paramedic), and 122 in the second. We surfaced 14 key tensions from the literature and identified five key findings. For example, we learned that: interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; the needs of the system often override staff wellbeing at work (‘serve &amp; sacrifice’); and there are unintended personal costs of upholding values at work.Discussion &amp; conclusions: healthcare organisations need to rebalance the working environment to enable healthcare professionals to recover and thrive, and identify and nurture future compassionate leaders. The initial focus should be on staff essential needs, system-level change and long-term planning. We recommend that interventions are co-designed with frontlines staff and experts-by-experience

Care Under Pressure 2: a realist synthesis of causes and interventions to mitigate psychological ill-health in nurses, midwives and paramedics

Background: nurses, midwives and paramedics comprise over half the clinical workforce in the UK NHS and have some of the highest prevalence of psychological ill-health. This study explored why psychological ill-health is a growing problem and how we might change this.Methods: a realist synthesis involved iterative searches of within MEDLINE, CINAHL and HMIC, supplementary handsearching and expert solicitation. We used reverse chronological quota screening and appraisal journaling to analyse each source and refine our initial programme theory. A stakeholder group comprising nurses, midwives, paramedics, patients and public representatives, educators, managers and policy makers contributed throughout.Results: following initial theory development from 8 key reports, 159 sources were included. We identified 26 CMOcs, with 16 explaining causes of psychological ill-health, and 10 explaining why interventions have not worked to mitigate psychological ill-health. These synthesised to five key findings: (1) it is difficult to promote staff psychological wellness where there is a blame culture; (2) the needs of the system often override staff psychological wellbeing at work; (3) there are unintended personal costs of upholding and implementing values at work; (4) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; and (5) it is challenging to design, identify and implement interventions.Conclusions: our final programme theory argues the need for healthcare organisations to rebalance the working environment to enable healthcare professionals to recover and thrive. This requires high standards for patient care to be balanced with high standards for staff psychological wellbeing; professional accountability to be balanced with having a listening, learning culture; reactive responsive interventions to be balanced by having proactive preventative interventions, and the individual focus balanced by an organisational focus

Assessing the benefits of participatory research: A rationale for a realist review

Participatory research (PR) experts believe that increased community and stakeholder participation in research augments program pertinence, quality, outcome, sustainability, uptake, and transferability. There is, however, a dearth of assessments and measurement tools to demonstrate the contribution of participation in health research and interventions. One systematic review of PR, conducted for the Agency for Health Research and Quality (AHRQ), provided no conclusive evidence concerning the benefits of community participation to enhance research and health outcomes. To overcome methodological gaps and barriers of the AHRQ review, we propose to conduct a systematic realist review, which can be understood as a theory-driven qualitative review capable of capturing the often complex, diffuse and obtuse evidence concerning participation. Reviewing how PR mechanisms and contextual factors mediate and moderate outcomes, the review will generate and test hypotheses (middle-range theories) conceptualizing the benefits of participation and will portray the manner and circumstances in which participation influences outcomes