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

A systematic mixed studies review on Organizational Participatory Research: towards operational... 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. Keywords: Participatory research, Organizational participatory research, Organizational change, Practice change, Qualitative synthesis, Mixed studies review, Healthcare organization * Correspondence: paula.bush@mcgill.ca Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Suite 300, Montréal, Quebec H3S 1Z1, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bush et al. BMC Health Services Research (2018) 18:992 Page 2 of 15 Background regarding the type and timing of organization stakeholders’ Collaborative approaches to research involve academic re- participation. Finally, some reported difficulty applying de- searchers partnering with those who have a stake in the tailed frameworks of participation as the reviewed studies research, but do not necessarily have any formal research were often lacking detail [3, 15]. Therefore, to gain clarity re- training. Stakeholders may include patients, policy makers, garding how participatory processes contribute to outcomes, communities, organizations or any other individual or we used a framework of two distinct forms of organization group who may benefit from or use the results [1–3]. The stakeholder participation, at opposite ends of the con- premise is that the non-academic stakeholders have tinuum: (1) providing input when consulted by academics insight into problems and their potential solutions [2]. (no research co-governance) for at least three research deci- The non-academic stakeholders may participate in identi- sions: (a) identification of the research question(s); (b) deter- fying the problem and formulating the research questions, mination of the methodology, and/or data collection and/or selecting the research methods, collecting the data, analys- analysis, and/or interpretation of results; (c) implementation ing the data, interpreting the results, and applying and or dissemination of results; or (2) co-constructing at least disseminating results. Throughout these stages of the re- these three research decisions with academic partners (re- search process, non-academic stakeholders may partici- search co-governance) [9]. Regarding OPR processes, we fo- pate to varying degrees. Typologies of this participation cussed on any academic-organization collaborative activity have been put forth illustrating continua from the non-ac- throughout all phases of a study. We conceived of an OPR ademics participating passively (e.g., providing input, but outcome as any consequence of an OPR process. not actively engaging in decisions) to taking full control of We used a sequential mixed methods review design the study [3–6]. Further, participatory research can be dis- where the quantitative synthesis of phase-1 informed the tinguished by the three main drivers of the various re- qualitative synthesis of phase-2 [17–20]. Phase-1, re- search approaches, namely knowledge translation, social ported elsewhere [9], measured the likelihood of an OPR and environmental justice, and self-determination [1]. study yielding ‘extra benefits’. We define ‘extra benefits’ Herein, we focus on organizational participatory research as positive outcomesof an OPR study that clearly do not (OPR) which is most closely aligned with the knowledge meet the specific participatory research project objec- translation driver. tive(s) for change (for a complete definition, see PL An organization is a “context of action in which rela- Bush, P Pluye, C Loignon, V Granikov, MT Wright, J-F tionships of cooperation, exchange, and conflict between Pelletier, G Bartlett-Esquilant, AC Macaulay, J Haggerty, actors with divergent interests are being established and S Parry, et al. [9]). We compared OPR studies that managed” [7] and which fluctuates in response to clearly represented either Co-construction OPR (n = 83) changes in the environment. OPR takes place with and or consultation OPR (n = 24). We found no significant within organizations—in this article, organizations offer- association between the form of participation and the ing healthcare-related services—for the purpose of likelihood of at least one extra benefit of OPR. Yet, when organizational learning and/or practice improvement the OPR was initiated by the organization (as opposed [8–11]. This research approach is rooted in the works of to the academic stakeholders or the organization and Kurt Lewin on action research [12] and of Chris Argyris academic stakeholders together), the likelihood of the and Donald Schön on action science [8]. It is a capacity study resulting in at least one extra benefit was quadru- building endeavour where capacity building is a process or pled (OR = 4.11, CI = 1.21–14.01) [9]. an approach used to develop, enhance, or leverage a collec- This paper reports phase-2 of the review with the follow- tion of characteristics (e.g., organization stakeholders’ insider ing three objectives: 1) to identify OPR processes and the knowledge, academic stakeholders’ research methods expert- outcomes to which they contribute (descriptive objective); ise) for a purpose (e.g., effecting sustainable organizational 2) to understand the sequence of OPR processes and out- change) that is context dependent [13]. comes, in particular extra benefits (analytical objective); 3) Extant reviews of participatory forms of research taking to identify ideal-types of OPR process-outcome sequences place within healthcare organizations and with their stake- (explanatory objective). OPR is an inherently chaotic or holders (practitioners, staff, management, or service users) ‘messy’ [21] endeavour. Identifying characteristics of OPR report positive outcomes, such as stakeholders gaining con- in the empirical literature and assembling them into ideal fidence, skills, and knowledge; addressing challenges and types [22] may help to provide some order to our under- implementing innovations; improved job and patient satis- standing of this messy research approach. The ultimate goal faction [3, 14–16]. However, attributing the outcomes to the of this mixed studies review is to provide recommendations participatory processes has been difficult. A minimum level for OPR practice to help academic and organization re- of non-academic partner participation needed to guarantee search teams achieve their agreed upon objectives and ex- success has not been determined, either [3]. Furthermore, perience extra benefits; thereby, helping to ensure the these reviews examined studies that were heterogeneous added value of the participatory approach to their research. Bush et al. BMC Health Services Research (2018) 18:992 Page 3 of 15 Methods no such statement. Among the 107 studies included in A participatory research approach was used to conduct this phase-1, 83 represent the co-construction type of par- systematic review which followed a process as outlined in ticipation and were thus selected for phase-2. QN Hong, P Pluye, M Bujold and M Wassef [19]. Specific- ally, academic researchers and health organization stake- Data extraction holders on our team co-constructed the research questions, For each included study, the lead author and two re- the interpretation of results and the resulting publications. search assistants extracted descriptive data, study objec- Moreover, some academic and organization stakeholders tives, and text passages describing OPR processes, OPR contributed to various other stages of the review including outcomes, and OPR processes explicitly linked with developing the bibliographic data base search strategy, OPR outcomes (Additional file 2). For the purposes of examining raw data, guiding the analysis, and discussing this review, OPR processes that are explicitly linked to preliminary results. In this second phase of the review, the outcomes are ‘key processes’ of OPR. Moreover, OPR subset of studies incorporating a co-construction form of outcomes are not the study results, but rather anything health organization stakeholder participation from Phase-1 that occurs following an OPR process. For instance, an was included. The rationale for this purposeful sample was OPR outcome that is explicitly linked to an OPR process that these studies provide a richer description of participa- could be a statement such as: “working together on the tory process and their consequences. As per PROSPERO OPR project helped to develop the synergy of the part- inclusion criteria, this review is not registered. The Enhan- nership”. In this example, the OPR process is ‘working cing Transparency in Reporting the Synthesis of Qualitative together’ and the partnership synergy is the OPR out- Research (ENTREQ) framework guided the reporting of come. Thus, we reviewed the authors’ descriptions of the synthesis [23]. the OPR processes they used and the outcomes they said occurred as a result (in the above example, working to- Search methods gether helped to develop the synergy of the partnership). Peer reviewed and grey literature databases were searched Consequently, many data were extracted from the from inception through 2012 using MEDLINE, CINAHL, methods and discussion sections. For studies described Embase Classic + Embase, PsycINFO, the Cochrane Li- across multiple publications, all papers were used, and brary, Social Work Abstracts, Business Source Complete, data were extracted in order, beginning with the earliest ProQuest Dissertations & Theses database, the New York publication. Data were entered into one Excel workbook Academy of Medicine – Grey Literature Report, Open- per study with the descriptive and process-outcome data Grey, and Google. The search was updated in 2014 using on separate pages. The process-outcome page had one forward citation tracking. See Additional file 1 for search column for processes and one for outcomes. OPR strategies. Full details regarding search methods are re- process and outcome passages were pasted in order, one ported in PL Bush, P Pluye, C Loignon, V Granikov, MT per row. Text passages that made an explicit link be- Wright, J-F Pelletier, G Bartlett-Esquilant, AC Macaulay, J tween an OPR process and outcome were pasted on the Haggerty, S Parry, et al. [9]. same row, and the process and outcome cells were merged. The top row was reserved for the study object- Search outcome ive. The resulting process-outcome pages of each Excel The database search identified 13,837 records which workbook presented a clear story of the study objective, were exported to EndNote where duplicates were re- the OPR processes used, and the OPR outcomes ob- moved. Forward citation tracking led to an additional served. The lead author reviewed all Excel workbooks 150 records for a total of 8873 unique records. As de- for accuracy of extracted data and of the categorisation scribed elsewhere [9], nine inclusion criteria were itera- of text excerpts as OPR process and/or outcome. tively developed with all research team members. Two independent reviewers screened the records for rele- Synthesis vance and selected 992 full texts for further assessment. The co-authors of this study are academic and organization In all, 140 studies met the inclusion criteria. (See PL stakeholders with experience in OPR. As per a participatory Bush, P Pluye, C Loignon, V Granikov, MT Wright, J-F research approach, co-authors participated in decisions Pelletier, G Bartlett-Esquilant, AC Macaulay, J Haggerty, throughout this review. Regarding this qualitative synthesis, S Parry, et al. [9] for full details and flow chart.) co-authors commented on the Excel documents prepared in the preceding phase. Then, the lead author copied the Quality appraisal process-outcome pages of each Excel workbook into MS The quality appraisal focused on identifying studies Word, removed redundancies, and re-arranged the excerpts reporting an explicit link between OPR processes and into OPR summaries with: (1) objective(s), people and outcomes; 33 studies were excluded because there was place; (2) OPR processes; (3) linked OPR processes and Bush et al. BMC Health Services Research (2018) 18:992 Page 4 of 15 outcomes. This reflexive step was necessary because much toward the end of an OPR and proposed types based on ul- ofthedatawerenot theproduct of empirical investigation, timate OPR outcomes. These OPR ideal types were verified but rather the authors’ reflections on their practical experi- and refined during a grouping exercise [32]. Two research ence with OPR. Yet, all included studies were peer reviewed assistants with expertise in OPR (RS & JH) and two and most were co-authored by a team of investigators. For co-authors (PLB & PP) met to read and discuss the 83 sum- the most part, the OPR summaries (raw data) are the study maries in relation to the proposed types. They grouped the authors’ words; although, some excerpts were rewritten to summaries according to the dominant OPR type and de- ensure proper grammar and syntax or paraphrased for the fined ideal-types [33]ofOPR. sake of parsimony. To identify processes linked with outcomes and to Results understand their sequences throughout an OPR (objec- Characteristics of included studies tives 1 and 2), the lead author used hybrid (inductive/de- In total, 83 studies described across 145 publications, ductive) thematic analysis [24]. She coded all of the OPR met our inclusion criteria. The complete results of our summaries (assigned extracts of text to themes) according search and selection processes are published elsewhere to OPR process, OPR outcome, and linked OPR [9]. The 83 studies were each reduced to an OPR sum- process-outcome using qualitative data analysis software mary of 450 words, on average (Additional file 3). The (NVivo 10). Coding the data pertaining only to an OPR coding trees are in Additional file 4. To respond to our process or only to an OPR outcome was important to gain first two objectives, below we detail the eight key OPR an understanding of the data corpus. However, given the processes that were identified (objective 1). Four of these specific objectives of this review, the final synthesis is occur during subsequent research phases, and four are based solely on the linked process-outcome codes. This present throughout an OPR. We then describe and ex- coding was guided by partnership synergy theory [25, 26] emplify the extra benefits for the organization stake- capacity building [27, 28] and benefits of participatory re- holders and the organization as a whole that the OPR search [29] frameworks (deductive coding). Themes and processes contribute to (objective 1). These OPR pro- codes outside of these frameworks were also used where cesses and OPR outcomes are presented in our results the data suggested them (inductive coding). following the sequence in which they occur in OPR (ob- In line with traditional guidance for consistency and jective 2). Finally, we present four ideal-types [33]of rigour in qualitative thematic data analysis [30] and its OPR (objective 3). Each is illustrated with an OPR sum- application as ‘qualitative thematic synthesis’ in litera- mary. To lend credibility to our findings and to help ture reviews [31], our synthesis is based on an interpret- readers relate to them and determine their applicability ative method and research meetings, where coding to their contexts, excerpts from the OPR summaries processes were shared and discussed. Through iterations (raw data) are included throughout the results section. of analysis and discussion of preliminary results with When the excerpts are direct quotations from the ori- team members, the analysis became increasingly induct- ginal publications, they are indicated in italic text. ive. All 83 summaries were coded, rather than stopping the analysis once saturation had been reached. All Eight key OPR processes results reported herein were found in multiple summar- Four phases of OPR ies. The lead author aggregated the codes into OPR We begin by illustrating the four key processes of OPR that process-outcome themes and wrote an overall OPR describethesequenceofactivities that should be carried process-outcome story depicting themes that occur at out to help achieve extra benefits from the OPR approach. the beginning of an OPR and others that occur during and toward the end of an OPR. Co-authors revised this story commenting, in particular, on its credibility. The Form a working group (WG) and hold meetings Typ- lead author delved back into the data and refined the ically, a WG of university and organization stakeholders analysis to address co-authors’ comments. The contin- is formed to carry out the OPR. Organization stake- ued interaction among the university and organization holders vary depending on the needs of the project, but co-authors was critical to recognize, discuss and deal a multidisciplinary WG is common (e.g., nurse, phys- with our biases. Additionally, preliminary findings were ician, manager, social worker, etc.). Many conclude that presented at academic conferences over the course of diverse membership is crucial and can help ensure the the analysis process, and discussions with academic re- relevance and uptake of the OPR. For instance, some as- searcher and health practitioner delegates provided fur- sert “the diverse blend of experts from the [organization] ther perspectives that were taken into account. and the academic investigators has created projects and To identify ideal types of OPR (objective 3), the lead au- programs that are better suited to and accepted by the thor examined the process-outcome sequences that occur community and with greater chance for sustainability Bush et al. BMC Health Services Research (2018) 18:992 Page 5 of 15 than could have been produced by either group inde- The OPR process began with a number of meetings pendently” [34]. between members of the team, in which the nature Regarding administration’s and management’s partici- and scope of the problems with practice were pation in OPR, L Hamelin Brabant, M Lavoie-Tremblay, explored and critically examined. A C Viens and L Lefrancois [35] write that administrators’ multidisciplinary team decided to develop a involvement helped to “instil the motivation needed to chemotherapy protocol manual (based on analysis implement new practices.” Others suggest roles manage- of the data related to timing of the administration ment can assume, such as supporting the OPR by redu- protocols and reflection on these results) that cing red tape, acknowledging progress reports by letter, would explain all the requirements of each protocol implementing some recommendations, and encouraging and provide more accurate estimations of the time staff to become actively involved in the process. required to administer the protocol and care for The reviewed studies suggest that WGs meet regularly, the patient. though the frequency of meetings varies (once per week to once every month or two, or less often). Meetings must While it can be challenging to reconcile differing per- be facilitated effectively and often an academic partner spectives and priorities of WG members, addressing or- assumes this role. In one study, WG members “believed ganisation stakeholders’ needs can lead to more relevant the project was well-managed and that this was a factor in and longer lasting changes, as underscored by H its success” [36, 37]. This may suggest the importance of Waterman, R Harker, H MacDonald, R McLaughlan and WG meetings being structured and focussed on specific CWaterman[43]: “We would argue that, once the project issues or tasks, as described by some author teams. had reconfigured its interests to those of patients, more WG meetings provide opportunities for the inter- detailed and lasting suggestions were implemented.” action, discussion, debate, reflection, and consensus re- Furthermore, R Khresheh and L Barclay [40]write: “shared quired to enhance the OPR and achieve more nuanced goals guided the researcher and practitioners in their joint results and products. During meetings, members work and created commitment for the considerable effort complete OPR tasks, make decisions, learn from the ex- needed for the research to succeed.” perience of others, become more familiar with one an- other, and understand each other more in their various Collectively analyse data Collective, iterative data ana- professional contexts, roles, and contributions--ulti- lysis provides opportunities for WG members to ex- mately changing and improving practice. Furthermore, change thoughts, understand each other’s perspectives, the OPR processes contribute to improved professional and reflect as a group. This helps to further develop re- relationships and collaborations and increased job satisfac- lationships. For instance, EM Eisenberg, J Baglia and JE tion. S Andrews, E Lea, T Haines, J Nitz, B Haralambous, Pynes [44] note that “working through the narratives K Moore, K Hill and A Robinson [38] explain that WG with the ER staff gave them a role as research partners members’“collaborative working challenged the trad- and enabled a dialogue that encouraged the ER staff to itional hierarchical relationships between staff and opened acknowledge and understand each other’s ways of view- up an opportunity to work in partnership, thus building ing the world.” Two studies describe what collective data capacity and empowering staff.” analysis may entail. B Taylor [45] writes: “Descriptions of WG members typically value and benefit from the meet- participant observation were analysed individually using a ings. In one study, WG members “felt that the [OPR] reflective analysis method and collectively by group process was worthwhile. All staff agreed that ‘the meetings discussion.” For their part, A Gregorowski, E Brennan, S were valuable because we could discuss different ideas’. Chapman, F Gibson, K Khair, L May and A Lindsay-Waters Generally, staff welcomed the opportunity of raising issues [46] indicate: and discussing ways that these could be dealt with” [39]. The nurse consultants met with the research fellow Collectively determine research objectives The WG on a regular basis to analyse the data together. In begins by determining objectives that all members con- this way, a number of themes were collaboratively sider valuable. This process helps members to develop identified and divided into subthemes through relationships and contributes to the success of the OPR paired and group work. Once themes were by, for example, helping WG members to “feel great en- identified, the nurse consultants agreed to work in thusiasm about the project” [40]. Some suggest that es- pairs on the individual themes. Each took a theme tablishing project goals quickly “helps promote unity to work on as the primary researcher and another between the participants working towards this chosen to work on as the secondary researcher. The group end” [41]. M Wallis and S Tyson [42] discuss how they then came together to organise the themes and determined their OPR objective: subthemes into a framework. Bush et al. BMC Health Services Research (2018) 18:992 Page 6 of 15 Collectively interpret results and decide how to use can help “to reflect on discussions and ignite new thoughts them Discussing and interpreting results during WG and deliberations” [52], and “correct any misunderstand- meetings can be validating for organization stakeholders ings” [53]. In one study, a public website was used to post when the results confirm their perceptions. Additionally, information about the OPR: WG members can learn how to use study results to make evidence informed decisions about practice, and Interestingly, even when a member could not attend a their motivation to effect change may increase given the session, reading the archive allowed them to feel that awareness they gain regarding the issues under study. they had participated and resume without disruption. One author team writes: “by creating a structured and There was no evidence that the group regressed supportive environment for data interpretation, the study throughout the year or lost productivity when new reduced their fear. As they became more familiar with members joined, which was unexpected [54]. the charts and graphs, they began to look at data as a basis for decision making” [47]. KT Ngwerume and M Communication between the WG and the rest of the Themessl-Huber [48] provide another example: “Discus- organization regarding the OPR is important and can in- sions about challenges in utilizing this knowledge also crease interdepartmental understanding, help to prevent made them aware of the difficulties in applying this new resistance to change and enhance buy-in. Moreover, knowledge in practice and at the same time provided reaching out to the whole organization increases the them with options about how to implement changes.” number of voices that are heard and taken into account. H Waterman and J Grabham [55] provide an example: Four continuous OPR processes Our analyses suggest that an additional four key pro- The action research group was not insular in that cesses are present throughout a successful OPR: com- it integrated closely with hospital management munication, relationships development, commitment, systems, for example, senior nurse and general and collective reflection. First, effective communication management meetings. Some people who attended is open, two-way, transparent (e.g., making findings ac- the action research meetings, also attended these cessible), ongoing, and requires language all OPR team other meetings, and so ideas and actions from one members understand. To exemplify, L Olsen and L influenced the other. This ‘spreading and Wagner [49] write: “Using broadly defined terms (e.g., for enveloping’ of understanding of issues from all ‘discharge’ and ‘prevention’) helped participants to find perspectives became vital in the acceptance and some common ground, despite their different backgrounds inauguration of change. and mandates.” The quality of the communication within the WG can Second, relationships characterised by mutual trust, enhance stakeholder involvement and influence the OPR, respect and support, develop over time, and are import- help pursue issues to stakeholders’ satisfaction, improve ant to the success of the OPR. AJ Beringer and ME team work and team spirit, and help to bring about Fletcher [56] write: “The single most important indicator change, as described by J Bothe and J Donoghue [50]: of full achievement of outcomes was that the work group members developed mutually supportive and trusting re- As a result of the opportunity to communicate openly lationships between themselves and with the facilitator. with others, in addition to the team’s ability to think Where these relationships did not develop, this impeded and discuss their work critically, their practice became achievement.” Strategies for nurturing relationships in- more effective, safer for patients and patient centred. clude recognizing partners’ contributions and providing These changes were apparent to others, and provided positive reinforcement. One author team suggests: “the a model of enablement that is now used elsewhere in value of commending the partnership and acknowledg- the organization. ing the productivity of the collaboration cannot be underestimated as a means reinvigorating the relation- The meeting facilitator plays an important role by foster- ship and sustaining the collaboration” [34, 57]. ing an environment of trust and respect to enhance the Third, WG members’ commitment can lead to more sharing of diverse viewpoints. K Galvin, C Andrewes, D active involvement and the sustainability of changes as Jackson, S Cheesman, T Fudge, R Ferris and I Graham [51] illustrated by the following: note that sharing views during meetings “facilitated collab- orative working and provided an opportunity to clarify any The Admiral Nurses’ commitment to stay with the confusion, air any tensions, and to agree a way forward.” project, organizational commitment to embed the Producing and circulating meeting notes or other docu- framework in their practice development strategy ments is one communication method some have used. This and support from service managers contributed to Bush et al. BMC Health Services Research (2018) 18:992 Page 7 of 15 the success of the development and implementation During the data interpretation activities, the of the Admiral Nurses’ Competency Framework. physicians moved from a classical medical orientation The project commissioners are continuing their of the individual as the unit of analysis to examining support for the framework by explicitly linking it disease patterns in the population. The physicians also with work on standards of care, new job began to move from an exclusively curative descriptions and, importantly, through the role of orientation to disease to a more preventive one [47]. the Consultant Admiral Nurse [58]. These authors discuss that when partners “saw study Fourth, the collective reflection that occurs during results in the form of charts and tables, their level of en- WG meetings seems particularly important. Specifically, thusiasm rose markedly, and they began to participate collectively reflecting on the OPR and about professional actively in data interpretation, and to understand how practices stimulates personal reflection and objectivity the study could be helpful to them in operating the clin- and supports increased confidence, skills, and insights ical or preventive sectors of their facility.” Others report among WG members. This leads to modifications or ad- that the confidence and sense of ownership organization justments to the OPR and the identification of new or stakeholders gain from the process increase their auton- additional issues to pursue via OPR. omy, enthusiasm and responsibility for the work, and empowers them to effect change. The opportunity for the [Falls Action Research The new behaviours, practices, and skills developed Group] members to meet with their colleagues, from through the OPR also contribute to extra benefits. As S within their own facility and those from another Lauri [60] writes: [Residential Aged Care Facility], fostered the development of new understandings about their In the opinions of the public health nurses, the respective workplaces and the conditions that conscious implementation of the action model also shaped their practice. As such, the [Falls Action produced beneficial effects on their work as a whole. Research Group] members became more familiar Most nurses began to pay more attention to the with the contributions their colleagues, from other various areas of child development, and to explore the occupational groups, made to resident care [38]. needs of the child more extensively as the basis of guidance. The objectives and programmes, in the Participation in the inquiry by health professionals opinion of the public health nurses, gave a direction to was important as it fostered cooperation among and a foundation for the guidance and counselling. clinicians and shared decision-making at different levels of interaction. (….) Doctors, pharmacists, and Regarding the organization, OPR that takes place in a nurses had an opportunity to work closely together part of a health organisation (e.g., hospital ward) can ul- on thecommongoalof implementingchangeto timately affect other parts of the organisation, or beyond. medication management. In the process, team Some studies lead to additional OPR or initiatives as the members also gained a deeper understanding following OPR summary excerpt illustrates. of effective and safe prescribing practices [59]. As a result of the hospital study, the health education staff already plan to focus on alcohol abuse in those Extra benefits communities which seem to have an elevated problem. The process-outcome sequences above lead to extra bene- Tuberculosis has emerged as a second area of outreach fits for individual stakeholders and the organization as a program development. The Foundation’sboard of whole. Regarding stakeholders, the awareness, under- directors has used the hospital data in a fundraising standing, and general knowledge they gain about research, effort for a community education and control program. their work, and their colleagues’ work has many benefits. The hospital’s medical director planned to use the data For example, they experience a sense of achievement, their to identify the priority villages for the tuberculosis clinical confidence, skills, and care practices improve, and program [47]. they develop a drive to do research. In one study, “data had a direct impact on staff serving to broaden under- The OPR process may also expose or raise awareness standing of patients’ views on equipment and preoperative for additional issues the organization may subsequently education, and it helped monitor the changes that were address. Two excerpts provide examples: being put into place” [43]. Attitude changes also occur through the OPR process Using the suggestions for change that had been and lead to practice improvements and other benefits. made by patients, carers and healthcare Bush et al. BMC Health Services Research (2018) 18:992 Page 8 of 15 professionals, eight changes to practice were processes that contribute to achieving intended outcomes. identified and it was agreed who would be This is depicted in a study by Lucas et al. [36, 37]. This responsible for their implementation. The first OPR ideal type can lead to random benefits unrelated changes are now being re-evaluated providing the to the study objectives (OPR ideal type 2). The summary opportunity for healthcare professionals within the of an OPR by Barker & Barker [62]illustrates multiple colorectal unit, and a new group of patients and such benefits. The third ideal type consists of the OPR (or carers, to comment on the effects and effectiveness part of it) being replicated elsewhere in the healthcare of the changes made thus far [61]. organization or even outside of it. A study by Boniface et al. [63] illustrates an OPR in one unit spreading After the manual and new forms had been used for county-wide. In the fourth ideal type, OPR processes con- some time, the nurses thought that there were still tribute to achieving intended outcomes and also to gener- inefficiencies in the system. Consequently, further ating, or initiating, new activities or new OPR. The OPR phases of the action research project were designed summary of a study by P O’Connor, RR Franklin and CH to improve the patient appointment booking and Behrhorst [47] mentions a variety of new activities that staff allocation systems [42]. were initiated as a result of the OPR. Any combination of these four ideal types is possible. Some studies in our sam- ple illustrate two, three or all four of the ideal types. For Four ideal-types of OPR example, a combination of ideal types 2 and 4 is repre- The third and final objective of this synthesis was to sented in the summary of the dissertation by Heyns [64] identify ideal types of OPR. We found that the 83 studies (see additional file 3, p. 111). The summary of the study reviewed can be grouped into four such ideal-types, as by Sorensen and Haugbolle [65] illustrates a combination presented in Table 1. Additional file 3 presents the 83 of ideal types 1, 2, and 3. (see additional file 3,p.106). The summaries organised by the four ideal-types. Select OPR summary of the study by MS Fagermoen, GA Hamilton, B summaries illustrating the ideal types are presented in Svendsen and H Hjellup [66] illustrates an OPR represent- Table 2 as follows. The most basic type consists of OPR ing all 4 ideal types (Table 2). Table 1 Four ideal types of OPR The Four Ideal Types of OPR: 1, 1 + 2, 1 + 3, and 1 + 4 1. OPR processes contribute to achieving intended outcomes 2. …and ‘random sparks’ (basic OPR) Successful OPR focuses on a vested interest of organization stakeholders, Throughout an OPR endeavour, Working Group members learn from be it an interpersonal or organizational one. Through ongoing one another in myriad ways (e.g., research knowledge and skills, discussion and critical reflection, a Working Group of academic and organization or professional constraints, professional knowledge and organization stakeholders reach consensus over time, regarding this skills, service users’ and other professionals’ experiences) and some focus, together with all other research-related decisions. Working Groups take their learning forward and, for example, enrol in graduate are often multidisciplinary and may include stakeholders from one or studies or use their new talents in other contexts. Organization multiple organizations with a common interest. Arguments may occur stakeholders develop a stronger awareness of contextual issues and throughout the process, but a structured and supportive environment concerns in their workplace, gaps in their own professional helps to work through them. Likewise, valuing input, acknowledging knowledge and skills, and experience changes in their attitudes and celebrating contributions and outputs, positive attitude, and toward one another and their practice. Communication, team work, fostering motivation, teamwork and trust are important for achieving and staff morale improve, and staff turnover decreases. Further, a shared vision for the OPR and reaching objective(s). professionals experience increased clinical confidence, empowerment, Whether the technical work of the analyses is completed by the and job satisfaction. All stakeholders’ perspective of collaboration academic stakeholders or the whole Working Group, communicating evolves and the OPR partnership and stakeholder relationships come preliminary results is important to develop the commitment and to be viewed as valuable outcomes, and this, even when stakeholders’ motivation of the organisation stakeholders. Moreover, research results relationships are characterised by tension and mistrust at the outset. help organization stakeholders to see how research can be helpful to 3. …and the replication of intended outcomes them for their health care practice and become a basis for decision making. Preliminary results may include such things are charts, graphs, Processes used in the OPR become new practices that are maintained. and fieldwork summaries. Notably, care must be taken to use the right For instance, communication means, such as log books and monthly language when communicating research results to assuage potential meetings, are taken up by the whole organization and become regular worries about understanding them. Final results are communicated by practice. Additionally, practice changes resulting from the OPR (e.g., the WG to the rest of the organisation and beyond, as needed. This interventions, education packages for service users, professional continuing helps to engage additional stakeholders in the OPR. Overall, the OPR education activities) may be taken up by the whole organization and processes (ongoing discussion, consensus seeking, data analysis and beyond, to a whole health care services territory or country. interpretation of results, decision making, and problem solving) leads 4. … and the initiation of new activities or new OPR to the Working Group achieving its OPR objectives. Ultimately, additional priorities are identified leading to spin off projects or additional OPR. Sometimes, other organizations aware of the OPR, request OPR facilitation help from the academic stakeholders to address a practice change need in their own milieu. Bush et al. BMC Health Services Research (2018) 18:992 Page 9 of 15 Table 2 OPR summaries illustrating each of the four ideal-types Table 2 OPR summaries illustrating each of the four ideal-types of OPR and their combination of OPR and their combination (Continued) Illustration of OPR ideal type 1: Basic OPR staff relations (e.g., good-natured teasing and humor compared to sarcasm and blaming readily observed in meetings prior to the pro- This 10-month project sought to examine the process of change ject), c) lower staff turnover, d) more open intradisciplinary and inter- when developing a preparation programme for patients awaiting disciplinary communication (e.g., staff members now openly support Total Knee Replacement (TKR) Surgery in an outer London acute NHS each other, ask for assistance from staff members in other disciplines, hospital. The researcher initiated and facilitated the project which in- and collaborate on problem solving), e) new skills (e.g., team problem volved ‘back office’ activities of organisation and encouragement. A identification, decision making, cooperation, leadership), and f) staff Project Management Group (PMG) was established consisting of appear willing to take more risks in making suggestions, confronting orthopaedic consultants, nursing staff, physiotherapists, occupational issues, and encouraging and supporting others. therapists, managers and service, users who were patients who had had Total Knee Replacement surgery at the project site, and the uni- Illustration of OPR ideal type 3: Replication versity researcher who was a nurse practitioner within the organisa- The aim of this study was to embed the theoretical tenets of the tion. Nine monthly PMG meetings held between January and Canadian Model of Occupational Performance and its structures in a October, with the aims of planning and reviewing the action cycles way that was appropriate to, and would be used by, all staff within related to the development of the Knee Clinic and information book- an integrated health and social care setting. Initially enthusiasts were let, and reflection on the progress of the project, including the called upon to work in the localities and join a short-term steering change process. The researcher took notes during PMG meetings group. This small group of self-selecting members of the service and which were distributed to PMG members for checking and correction. the university lecturer, soon grew to include representatives from all PMG members were involved in the action cycles to varying degrees. geographical areas and services within the trust (n =16–20). It was They worked within the meetings to plan, discuss, analyse and refine non-hierarchical and disseminated the notes of its meetings to the the test cycles. They decided which test cycles should continue and whole service through individual ‘champions’ of the model’s imple- which should not be pursued. They participated in the test cycles mentation. Despite the attempt to include all staff in the action themselves in various roles including data collection, participation in phases of the research (led by their own representative on the action the Knee Clinic, and administrative tasks. Ultimately, the PMG research steering group), the steering group was a large group and, developed into an effective team, demonstrating the behaviours of not all the members were present at all the reflection cycles, but they good communication and adaptability. were crucial to the research’s action phases. Some of the PMG members believed the project was well-managed The steering group recognised their supervisory and influential role and that this was a factor in its success. Some staff did not have high but did not want staff to feel the model was being imposed upon expectations of the project but nevertheless participated. It appeared them. The group discussed what resources were required to assist that this participation modified their behaviour in that they continued staff confidence and keep the momentum going. Given staff to provide support to the Knee Clinic after the project ended. For the criticisms of communication and dissemination of up to date service users the project provided the environment for them to share information the steering group recognised the need to engage both and use their experiences of TKR surgery with staff and other patients. occupational therapists and the managers in the different They helped to shape the direction of the project and changed the organisations, and that management and senior occupational environment through the decision to set up a service user group for therapists needed to support and help maintain enthusiasm for the others to share their experiences of surgery after the project ended. model within their teams. Thus issues, concerns and good practice Illustration of OPR ideal type 2: Sparks were brought to the steering group meetings, and over time tools and materials were developed to help staff in the sharing of good In 1989 a three-year study began in a substance abuse inpatient unit work and solutions to issues and concerns. in a large university teaching hospital in the UK, to generate a de- The collaborative way of carrying out the research ensured the scription of the substance abuse inpatient program, define and workability of the action. For instance, the steering group member prioritize target areas for change, implement and evaluate change ef- who had previously experienced the dilution of the model’s theory forts, and provide an opportunity for staff participation and input into by its paperwork being implemented too early influenced the the change process. The nurse, medical, and unit directors, and other steering group to delay paperwork implementation. At the same key staff members (e.g., admitting nurse) formed the team bringing time, other staff members were clamouring for its creation. The result nursing, medical, and psychosocial staff members’ perspectives to following was that staff in their own settings began to create their meetings. Other staff members volunteered to form various subcom- own paperwork, which was then brought back to the steering group mittees that developed and implemented changes (e.g., revision of for further reflection and consequent action. The assessment and criteria and procedures for monitoring patient progress in treatment, planning paperwork that has evolved through this process is now provision of written policies addressing major issues). All action almost countywide, applicable to most areas, firmly embedded in the followed a developmental process in which committees circulated theory of the model. Another example concerns training. Champions drafts for staff feedback, thereby insuring that staff members were in- in the acute hospitals produced a training package on the model’s formed and invited to participate in all change efforts. The unit direc- theory and use and the steering group became aware that other tor’s role was that of facilitator, providing encouragement, process areas were keen to use this or a similar package and recognised that monitoring, and feedback. The director relied heavily on group facili- the training package was a good way of a team working together to tation skills to achieve consensus among staff members. However, this strengthen understanding of the model, share how it could be consensus seeking did not occur overnight and actually involved sev- practically adopted in individual clinical areas and address any issues eral months of discussions. Through the group process, opinions were or concerns. The steering group realised this sharing of knowledge voiced resulting in all staff members supporting clinically sound would not have happened if the information had not been taken to a changes that were consistent with the unit goals and philosophy. group steering the implementation of the model. Changes were assessed by surveys and results were provided to the The steering group was critical in guiding the model’simplementation, inservice staff to plan and implement adjustments and, then, re- in sustaining motivation and energy across the service, and for assess. Administrators’ support was readily forthcoming by including communicating information across a wide staff group on an ongoing some in the action research process and by keeping others informed basis. Many heated discussions occurred, and all members of the group through the distribution of survey forms and committee and evalu- found that their thinking about occupational therapy practice ation reports. developed and changed. The group has continued to have an The use of the action research model employing staff participation important role in making decisions and recognising when staff needed increased the effectiveness of this multidisciplinary inpatient unit. re-energising. The process so far has taken 4 years and is ongoing. Benefits include: a) an observed increase in staff morale, b) improved Bush et al. BMC Health Services Research (2018) 18:992 Page 10 of 15 Table 2 OPR summaries illustrating each of the four ideal-types Table 2 OPR summaries illustrating each of the four ideal-types of OPR and their combination (Continued) of OPR and their combination (Continued) Illustration of OPR Ideal-Type 4: Initiation supportive, and accepting mentoring style and gave credit, guided and advised throughout. The researcher was responsible for the When this project began, although the local staff were helpful, they agenda and the minutes from project meetings. All met frequently to did not envision how the study would be useful and they went along collectively discuss the work of each group. They developed a wel- with the initial steps of data collection and analysis passively. One of come brochure the use of which for all patients admitted to the ward the major tasks in data analysis was the regrouping of individual is now regular practice, and other brochures that are sent patients diagnoses into manageable categories. Through repeated discussions, when they receive their date for admission, also now regular practice. among groups composed of Guatemalan and Tulane physicians and Indeed, admission of patients by one nurse each day is now a well- epidemiologists, consensus was achieved in developing clinically and established practice with benefits for all patients, not only the trans- conceptually meaningful diagnostic groups. After data processing had urethral resection -patients. Additionally, guidelines were necessary to been completed, a series of two meetings were held in Guatemala ensure that all patients got a certain amount of information at dis- for interpretation of the information generated. The Tulane staff had charge. To evaluate the changes, given no adequate instrument was prepared charts and graphs of the results on a large drawing pad. found, the researchers worked with the nurses to develop an instru- When staff saw the graphs and tables, the level of enthusiasm rose ment, reaching consensus on topic, readability (literacy level), rele- markedly. They began to participate actively in data interpretation, vance, and ease of use for the patient. Guidelines for administering better understand what Tulane staff were doing, what the results the data-collection were established and nurse was designated to do would look like, and how the study could be helpful to them in this. The hospital financed a course in SPSS for this nurse, who then operating the clinical or preventive sectors of their facility. was able to participate in developing codebooks and to carry out Interpretations of the data were developed primarily by the three data-entry. hospital staff physicians through group discussions. They frequently The pace of the study was slower than anticipated given a lower argued about the results, but usually they eventually achieved group than usual admittance rate of trans-urethral resection patients. This af- consensus regarding their interpretations. By creating a structured fected the implementation that had been planned to coincide with and supportive environment for data interpretation, the study the merger between the project ward and another urology clinic. The reduced their fear. As they became more familiar with the charts and issue of ownership was an important concern. By the end of 2000 graphs, they began to look at data as a basis for decision making. most nurses on the ward had not been part of the processes the year Within several months of the completion of the data analysis, the before. They received information informally by the nurses closely in- findings were being used to identify areas of research and to improve volved in the project and formally by the nursing professor who met health education and outreach programs. Thus, this project provided with smaller groups of staff to inform and include them in the on- a learning experience that afforded an opportunity to become going processes. familiar with how data can be useful. The second educational Positive outcomes have resulted for patients and staff through the outcome of the joint study was the emergence of a stronger project. The new brochures improved the patient information, and awareness of public health problems. During the data interpretation patients valued the nurses’ interaction and approach, and appreciated activities, the physicians moved from a classical medical orientation of the correspondence between the information in the brochures and the individual as the unit of analysis to examining disease patterns in what went on while in the hospital. Re-designing the brochures the population. The physicians also began to move from an benefited staff as well. Structuring the admission talk created a clearer, exclusively curative orientation to disease to a more preventive one. concise and consistent approach for imparting information. Moreover, As a result of the hospital study, the health education staff already as the discussions about the discharge talk evolved, the nurses recog- plan to focus on alcohol abuse in those communities which seem to nised other areas that needed attention. They identified a need for have an elevated problem. Tuberculosis has emerged as a second standardisation of the nurses’ talk with patients on admission and subse- area of outreach program development. The Foundation’s board of quently developed guidelines for this event. directors has used the hospital data in a fundraising effort for a community education and control program. The hospital’s medical director planned to use the data to identify the priority villages for the tuberculosis program. The process of interpreting the findings Discussion highlighted a need for larger population based epidemiologic studies The qualitative synthesis of 83 co-construction OPR to examine relationships between sociodemographic characteristics, studies suggested eight key OPR processes, four that fol- cultural beliefs and health practices. To assess the impact of community participation in water projects, the extension staff are low the sequence of the research endeavour (form a now collecting baseline data through a “community diagnosis” working group and hold meetings, collectively determine instrument. The staff are also participating in a second record study. research objectives, collectively analyse data, and collect- Preliminary discussions about the establishment of an information system which could be used for program monitoring and impact ively interpret results and decide how to use them) and assessment are also underway. four that can be observed throughout an OPR (commu- In Summary, the authors believe that the study had two major nication, relationships development, commitment, and impacts: (1) the hospital physicians developed a stronger data orientation in studying hospital policies and services and (2) they collective reflection). Extra benefits resulting from these gained an increased awareness of public health issues. key OPR processes occur at the individual and organizational Illustration of a Combination of the Four Ideal-Types levels. The purpose of this part of the project was to improve patient Together, these key processes and outcomes of OPR information before and at admission for trans-urethral resection and can be interpreted through a model for how to conduct to explore the effect of the changes in the information practices as an OPR to achieve extra benefits (Fig. 1). This concep- perceived by the patients. The highly supportive head-nurse selected nine enthusiastic nurses judged to have the necessary professional tual model suggests that through regular, structured WG background and interest to work on the project. Two work-groups meetings stakeholders can voice their varied experiences, were formed, each group a mix of experience and expertise. The ideas for change, fears and other feelings. The WG nurses identified the problem to be solved and were active partici- pants in the process of change as equal partners with the researcher should assemble a broad variety of stakeholders (practi- who had the role of facilitator who used a non-threatening, tioners, patients, managers, etc.) and provide a Bush et al. BMC Health Services Research (2018) 18:992 Page 11 of 15 Fig. 1 The OPR model – Iterative processes and outcomes of OPR supportive environment with the promise of confidenti- coordination both within the WG and between the WG ality. WG meeting processes include identifying needs and their healthcare organization, which in turn in- and formulating study objectives, collectively analysing creases the organization members’ acceptance of change. data, and discussing results and how to act on them. Ultimately, WG members improve or develop new skills Circulating meeting summaries between meetings is im- (supports empowerment), and teamwork, mutual under- portant for deliberations, to correct misunderstandings, standing and job satisfaction are increased or improved. and to help engage WG members who are unable to at- Readiness for change increases and improved care and tend some meetings. During meetings, WG members sustainable changes ensue. Importantly, the changes learn from one another, gain awareness of constraints to pave the way for subsequent changes. While H Water- addressing the OPR objectives, gain confidence (which man, D Tillen, R Dickson and K de Koning [3] cite many in turn increases commitment to continue the research of these results as benefits of participation, our synthesis and to take responsibility for decisions and actions) clearly suggests it is the WG meetings that contribute to through systematic reflection on the OPR. This is in line these outcomes because they provide invaluable time with H Waterman, D Tillen, R Dickson and K de Koning and space for WG members to present, discuss, debate, [3] who found that sharing ideas is part of learning that and reflect on various identified needs. They are also a takes place through the process, which in turn increases space to reach consensus or to accept compromise. participation in the research. Discussing OPR results Similarly, in their review, G Munten, J Van Den Bogaard, within the WG is valuable in that results often validate K Cox, H Garretsen and I Bongers [15] found that meet- perceptions and raise awareness. Discussing results also ings in small or large groups was the strategy most often increases WG members’ understanding of how to use cited in included studies. However, they found the na- research findings to inform changes, enables joint prob- ture of the interactions during these meetings was not lem solving, increases members’ motivation to make sufficiently described. They underscore the need for au- change, and helps them identify additional needs. In thors to provide detailed descriptions to help understand their review, G Munten, J Van Den Bogaard, K Cox, H the ‘black box’ of this research approach in order to close Garretsen and I Bongers [15] identified communication the research-practice gap. We have delved into the ‘mess’ and feedback of results strategies as common. Our work [21] of OPR combining the experiential, propositional and goes a step farther in illustrating the potential conse- practical OPR knowledge of our diverse team. Examining quences of such strategies. authors’ reports of their OPR activities and consequences The OPR processes in which the WG engages during (process-outcome linkages) in their OPR studies helped us meetings contribute to improved communications and to begin to unpack this black box. Bush et al. BMC Health Services Research (2018) 18:992 Page 12 of 15 Applicability and practical implications of the review findings participatory research leads to new unanticipated projects Previous reviews, whether about OPR or other types of and activity, can be conceived of as initiation, as per JC participatory research, have not described how to con- Greene, VJ Caracelli and WF Graham [72]. While previous duct this type of research to the same degree, nor have works provide typologies of non-academic stakeholder par- they illustrated how participatory processes contribute ticipation [3, 5, 14], going forward, it may be relevant to to outcomes. In phase-1 of this systematic review [9], we categorise studies as per the four ideal-types of OPR. found five types of extra benefits related to a framework of capacity building: leadership, general workforce devel- Limitations and strengths and transferability of the evidence opment, group benefits, broad systemic developments or This qualitative synthesis is not entirely based on empir- changes, academic researchers’ capacity. With this sec- ical results of included studies. In many cases, the data ond phase of the review, we have been able to go beyond were from the discussion section of the reviewed studies this description of extra benefits to explain how to and are, thus, the authors’ reflections on their practical achieve them. The conceptual model (Fig. 1), can be ap- experience with OPR. Given that our analysis is there- plied widely to guide the conduct and assessment of fore a meta-reflection, it is possible that our results OPR. While based on OPR with healthcare organiza- underscore the assumptions and beliefs of the authors of tions, the processes and outcomes illustrated in the the publications included in this review. Future research model may be applicable to any organization. Since we fo- should test our conceptual model and ideal types of cussed on OPR processes linked to OPR outcomes, the OPR. However, our team consists of eleven OPR practi- data analysed had an inherent chronology (narrative caus- tioners and scholars with varied frames of reference, and ation) [67]: processes lead to outcomes. This is visible in the critical input of each throughout our review helped the final coding trees which consist of process-outcome us to challenge our own assumptions about the data and sequences, each with inductively derived codes that depict our analyses; thereby, adding to the trustworthiness of passage of time (additional file 4). It is important to note our results. Moreover, the large number of studies in- the iterative nature of the processes and outcomes. In cluded in this review, the multiple descriptions of OPR practice, OPR is not as linear as the model suggests. processes-outcome sequences in these studies, and the Throughout an OPR project, the process-outcome se- data saturation lends credibility to our results. quences repeat and overlap, and there are feedback loops Although predominantly influenced by nursing studies between them. However, in keeping with the principle of in hospital settings (given this is the most common type parsimony, our model provides a simple illustration of the of OPR to date), this review is more comprehensive than overall flow of theses sequences and explains how to con- previous ones which focussed on OPR in UK health set- duct OPR to achieve extra benefits. The parsimonious tings [3] in nursing [14], on implementation of representation is also in line with the philosophy of OPR evidence-based practice in nursing [15] or in adult in- to produce useful results. Finally, this simplified conceptu- tensive care units [16]. We included a variety of types of alisation is an actionable message, which some would health OPR in diverse types of healthcare organizations. argue is necessary for its uptake and use [68, 69]. The Moreover, this review overcomes issues previously re- model is thus a significant contribution of our work. ported regarding attributing organization members’ par- The four ideal types illustrate features of learning organi- ticipation in research to particular outcomes [3, 14, 15] sations such as open systems thinking, building individuals’ since we selected studies based on a precise definition of capacities, sharing knowledge, and learning collectively OPR and excluded those that did not make an explicit [70]. Our synthesis illustratesthatwhile OPRisameansto link between OPR processes and outcomes [3, 14, 15]. achieve study objectives (basic OPR), it may also lead to Similar to all literature reviews, our work is limited by any combination of (a) outcomes unrelated to the study, or publication bias. As found in previous reviews [15, 16], ‘random sparks’ as described by H Atlan [71](OPRideal the challenges of OPR (i.e., negative outcomes), and type 2), (b) replication of outcomes (OPR ideal-type 3), or means to mitigate with them (processes), were rarely re- (c) initiation of new OPR or activities (OPR ideal type 4) ported in the included studies and are, thus, not covered [72]. Replication was also a finding of one OPR review that in this article. Our practical experience, however, sug- reported effects beyond the location in 13% of included gests that OPR can be quite challenging. A primary studies (n =4) [3]. Moreover,thisisinlinewith the capacity study to identify challenges OPR stakeholders face and building and sustainability literature [73, 74] which suggests describe how they deal with them would be a valuable change is more likely to endure if it spreads or multiplies. contribution to the literature. Thus, OPR as we have operationalised it in our model, can be a means for academic and organization stakeholder to Conclusion co-create lasting change. Our findings are in line with a With this review, we have broadened the understanding of CBPR review [29] found that community-based OPR and the value of this research approach by Bush et al. BMC Health Services Research (2018) 18:992 Page 13 of 15 identifying and illustrating sequences of OPR the data extraction forms, interpret the findings and draft the manuscript. All authors read and approved the final manuscript. process-outcome sequences. Specifically, our results sug- gest that OPR stakeholders form a WG and hold meetings Ethics approval and consent to participate where they collectively determine the research objectives, None required. analyse the data and interpret the results and decide how Consent for publication to use them. Throughout these research phases, commu- Not applicable. nication, relationships development, commitment, and Competing interests collective reflection should be maintained. These pro- All co-authors declare they have no competing interests. cesses contribute to knowledge, attitude and behaviour changes in the stakeholders and the healthcare Publisher’sNote organization. Since our analysis is based only on OPR pro- Springer Nature remains neutral with regard to jurisdictional claims in cesses that were explicitly linked with OPR outcomes, we published maps and institutional affiliations. assert that these are the key processes to follow when con- Author details ducting OPR. Moreover, as per the four ideal types of OPR, 1 Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, we submit that when these processes are followed, OPR Suite 300, Montréal, Quebec H3S 1Z1, Canada. Department of Family Medicine, Sherbrooke University, 150 Place Charles Lemoyne suite 200, teams will achieve their objectives, and may also achieve Longueuil, Quebec J4K 0A8, Canada. Institute for Social Health, Catholic one or more extra benefits in the form of sparks, replication University of Applied Sciences Berlin, Köpenicker Allee 39-57, 10318 Berlin, or initiation. Overall, this review provides operational guid- Germany. Special projects, Canadian Pharmacists Association, 1785 Alta Vista Drive, Ottawa, ON K1G 3Y6, Canada. West Island YMCA, 230 Brunswick Blvd, ance to help OPR stakeholders collaboratively address Pointe-Claire, Quebec H9R 5N5, Canada. Mental health research institute, organizational issues and achieve desired outcomes and 7 University of Montreal, Montreal, Canada. CIET/Participatory Research at more. McGill (PRAM), 5858 Cote de Neiges, 3rd floor, Montreal, Montreal, QC H3S 1Z1, Canada. Additional files Received: 2 May 2018 Accepted: 28 November 2018 Additional file 1: Search strategies. This documents provides the References detailed search strategies for each bibliographic data base we searched. 1. Cargo M, Mercer SL. The value and challenges of participatory research: (PDF 195 kb) strengthening its practice. Annu Rev Public Health. 2008;29. Additional file 2: Data extraction form. This Excel form used for all 83 2. Green LW, George MA, Daniel M, Frankish CJ, Herbert CJ, Bowie WR, O'Neill studies included in this review. (XLSX 12 kb) M. Study of participatory research in health promotion: review and Additional file 3: Eighty-three Organizational Participatory Research recommendations for the development of participatory research in health Summaries. This document includes the 83 OPR summaries organized promotion in Canada. Ottawa: The Royal Society of Canada; 1995. according to four ideal-types of OPR. (PDF 873 kb) 3. Waterman H, Tillen D, Dickson R, de Koning K. Action research: a systematic review and guidance for assessment. Health Technol Assess. 2001;5(23). Additional file 4: Coding trees. This document includes screenshots of 4. Cornwall A, Jewkes R. What is participatory research? Soc Sci Med. 1995; the coding trees with the number of OPR summaries (sources) per code 41(12):1667–76. and number of codes per summary (references). (PDF 199 kb) 5. Hart EO, Bond M. Action research for health and social care : a guide to practice. Buckingham: Open University Press; 1995. 6. Holter IM, Schwartz-Barcott D. Action research: what is it? How has it been used Abbreviations and how can it be used in nursing? Journal of Advanced Aging. 1993;18:298–304. OPR: Organizational Participatory Research; WG: Working group 7. Friedberg E: Local orders : dynamics of organized action. Greenwich, Conn: jai Press; 1997. Acknowledgements 8. Argyris C, Putnam R, Smith DM. Action science: concepts, methods, and skills We would like to thank Joseph LeMaster, MD, MPH and Anne MacFarlane, for research and intervention. 1st ed. San Francisco, CA: Jossey-Bass; 1985. PhD for their comments on preliminary analyses; Reem El Sherif, MSc. MBBCh 9. Bush PL, Pluye P, Loignon C, Granikov V, Wright MT, Pelletier J-F, Bartlett- and Joshua Hamzeh, BSc for their contribution to grouping the 83 Esquilant G, Macaulay AC, Haggerty J, Parry S, et al. Organizational participatory summaries according to four ideal types of OPR; Soultana Macridis PhD and research: a systematic mixed studies review exposing its extra benefits and the Rafaela Queiroga Souto PhD for their help with data extraction. key factors associated with them. Implement Sci. 2017;12(1):119. 10. Pluye P, Nadeau N, Lehoux P. Comment favoriser la recherche clinique en Funding pédopsychiatrie? Une expérience de recherche-action collaborative. Santé This systematic mixed studies review was supported by the Canadian Mentale au Québec. 2001;16:245–66. Institutes of Health Research (CIHR reference number 136889) and the 11. Pluye P, Nadeau N, Nadeau L. Les contraintes imposées par le terrain sur la Quebec-SPOR SUPPORT Unit (http://unitesoutiensrapqc.ca/). rigueur. Recherches Qualitatives [wwwrecherche-qualitativeqcca]. 2000;21:125–44. 12. Lewin K. Action research and minority problems. J Soc Issues. 1946;2:34–46. Avalability of data and materials 13. Simmons A, Reynolds RC, Swinburn B. Defining community capacity The 83 OPR summaries and the coding trees are provided as an online building: is it possible? Prev Med. 2011;52(3–4):193–9. appendix to this manuscript (Additional files 1 and 2). 14. Munn-Giddings C, McVicar A, Smith L. Systematic review of the uptake and design of action research in published nursing research, 2000-2005. J Res Authors’ contributions Nurs. 2008;13(6):465–77. PLB led the review, carried out the study selection, data extraction, wrote the 15. Munten G, Van Den Bogaard J, Cox K, Garretsen H, Bongers I. OPR summaries, and carried out the analyses and drafted the manuscript. PP Implementation of evidence-based practice in nursing using action supervised PLB through all phases of the review process. VG developed and research: a review. Worldviews Evid-Based Nurs. 2010;7(3):135–57. ran the search strategy and carried out the study selection. All authors 16. Soh KL, Davidson PM, Leslie G, Rahman ABA. 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A systematic mixed studies review on Organizational Participatory Research: towards operational guidance

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Springer Journals
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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Research
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1472-6963
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10.1186/s12913-018-3775-5
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Abstract

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. Keywords: Participatory research, Organizational participatory research, Organizational change, Practice change, Qualitative synthesis, Mixed studies review, Healthcare organization * Correspondence: paula.bush@mcgill.ca Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Suite 300, Montréal, Quebec H3S 1Z1, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bush et al. BMC Health Services Research (2018) 18:992 Page 2 of 15 Background regarding the type and timing of organization stakeholders’ Collaborative approaches to research involve academic re- participation. Finally, some reported difficulty applying de- searchers partnering with those who have a stake in the tailed frameworks of participation as the reviewed studies research, but do not necessarily have any formal research were often lacking detail [3, 15]. Therefore, to gain clarity re- training. Stakeholders may include patients, policy makers, garding how participatory processes contribute to outcomes, communities, organizations or any other individual or we used a framework of two distinct forms of organization group who may benefit from or use the results [1–3]. The stakeholder participation, at opposite ends of the con- premise is that the non-academic stakeholders have tinuum: (1) providing input when consulted by academics insight into problems and their potential solutions [2]. (no research co-governance) for at least three research deci- The non-academic stakeholders may participate in identi- sions: (a) identification of the research question(s); (b) deter- fying the problem and formulating the research questions, mination of the methodology, and/or data collection and/or selecting the research methods, collecting the data, analys- analysis, and/or interpretation of results; (c) implementation ing the data, interpreting the results, and applying and or dissemination of results; or (2) co-constructing at least disseminating results. Throughout these stages of the re- these three research decisions with academic partners (re- search process, non-academic stakeholders may partici- search co-governance) [9]. Regarding OPR processes, we fo- pate to varying degrees. Typologies of this participation cussed on any academic-organization collaborative activity have been put forth illustrating continua from the non-ac- throughout all phases of a study. We conceived of an OPR ademics participating passively (e.g., providing input, but outcome as any consequence of an OPR process. not actively engaging in decisions) to taking full control of We used a sequential mixed methods review design the study [3–6]. Further, participatory research can be dis- where the quantitative synthesis of phase-1 informed the tinguished by the three main drivers of the various re- qualitative synthesis of phase-2 [17–20]. Phase-1, re- search approaches, namely knowledge translation, social ported elsewhere [9], measured the likelihood of an OPR and environmental justice, and self-determination [1]. study yielding ‘extra benefits’. We define ‘extra benefits’ Herein, we focus on organizational participatory research as positive outcomesof an OPR study that clearly do not (OPR) which is most closely aligned with the knowledge meet the specific participatory research project objec- translation driver. tive(s) for change (for a complete definition, see PL An organization is a “context of action in which rela- Bush, P Pluye, C Loignon, V Granikov, MT Wright, J-F tionships of cooperation, exchange, and conflict between Pelletier, G Bartlett-Esquilant, AC Macaulay, J Haggerty, actors with divergent interests are being established and S Parry, et al. [9]). We compared OPR studies that managed” [7] and which fluctuates in response to clearly represented either Co-construction OPR (n = 83) changes in the environment. OPR takes place with and or consultation OPR (n = 24). We found no significant within organizations—in this article, organizations offer- association between the form of participation and the ing healthcare-related services—for the purpose of likelihood of at least one extra benefit of OPR. Yet, when organizational learning and/or practice improvement the OPR was initiated by the organization (as opposed [8–11]. This research approach is rooted in the works of to the academic stakeholders or the organization and Kurt Lewin on action research [12] and of Chris Argyris academic stakeholders together), the likelihood of the and Donald Schön on action science [8]. It is a capacity study resulting in at least one extra benefit was quadru- building endeavour where capacity building is a process or pled (OR = 4.11, CI = 1.21–14.01) [9]. an approach used to develop, enhance, or leverage a collec- This paper reports phase-2 of the review with the follow- tion of characteristics (e.g., organization stakeholders’ insider ing three objectives: 1) to identify OPR processes and the knowledge, academic stakeholders’ research methods expert- outcomes to which they contribute (descriptive objective); ise) for a purpose (e.g., effecting sustainable organizational 2) to understand the sequence of OPR processes and out- change) that is context dependent [13]. comes, in particular extra benefits (analytical objective); 3) Extant reviews of participatory forms of research taking to identify ideal-types of OPR process-outcome sequences place within healthcare organizations and with their stake- (explanatory objective). OPR is an inherently chaotic or holders (practitioners, staff, management, or service users) ‘messy’ [21] endeavour. Identifying characteristics of OPR report positive outcomes, such as stakeholders gaining con- in the empirical literature and assembling them into ideal fidence, skills, and knowledge; addressing challenges and types [22] may help to provide some order to our under- implementing innovations; improved job and patient satis- standing of this messy research approach. The ultimate goal faction [3, 14–16]. However, attributing the outcomes to the of this mixed studies review is to provide recommendations participatory processes has been difficult. A minimum level for OPR practice to help academic and organization re- of non-academic partner participation needed to guarantee search teams achieve their agreed upon objectives and ex- success has not been determined, either [3]. Furthermore, perience extra benefits; thereby, helping to ensure the these reviews examined studies that were heterogeneous added value of the participatory approach to their research. Bush et al. BMC Health Services Research (2018) 18:992 Page 3 of 15 Methods no such statement. Among the 107 studies included in A participatory research approach was used to conduct this phase-1, 83 represent the co-construction type of par- systematic review which followed a process as outlined in ticipation and were thus selected for phase-2. QN Hong, P Pluye, M Bujold and M Wassef [19]. Specific- ally, academic researchers and health organization stake- Data extraction holders on our team co-constructed the research questions, For each included study, the lead author and two re- the interpretation of results and the resulting publications. search assistants extracted descriptive data, study objec- Moreover, some academic and organization stakeholders tives, and text passages describing OPR processes, OPR contributed to various other stages of the review including outcomes, and OPR processes explicitly linked with developing the bibliographic data base search strategy, OPR outcomes (Additional file 2). For the purposes of examining raw data, guiding the analysis, and discussing this review, OPR processes that are explicitly linked to preliminary results. In this second phase of the review, the outcomes are ‘key processes’ of OPR. Moreover, OPR subset of studies incorporating a co-construction form of outcomes are not the study results, but rather anything health organization stakeholder participation from Phase-1 that occurs following an OPR process. For instance, an was included. The rationale for this purposeful sample was OPR outcome that is explicitly linked to an OPR process that these studies provide a richer description of participa- could be a statement such as: “working together on the tory process and their consequences. As per PROSPERO OPR project helped to develop the synergy of the part- inclusion criteria, this review is not registered. The Enhan- nership”. In this example, the OPR process is ‘working cing Transparency in Reporting the Synthesis of Qualitative together’ and the partnership synergy is the OPR out- Research (ENTREQ) framework guided the reporting of come. Thus, we reviewed the authors’ descriptions of the synthesis [23]. the OPR processes they used and the outcomes they said occurred as a result (in the above example, working to- Search methods gether helped to develop the synergy of the partnership). Peer reviewed and grey literature databases were searched Consequently, many data were extracted from the from inception through 2012 using MEDLINE, CINAHL, methods and discussion sections. For studies described Embase Classic + Embase, PsycINFO, the Cochrane Li- across multiple publications, all papers were used, and brary, Social Work Abstracts, Business Source Complete, data were extracted in order, beginning with the earliest ProQuest Dissertations & Theses database, the New York publication. Data were entered into one Excel workbook Academy of Medicine – Grey Literature Report, Open- per study with the descriptive and process-outcome data Grey, and Google. The search was updated in 2014 using on separate pages. The process-outcome page had one forward citation tracking. See Additional file 1 for search column for processes and one for outcomes. OPR strategies. Full details regarding search methods are re- process and outcome passages were pasted in order, one ported in PL Bush, P Pluye, C Loignon, V Granikov, MT per row. Text passages that made an explicit link be- Wright, J-F Pelletier, G Bartlett-Esquilant, AC Macaulay, J tween an OPR process and outcome were pasted on the Haggerty, S Parry, et al. [9]. same row, and the process and outcome cells were merged. The top row was reserved for the study object- Search outcome ive. The resulting process-outcome pages of each Excel The database search identified 13,837 records which workbook presented a clear story of the study objective, were exported to EndNote where duplicates were re- the OPR processes used, and the OPR outcomes ob- moved. Forward citation tracking led to an additional served. The lead author reviewed all Excel workbooks 150 records for a total of 8873 unique records. As de- for accuracy of extracted data and of the categorisation scribed elsewhere [9], nine inclusion criteria were itera- of text excerpts as OPR process and/or outcome. tively developed with all research team members. Two independent reviewers screened the records for rele- Synthesis vance and selected 992 full texts for further assessment. The co-authors of this study are academic and organization In all, 140 studies met the inclusion criteria. (See PL stakeholders with experience in OPR. As per a participatory Bush, P Pluye, C Loignon, V Granikov, MT Wright, J-F research approach, co-authors participated in decisions Pelletier, G Bartlett-Esquilant, AC Macaulay, J Haggerty, throughout this review. Regarding this qualitative synthesis, S Parry, et al. [9] for full details and flow chart.) co-authors commented on the Excel documents prepared in the preceding phase. Then, the lead author copied the Quality appraisal process-outcome pages of each Excel workbook into MS The quality appraisal focused on identifying studies Word, removed redundancies, and re-arranged the excerpts reporting an explicit link between OPR processes and into OPR summaries with: (1) objective(s), people and outcomes; 33 studies were excluded because there was place; (2) OPR processes; (3) linked OPR processes and Bush et al. BMC Health Services Research (2018) 18:992 Page 4 of 15 outcomes. This reflexive step was necessary because much toward the end of an OPR and proposed types based on ul- ofthedatawerenot theproduct of empirical investigation, timate OPR outcomes. These OPR ideal types were verified but rather the authors’ reflections on their practical experi- and refined during a grouping exercise [32]. Two research ence with OPR. Yet, all included studies were peer reviewed assistants with expertise in OPR (RS & JH) and two and most were co-authored by a team of investigators. For co-authors (PLB & PP) met to read and discuss the 83 sum- the most part, the OPR summaries (raw data) are the study maries in relation to the proposed types. They grouped the authors’ words; although, some excerpts were rewritten to summaries according to the dominant OPR type and de- ensure proper grammar and syntax or paraphrased for the fined ideal-types [33]ofOPR. sake of parsimony. To identify processes linked with outcomes and to Results understand their sequences throughout an OPR (objec- Characteristics of included studies tives 1 and 2), the lead author used hybrid (inductive/de- In total, 83 studies described across 145 publications, ductive) thematic analysis [24]. She coded all of the OPR met our inclusion criteria. The complete results of our summaries (assigned extracts of text to themes) according search and selection processes are published elsewhere to OPR process, OPR outcome, and linked OPR [9]. The 83 studies were each reduced to an OPR sum- process-outcome using qualitative data analysis software mary of 450 words, on average (Additional file 3). The (NVivo 10). Coding the data pertaining only to an OPR coding trees are in Additional file 4. To respond to our process or only to an OPR outcome was important to gain first two objectives, below we detail the eight key OPR an understanding of the data corpus. However, given the processes that were identified (objective 1). Four of these specific objectives of this review, the final synthesis is occur during subsequent research phases, and four are based solely on the linked process-outcome codes. This present throughout an OPR. We then describe and ex- coding was guided by partnership synergy theory [25, 26] emplify the extra benefits for the organization stake- capacity building [27, 28] and benefits of participatory re- holders and the organization as a whole that the OPR search [29] frameworks (deductive coding). Themes and processes contribute to (objective 1). These OPR pro- codes outside of these frameworks were also used where cesses and OPR outcomes are presented in our results the data suggested them (inductive coding). following the sequence in which they occur in OPR (ob- In line with traditional guidance for consistency and jective 2). Finally, we present four ideal-types [33]of rigour in qualitative thematic data analysis [30] and its OPR (objective 3). Each is illustrated with an OPR sum- application as ‘qualitative thematic synthesis’ in litera- mary. To lend credibility to our findings and to help ture reviews [31], our synthesis is based on an interpret- readers relate to them and determine their applicability ative method and research meetings, where coding to their contexts, excerpts from the OPR summaries processes were shared and discussed. Through iterations (raw data) are included throughout the results section. of analysis and discussion of preliminary results with When the excerpts are direct quotations from the ori- team members, the analysis became increasingly induct- ginal publications, they are indicated in italic text. ive. All 83 summaries were coded, rather than stopping the analysis once saturation had been reached. All Eight key OPR processes results reported herein were found in multiple summar- Four phases of OPR ies. The lead author aggregated the codes into OPR We begin by illustrating the four key processes of OPR that process-outcome themes and wrote an overall OPR describethesequenceofactivities that should be carried process-outcome story depicting themes that occur at out to help achieve extra benefits from the OPR approach. the beginning of an OPR and others that occur during and toward the end of an OPR. Co-authors revised this story commenting, in particular, on its credibility. The Form a working group (WG) and hold meetings Typ- lead author delved back into the data and refined the ically, a WG of university and organization stakeholders analysis to address co-authors’ comments. The contin- is formed to carry out the OPR. Organization stake- ued interaction among the university and organization holders vary depending on the needs of the project, but co-authors was critical to recognize, discuss and deal a multidisciplinary WG is common (e.g., nurse, phys- with our biases. Additionally, preliminary findings were ician, manager, social worker, etc.). Many conclude that presented at academic conferences over the course of diverse membership is crucial and can help ensure the the analysis process, and discussions with academic re- relevance and uptake of the OPR. For instance, some as- searcher and health practitioner delegates provided fur- sert “the diverse blend of experts from the [organization] ther perspectives that were taken into account. and the academic investigators has created projects and To identify ideal types of OPR (objective 3), the lead au- programs that are better suited to and accepted by the thor examined the process-outcome sequences that occur community and with greater chance for sustainability Bush et al. BMC Health Services Research (2018) 18:992 Page 5 of 15 than could have been produced by either group inde- The OPR process began with a number of meetings pendently” [34]. between members of the team, in which the nature Regarding administration’s and management’s partici- and scope of the problems with practice were pation in OPR, L Hamelin Brabant, M Lavoie-Tremblay, explored and critically examined. A C Viens and L Lefrancois [35] write that administrators’ multidisciplinary team decided to develop a involvement helped to “instil the motivation needed to chemotherapy protocol manual (based on analysis implement new practices.” Others suggest roles manage- of the data related to timing of the administration ment can assume, such as supporting the OPR by redu- protocols and reflection on these results) that cing red tape, acknowledging progress reports by letter, would explain all the requirements of each protocol implementing some recommendations, and encouraging and provide more accurate estimations of the time staff to become actively involved in the process. required to administer the protocol and care for The reviewed studies suggest that WGs meet regularly, the patient. though the frequency of meetings varies (once per week to once every month or two, or less often). Meetings must While it can be challenging to reconcile differing per- be facilitated effectively and often an academic partner spectives and priorities of WG members, addressing or- assumes this role. In one study, WG members “believed ganisation stakeholders’ needs can lead to more relevant the project was well-managed and that this was a factor in and longer lasting changes, as underscored by H its success” [36, 37]. This may suggest the importance of Waterman, R Harker, H MacDonald, R McLaughlan and WG meetings being structured and focussed on specific CWaterman[43]: “We would argue that, once the project issues or tasks, as described by some author teams. had reconfigured its interests to those of patients, more WG meetings provide opportunities for the inter- detailed and lasting suggestions were implemented.” action, discussion, debate, reflection, and consensus re- Furthermore, R Khresheh and L Barclay [40]write: “shared quired to enhance the OPR and achieve more nuanced goals guided the researcher and practitioners in their joint results and products. During meetings, members work and created commitment for the considerable effort complete OPR tasks, make decisions, learn from the ex- needed for the research to succeed.” perience of others, become more familiar with one an- other, and understand each other more in their various Collectively analyse data Collective, iterative data ana- professional contexts, roles, and contributions--ulti- lysis provides opportunities for WG members to ex- mately changing and improving practice. Furthermore, change thoughts, understand each other’s perspectives, the OPR processes contribute to improved professional and reflect as a group. This helps to further develop re- relationships and collaborations and increased job satisfac- lationships. For instance, EM Eisenberg, J Baglia and JE tion. S Andrews, E Lea, T Haines, J Nitz, B Haralambous, Pynes [44] note that “working through the narratives K Moore, K Hill and A Robinson [38] explain that WG with the ER staff gave them a role as research partners members’“collaborative working challenged the trad- and enabled a dialogue that encouraged the ER staff to itional hierarchical relationships between staff and opened acknowledge and understand each other’s ways of view- up an opportunity to work in partnership, thus building ing the world.” Two studies describe what collective data capacity and empowering staff.” analysis may entail. B Taylor [45] writes: “Descriptions of WG members typically value and benefit from the meet- participant observation were analysed individually using a ings. In one study, WG members “felt that the [OPR] reflective analysis method and collectively by group process was worthwhile. All staff agreed that ‘the meetings discussion.” For their part, A Gregorowski, E Brennan, S were valuable because we could discuss different ideas’. Chapman, F Gibson, K Khair, L May and A Lindsay-Waters Generally, staff welcomed the opportunity of raising issues [46] indicate: and discussing ways that these could be dealt with” [39]. The nurse consultants met with the research fellow Collectively determine research objectives The WG on a regular basis to analyse the data together. In begins by determining objectives that all members con- this way, a number of themes were collaboratively sider valuable. This process helps members to develop identified and divided into subthemes through relationships and contributes to the success of the OPR paired and group work. Once themes were by, for example, helping WG members to “feel great en- identified, the nurse consultants agreed to work in thusiasm about the project” [40]. Some suggest that es- pairs on the individual themes. Each took a theme tablishing project goals quickly “helps promote unity to work on as the primary researcher and another between the participants working towards this chosen to work on as the secondary researcher. The group end” [41]. M Wallis and S Tyson [42] discuss how they then came together to organise the themes and determined their OPR objective: subthemes into a framework. Bush et al. BMC Health Services Research (2018) 18:992 Page 6 of 15 Collectively interpret results and decide how to use can help “to reflect on discussions and ignite new thoughts them Discussing and interpreting results during WG and deliberations” [52], and “correct any misunderstand- meetings can be validating for organization stakeholders ings” [53]. In one study, a public website was used to post when the results confirm their perceptions. Additionally, information about the OPR: WG members can learn how to use study results to make evidence informed decisions about practice, and Interestingly, even when a member could not attend a their motivation to effect change may increase given the session, reading the archive allowed them to feel that awareness they gain regarding the issues under study. they had participated and resume without disruption. One author team writes: “by creating a structured and There was no evidence that the group regressed supportive environment for data interpretation, the study throughout the year or lost productivity when new reduced their fear. As they became more familiar with members joined, which was unexpected [54]. the charts and graphs, they began to look at data as a basis for decision making” [47]. KT Ngwerume and M Communication between the WG and the rest of the Themessl-Huber [48] provide another example: “Discus- organization regarding the OPR is important and can in- sions about challenges in utilizing this knowledge also crease interdepartmental understanding, help to prevent made them aware of the difficulties in applying this new resistance to change and enhance buy-in. Moreover, knowledge in practice and at the same time provided reaching out to the whole organization increases the them with options about how to implement changes.” number of voices that are heard and taken into account. H Waterman and J Grabham [55] provide an example: Four continuous OPR processes Our analyses suggest that an additional four key pro- The action research group was not insular in that cesses are present throughout a successful OPR: com- it integrated closely with hospital management munication, relationships development, commitment, systems, for example, senior nurse and general and collective reflection. First, effective communication management meetings. Some people who attended is open, two-way, transparent (e.g., making findings ac- the action research meetings, also attended these cessible), ongoing, and requires language all OPR team other meetings, and so ideas and actions from one members understand. To exemplify, L Olsen and L influenced the other. This ‘spreading and Wagner [49] write: “Using broadly defined terms (e.g., for enveloping’ of understanding of issues from all ‘discharge’ and ‘prevention’) helped participants to find perspectives became vital in the acceptance and some common ground, despite their different backgrounds inauguration of change. and mandates.” The quality of the communication within the WG can Second, relationships characterised by mutual trust, enhance stakeholder involvement and influence the OPR, respect and support, develop over time, and are import- help pursue issues to stakeholders’ satisfaction, improve ant to the success of the OPR. AJ Beringer and ME team work and team spirit, and help to bring about Fletcher [56] write: “The single most important indicator change, as described by J Bothe and J Donoghue [50]: of full achievement of outcomes was that the work group members developed mutually supportive and trusting re- As a result of the opportunity to communicate openly lationships between themselves and with the facilitator. with others, in addition to the team’s ability to think Where these relationships did not develop, this impeded and discuss their work critically, their practice became achievement.” Strategies for nurturing relationships in- more effective, safer for patients and patient centred. clude recognizing partners’ contributions and providing These changes were apparent to others, and provided positive reinforcement. One author team suggests: “the a model of enablement that is now used elsewhere in value of commending the partnership and acknowledg- the organization. ing the productivity of the collaboration cannot be underestimated as a means reinvigorating the relation- The meeting facilitator plays an important role by foster- ship and sustaining the collaboration” [34, 57]. ing an environment of trust and respect to enhance the Third, WG members’ commitment can lead to more sharing of diverse viewpoints. K Galvin, C Andrewes, D active involvement and the sustainability of changes as Jackson, S Cheesman, T Fudge, R Ferris and I Graham [51] illustrated by the following: note that sharing views during meetings “facilitated collab- orative working and provided an opportunity to clarify any The Admiral Nurses’ commitment to stay with the confusion, air any tensions, and to agree a way forward.” project, organizational commitment to embed the Producing and circulating meeting notes or other docu- framework in their practice development strategy ments is one communication method some have used. This and support from service managers contributed to Bush et al. BMC Health Services Research (2018) 18:992 Page 7 of 15 the success of the development and implementation During the data interpretation activities, the of the Admiral Nurses’ Competency Framework. physicians moved from a classical medical orientation The project commissioners are continuing their of the individual as the unit of analysis to examining support for the framework by explicitly linking it disease patterns in the population. The physicians also with work on standards of care, new job began to move from an exclusively curative descriptions and, importantly, through the role of orientation to disease to a more preventive one [47]. the Consultant Admiral Nurse [58]. These authors discuss that when partners “saw study Fourth, the collective reflection that occurs during results in the form of charts and tables, their level of en- WG meetings seems particularly important. Specifically, thusiasm rose markedly, and they began to participate collectively reflecting on the OPR and about professional actively in data interpretation, and to understand how practices stimulates personal reflection and objectivity the study could be helpful to them in operating the clin- and supports increased confidence, skills, and insights ical or preventive sectors of their facility.” Others report among WG members. This leads to modifications or ad- that the confidence and sense of ownership organization justments to the OPR and the identification of new or stakeholders gain from the process increase their auton- additional issues to pursue via OPR. omy, enthusiasm and responsibility for the work, and empowers them to effect change. The opportunity for the [Falls Action Research The new behaviours, practices, and skills developed Group] members to meet with their colleagues, from through the OPR also contribute to extra benefits. As S within their own facility and those from another Lauri [60] writes: [Residential Aged Care Facility], fostered the development of new understandings about their In the opinions of the public health nurses, the respective workplaces and the conditions that conscious implementation of the action model also shaped their practice. As such, the [Falls Action produced beneficial effects on their work as a whole. Research Group] members became more familiar Most nurses began to pay more attention to the with the contributions their colleagues, from other various areas of child development, and to explore the occupational groups, made to resident care [38]. needs of the child more extensively as the basis of guidance. The objectives and programmes, in the Participation in the inquiry by health professionals opinion of the public health nurses, gave a direction to was important as it fostered cooperation among and a foundation for the guidance and counselling. clinicians and shared decision-making at different levels of interaction. (….) Doctors, pharmacists, and Regarding the organization, OPR that takes place in a nurses had an opportunity to work closely together part of a health organisation (e.g., hospital ward) can ul- on thecommongoalof implementingchangeto timately affect other parts of the organisation, or beyond. medication management. In the process, team Some studies lead to additional OPR or initiatives as the members also gained a deeper understanding following OPR summary excerpt illustrates. of effective and safe prescribing practices [59]. As a result of the hospital study, the health education staff already plan to focus on alcohol abuse in those Extra benefits communities which seem to have an elevated problem. The process-outcome sequences above lead to extra bene- Tuberculosis has emerged as a second area of outreach fits for individual stakeholders and the organization as a program development. The Foundation’sboard of whole. Regarding stakeholders, the awareness, under- directors has used the hospital data in a fundraising standing, and general knowledge they gain about research, effort for a community education and control program. their work, and their colleagues’ work has many benefits. The hospital’s medical director planned to use the data For example, they experience a sense of achievement, their to identify the priority villages for the tuberculosis clinical confidence, skills, and care practices improve, and program [47]. they develop a drive to do research. In one study, “data had a direct impact on staff serving to broaden under- The OPR process may also expose or raise awareness standing of patients’ views on equipment and preoperative for additional issues the organization may subsequently education, and it helped monitor the changes that were address. Two excerpts provide examples: being put into place” [43]. Attitude changes also occur through the OPR process Using the suggestions for change that had been and lead to practice improvements and other benefits. made by patients, carers and healthcare Bush et al. BMC Health Services Research (2018) 18:992 Page 8 of 15 professionals, eight changes to practice were processes that contribute to achieving intended outcomes. identified and it was agreed who would be This is depicted in a study by Lucas et al. [36, 37]. This responsible for their implementation. The first OPR ideal type can lead to random benefits unrelated changes are now being re-evaluated providing the to the study objectives (OPR ideal type 2). The summary opportunity for healthcare professionals within the of an OPR by Barker & Barker [62]illustrates multiple colorectal unit, and a new group of patients and such benefits. The third ideal type consists of the OPR (or carers, to comment on the effects and effectiveness part of it) being replicated elsewhere in the healthcare of the changes made thus far [61]. organization or even outside of it. A study by Boniface et al. [63] illustrates an OPR in one unit spreading After the manual and new forms had been used for county-wide. In the fourth ideal type, OPR processes con- some time, the nurses thought that there were still tribute to achieving intended outcomes and also to gener- inefficiencies in the system. Consequently, further ating, or initiating, new activities or new OPR. The OPR phases of the action research project were designed summary of a study by P O’Connor, RR Franklin and CH to improve the patient appointment booking and Behrhorst [47] mentions a variety of new activities that staff allocation systems [42]. were initiated as a result of the OPR. Any combination of these four ideal types is possible. Some studies in our sam- ple illustrate two, three or all four of the ideal types. For Four ideal-types of OPR example, a combination of ideal types 2 and 4 is repre- The third and final objective of this synthesis was to sented in the summary of the dissertation by Heyns [64] identify ideal types of OPR. We found that the 83 studies (see additional file 3, p. 111). The summary of the study reviewed can be grouped into four such ideal-types, as by Sorensen and Haugbolle [65] illustrates a combination presented in Table 1. Additional file 3 presents the 83 of ideal types 1, 2, and 3. (see additional file 3,p.106). The summaries organised by the four ideal-types. Select OPR summary of the study by MS Fagermoen, GA Hamilton, B summaries illustrating the ideal types are presented in Svendsen and H Hjellup [66] illustrates an OPR represent- Table 2 as follows. The most basic type consists of OPR ing all 4 ideal types (Table 2). Table 1 Four ideal types of OPR The Four Ideal Types of OPR: 1, 1 + 2, 1 + 3, and 1 + 4 1. OPR processes contribute to achieving intended outcomes 2. …and ‘random sparks’ (basic OPR) Successful OPR focuses on a vested interest of organization stakeholders, Throughout an OPR endeavour, Working Group members learn from be it an interpersonal or organizational one. Through ongoing one another in myriad ways (e.g., research knowledge and skills, discussion and critical reflection, a Working Group of academic and organization or professional constraints, professional knowledge and organization stakeholders reach consensus over time, regarding this skills, service users’ and other professionals’ experiences) and some focus, together with all other research-related decisions. Working Groups take their learning forward and, for example, enrol in graduate are often multidisciplinary and may include stakeholders from one or studies or use their new talents in other contexts. Organization multiple organizations with a common interest. Arguments may occur stakeholders develop a stronger awareness of contextual issues and throughout the process, but a structured and supportive environment concerns in their workplace, gaps in their own professional helps to work through them. Likewise, valuing input, acknowledging knowledge and skills, and experience changes in their attitudes and celebrating contributions and outputs, positive attitude, and toward one another and their practice. Communication, team work, fostering motivation, teamwork and trust are important for achieving and staff morale improve, and staff turnover decreases. Further, a shared vision for the OPR and reaching objective(s). professionals experience increased clinical confidence, empowerment, Whether the technical work of the analyses is completed by the and job satisfaction. All stakeholders’ perspective of collaboration academic stakeholders or the whole Working Group, communicating evolves and the OPR partnership and stakeholder relationships come preliminary results is important to develop the commitment and to be viewed as valuable outcomes, and this, even when stakeholders’ motivation of the organisation stakeholders. Moreover, research results relationships are characterised by tension and mistrust at the outset. help organization stakeholders to see how research can be helpful to 3. …and the replication of intended outcomes them for their health care practice and become a basis for decision making. Preliminary results may include such things are charts, graphs, Processes used in the OPR become new practices that are maintained. and fieldwork summaries. Notably, care must be taken to use the right For instance, communication means, such as log books and monthly language when communicating research results to assuage potential meetings, are taken up by the whole organization and become regular worries about understanding them. Final results are communicated by practice. Additionally, practice changes resulting from the OPR (e.g., the WG to the rest of the organisation and beyond, as needed. This interventions, education packages for service users, professional continuing helps to engage additional stakeholders in the OPR. Overall, the OPR education activities) may be taken up by the whole organization and processes (ongoing discussion, consensus seeking, data analysis and beyond, to a whole health care services territory or country. interpretation of results, decision making, and problem solving) leads 4. … and the initiation of new activities or new OPR to the Working Group achieving its OPR objectives. Ultimately, additional priorities are identified leading to spin off projects or additional OPR. Sometimes, other organizations aware of the OPR, request OPR facilitation help from the academic stakeholders to address a practice change need in their own milieu. Bush et al. BMC Health Services Research (2018) 18:992 Page 9 of 15 Table 2 OPR summaries illustrating each of the four ideal-types Table 2 OPR summaries illustrating each of the four ideal-types of OPR and their combination of OPR and their combination (Continued) Illustration of OPR ideal type 1: Basic OPR staff relations (e.g., good-natured teasing and humor compared to sarcasm and blaming readily observed in meetings prior to the pro- This 10-month project sought to examine the process of change ject), c) lower staff turnover, d) more open intradisciplinary and inter- when developing a preparation programme for patients awaiting disciplinary communication (e.g., staff members now openly support Total Knee Replacement (TKR) Surgery in an outer London acute NHS each other, ask for assistance from staff members in other disciplines, hospital. The researcher initiated and facilitated the project which in- and collaborate on problem solving), e) new skills (e.g., team problem volved ‘back office’ activities of organisation and encouragement. A identification, decision making, cooperation, leadership), and f) staff Project Management Group (PMG) was established consisting of appear willing to take more risks in making suggestions, confronting orthopaedic consultants, nursing staff, physiotherapists, occupational issues, and encouraging and supporting others. therapists, managers and service, users who were patients who had had Total Knee Replacement surgery at the project site, and the uni- Illustration of OPR ideal type 3: Replication versity researcher who was a nurse practitioner within the organisa- The aim of this study was to embed the theoretical tenets of the tion. Nine monthly PMG meetings held between January and Canadian Model of Occupational Performance and its structures in a October, with the aims of planning and reviewing the action cycles way that was appropriate to, and would be used by, all staff within related to the development of the Knee Clinic and information book- an integrated health and social care setting. Initially enthusiasts were let, and reflection on the progress of the project, including the called upon to work in the localities and join a short-term steering change process. The researcher took notes during PMG meetings group. This small group of self-selecting members of the service and which were distributed to PMG members for checking and correction. the university lecturer, soon grew to include representatives from all PMG members were involved in the action cycles to varying degrees. geographical areas and services within the trust (n =16–20). It was They worked within the meetings to plan, discuss, analyse and refine non-hierarchical and disseminated the notes of its meetings to the the test cycles. They decided which test cycles should continue and whole service through individual ‘champions’ of the model’s imple- which should not be pursued. They participated in the test cycles mentation. Despite the attempt to include all staff in the action themselves in various roles including data collection, participation in phases of the research (led by their own representative on the action the Knee Clinic, and administrative tasks. Ultimately, the PMG research steering group), the steering group was a large group and, developed into an effective team, demonstrating the behaviours of not all the members were present at all the reflection cycles, but they good communication and adaptability. were crucial to the research’s action phases. Some of the PMG members believed the project was well-managed The steering group recognised their supervisory and influential role and that this was a factor in its success. Some staff did not have high but did not want staff to feel the model was being imposed upon expectations of the project but nevertheless participated. It appeared them. The group discussed what resources were required to assist that this participation modified their behaviour in that they continued staff confidence and keep the momentum going. Given staff to provide support to the Knee Clinic after the project ended. For the criticisms of communication and dissemination of up to date service users the project provided the environment for them to share information the steering group recognised the need to engage both and use their experiences of TKR surgery with staff and other patients. occupational therapists and the managers in the different They helped to shape the direction of the project and changed the organisations, and that management and senior occupational environment through the decision to set up a service user group for therapists needed to support and help maintain enthusiasm for the others to share their experiences of surgery after the project ended. model within their teams. Thus issues, concerns and good practice Illustration of OPR ideal type 2: Sparks were brought to the steering group meetings, and over time tools and materials were developed to help staff in the sharing of good In 1989 a three-year study began in a substance abuse inpatient unit work and solutions to issues and concerns. in a large university teaching hospital in the UK, to generate a de- The collaborative way of carrying out the research ensured the scription of the substance abuse inpatient program, define and workability of the action. For instance, the steering group member prioritize target areas for change, implement and evaluate change ef- who had previously experienced the dilution of the model’s theory forts, and provide an opportunity for staff participation and input into by its paperwork being implemented too early influenced the the change process. The nurse, medical, and unit directors, and other steering group to delay paperwork implementation. At the same key staff members (e.g., admitting nurse) formed the team bringing time, other staff members were clamouring for its creation. The result nursing, medical, and psychosocial staff members’ perspectives to following was that staff in their own settings began to create their meetings. Other staff members volunteered to form various subcom- own paperwork, which was then brought back to the steering group mittees that developed and implemented changes (e.g., revision of for further reflection and consequent action. The assessment and criteria and procedures for monitoring patient progress in treatment, planning paperwork that has evolved through this process is now provision of written policies addressing major issues). All action almost countywide, applicable to most areas, firmly embedded in the followed a developmental process in which committees circulated theory of the model. Another example concerns training. Champions drafts for staff feedback, thereby insuring that staff members were in- in the acute hospitals produced a training package on the model’s formed and invited to participate in all change efforts. The unit direc- theory and use and the steering group became aware that other tor’s role was that of facilitator, providing encouragement, process areas were keen to use this or a similar package and recognised that monitoring, and feedback. The director relied heavily on group facili- the training package was a good way of a team working together to tation skills to achieve consensus among staff members. However, this strengthen understanding of the model, share how it could be consensus seeking did not occur overnight and actually involved sev- practically adopted in individual clinical areas and address any issues eral months of discussions. Through the group process, opinions were or concerns. The steering group realised this sharing of knowledge voiced resulting in all staff members supporting clinically sound would not have happened if the information had not been taken to a changes that were consistent with the unit goals and philosophy. group steering the implementation of the model. Changes were assessed by surveys and results were provided to the The steering group was critical in guiding the model’simplementation, inservice staff to plan and implement adjustments and, then, re- in sustaining motivation and energy across the service, and for assess. Administrators’ support was readily forthcoming by including communicating information across a wide staff group on an ongoing some in the action research process and by keeping others informed basis. Many heated discussions occurred, and all members of the group through the distribution of survey forms and committee and evalu- found that their thinking about occupational therapy practice ation reports. developed and changed. The group has continued to have an The use of the action research model employing staff participation important role in making decisions and recognising when staff needed increased the effectiveness of this multidisciplinary inpatient unit. re-energising. The process so far has taken 4 years and is ongoing. Benefits include: a) an observed increase in staff morale, b) improved Bush et al. BMC Health Services Research (2018) 18:992 Page 10 of 15 Table 2 OPR summaries illustrating each of the four ideal-types Table 2 OPR summaries illustrating each of the four ideal-types of OPR and their combination (Continued) of OPR and their combination (Continued) Illustration of OPR Ideal-Type 4: Initiation supportive, and accepting mentoring style and gave credit, guided and advised throughout. The researcher was responsible for the When this project began, although the local staff were helpful, they agenda and the minutes from project meetings. All met frequently to did not envision how the study would be useful and they went along collectively discuss the work of each group. They developed a wel- with the initial steps of data collection and analysis passively. One of come brochure the use of which for all patients admitted to the ward the major tasks in data analysis was the regrouping of individual is now regular practice, and other brochures that are sent patients diagnoses into manageable categories. Through repeated discussions, when they receive their date for admission, also now regular practice. among groups composed of Guatemalan and Tulane physicians and Indeed, admission of patients by one nurse each day is now a well- epidemiologists, consensus was achieved in developing clinically and established practice with benefits for all patients, not only the trans- conceptually meaningful diagnostic groups. After data processing had urethral resection -patients. Additionally, guidelines were necessary to been completed, a series of two meetings were held in Guatemala ensure that all patients got a certain amount of information at dis- for interpretation of the information generated. The Tulane staff had charge. To evaluate the changes, given no adequate instrument was prepared charts and graphs of the results on a large drawing pad. found, the researchers worked with the nurses to develop an instru- When staff saw the graphs and tables, the level of enthusiasm rose ment, reaching consensus on topic, readability (literacy level), rele- markedly. They began to participate actively in data interpretation, vance, and ease of use for the patient. Guidelines for administering better understand what Tulane staff were doing, what the results the data-collection were established and nurse was designated to do would look like, and how the study could be helpful to them in this. The hospital financed a course in SPSS for this nurse, who then operating the clinical or preventive sectors of their facility. was able to participate in developing codebooks and to carry out Interpretations of the data were developed primarily by the three data-entry. hospital staff physicians through group discussions. They frequently The pace of the study was slower than anticipated given a lower argued about the results, but usually they eventually achieved group than usual admittance rate of trans-urethral resection patients. This af- consensus regarding their interpretations. By creating a structured fected the implementation that had been planned to coincide with and supportive environment for data interpretation, the study the merger between the project ward and another urology clinic. The reduced their fear. As they became more familiar with the charts and issue of ownership was an important concern. By the end of 2000 graphs, they began to look at data as a basis for decision making. most nurses on the ward had not been part of the processes the year Within several months of the completion of the data analysis, the before. They received information informally by the nurses closely in- findings were being used to identify areas of research and to improve volved in the project and formally by the nursing professor who met health education and outreach programs. Thus, this project provided with smaller groups of staff to inform and include them in the on- a learning experience that afforded an opportunity to become going processes. familiar with how data can be useful. The second educational Positive outcomes have resulted for patients and staff through the outcome of the joint study was the emergence of a stronger project. The new brochures improved the patient information, and awareness of public health problems. During the data interpretation patients valued the nurses’ interaction and approach, and appreciated activities, the physicians moved from a classical medical orientation of the correspondence between the information in the brochures and the individual as the unit of analysis to examining disease patterns in what went on while in the hospital. Re-designing the brochures the population. The physicians also began to move from an benefited staff as well. Structuring the admission talk created a clearer, exclusively curative orientation to disease to a more preventive one. concise and consistent approach for imparting information. Moreover, As a result of the hospital study, the health education staff already as the discussions about the discharge talk evolved, the nurses recog- plan to focus on alcohol abuse in those communities which seem to nised other areas that needed attention. They identified a need for have an elevated problem. Tuberculosis has emerged as a second standardisation of the nurses’ talk with patients on admission and subse- area of outreach program development. The Foundation’s board of quently developed guidelines for this event. directors has used the hospital data in a fundraising effort for a community education and control program. The hospital’s medical director planned to use the data to identify the priority villages for the tuberculosis program. The process of interpreting the findings Discussion highlighted a need for larger population based epidemiologic studies The qualitative synthesis of 83 co-construction OPR to examine relationships between sociodemographic characteristics, studies suggested eight key OPR processes, four that fol- cultural beliefs and health practices. To assess the impact of community participation in water projects, the extension staff are low the sequence of the research endeavour (form a now collecting baseline data through a “community diagnosis” working group and hold meetings, collectively determine instrument. The staff are also participating in a second record study. research objectives, collectively analyse data, and collect- Preliminary discussions about the establishment of an information system which could be used for program monitoring and impact ively interpret results and decide how to use them) and assessment are also underway. four that can be observed throughout an OPR (commu- In Summary, the authors believe that the study had two major nication, relationships development, commitment, and impacts: (1) the hospital physicians developed a stronger data orientation in studying hospital policies and services and (2) they collective reflection). Extra benefits resulting from these gained an increased awareness of public health issues. key OPR processes occur at the individual and organizational Illustration of a Combination of the Four Ideal-Types levels. The purpose of this part of the project was to improve patient Together, these key processes and outcomes of OPR information before and at admission for trans-urethral resection and can be interpreted through a model for how to conduct to explore the effect of the changes in the information practices as an OPR to achieve extra benefits (Fig. 1). This concep- perceived by the patients. The highly supportive head-nurse selected nine enthusiastic nurses judged to have the necessary professional tual model suggests that through regular, structured WG background and interest to work on the project. Two work-groups meetings stakeholders can voice their varied experiences, were formed, each group a mix of experience and expertise. The ideas for change, fears and other feelings. The WG nurses identified the problem to be solved and were active partici- pants in the process of change as equal partners with the researcher should assemble a broad variety of stakeholders (practi- who had the role of facilitator who used a non-threatening, tioners, patients, managers, etc.) and provide a Bush et al. BMC Health Services Research (2018) 18:992 Page 11 of 15 Fig. 1 The OPR model – Iterative processes and outcomes of OPR supportive environment with the promise of confidenti- coordination both within the WG and between the WG ality. WG meeting processes include identifying needs and their healthcare organization, which in turn in- and formulating study objectives, collectively analysing creases the organization members’ acceptance of change. data, and discussing results and how to act on them. Ultimately, WG members improve or develop new skills Circulating meeting summaries between meetings is im- (supports empowerment), and teamwork, mutual under- portant for deliberations, to correct misunderstandings, standing and job satisfaction are increased or improved. and to help engage WG members who are unable to at- Readiness for change increases and improved care and tend some meetings. During meetings, WG members sustainable changes ensue. Importantly, the changes learn from one another, gain awareness of constraints to pave the way for subsequent changes. While H Water- addressing the OPR objectives, gain confidence (which man, D Tillen, R Dickson and K de Koning [3] cite many in turn increases commitment to continue the research of these results as benefits of participation, our synthesis and to take responsibility for decisions and actions) clearly suggests it is the WG meetings that contribute to through systematic reflection on the OPR. This is in line these outcomes because they provide invaluable time with H Waterman, D Tillen, R Dickson and K de Koning and space for WG members to present, discuss, debate, [3] who found that sharing ideas is part of learning that and reflect on various identified needs. They are also a takes place through the process, which in turn increases space to reach consensus or to accept compromise. participation in the research. Discussing OPR results Similarly, in their review, G Munten, J Van Den Bogaard, within the WG is valuable in that results often validate K Cox, H Garretsen and I Bongers [15] found that meet- perceptions and raise awareness. Discussing results also ings in small or large groups was the strategy most often increases WG members’ understanding of how to use cited in included studies. However, they found the na- research findings to inform changes, enables joint prob- ture of the interactions during these meetings was not lem solving, increases members’ motivation to make sufficiently described. They underscore the need for au- change, and helps them identify additional needs. In thors to provide detailed descriptions to help understand their review, G Munten, J Van Den Bogaard, K Cox, H the ‘black box’ of this research approach in order to close Garretsen and I Bongers [15] identified communication the research-practice gap. We have delved into the ‘mess’ and feedback of results strategies as common. Our work [21] of OPR combining the experiential, propositional and goes a step farther in illustrating the potential conse- practical OPR knowledge of our diverse team. Examining quences of such strategies. authors’ reports of their OPR activities and consequences The OPR processes in which the WG engages during (process-outcome linkages) in their OPR studies helped us meetings contribute to improved communications and to begin to unpack this black box. Bush et al. BMC Health Services Research (2018) 18:992 Page 12 of 15 Applicability and practical implications of the review findings participatory research leads to new unanticipated projects Previous reviews, whether about OPR or other types of and activity, can be conceived of as initiation, as per JC participatory research, have not described how to con- Greene, VJ Caracelli and WF Graham [72]. While previous duct this type of research to the same degree, nor have works provide typologies of non-academic stakeholder par- they illustrated how participatory processes contribute ticipation [3, 5, 14], going forward, it may be relevant to to outcomes. In phase-1 of this systematic review [9], we categorise studies as per the four ideal-types of OPR. found five types of extra benefits related to a framework of capacity building: leadership, general workforce devel- Limitations and strengths and transferability of the evidence opment, group benefits, broad systemic developments or This qualitative synthesis is not entirely based on empir- changes, academic researchers’ capacity. With this sec- ical results of included studies. In many cases, the data ond phase of the review, we have been able to go beyond were from the discussion section of the reviewed studies this description of extra benefits to explain how to and are, thus, the authors’ reflections on their practical achieve them. The conceptual model (Fig. 1), can be ap- experience with OPR. Given that our analysis is there- plied widely to guide the conduct and assessment of fore a meta-reflection, it is possible that our results OPR. While based on OPR with healthcare organiza- underscore the assumptions and beliefs of the authors of tions, the processes and outcomes illustrated in the the publications included in this review. Future research model may be applicable to any organization. Since we fo- should test our conceptual model and ideal types of cussed on OPR processes linked to OPR outcomes, the OPR. However, our team consists of eleven OPR practi- data analysed had an inherent chronology (narrative caus- tioners and scholars with varied frames of reference, and ation) [67]: processes lead to outcomes. This is visible in the critical input of each throughout our review helped the final coding trees which consist of process-outcome us to challenge our own assumptions about the data and sequences, each with inductively derived codes that depict our analyses; thereby, adding to the trustworthiness of passage of time (additional file 4). It is important to note our results. Moreover, the large number of studies in- the iterative nature of the processes and outcomes. In cluded in this review, the multiple descriptions of OPR practice, OPR is not as linear as the model suggests. processes-outcome sequences in these studies, and the Throughout an OPR project, the process-outcome se- data saturation lends credibility to our results. quences repeat and overlap, and there are feedback loops Although predominantly influenced by nursing studies between them. However, in keeping with the principle of in hospital settings (given this is the most common type parsimony, our model provides a simple illustration of the of OPR to date), this review is more comprehensive than overall flow of theses sequences and explains how to con- previous ones which focussed on OPR in UK health set- duct OPR to achieve extra benefits. The parsimonious tings [3] in nursing [14], on implementation of representation is also in line with the philosophy of OPR evidence-based practice in nursing [15] or in adult in- to produce useful results. Finally, this simplified conceptu- tensive care units [16]. We included a variety of types of alisation is an actionable message, which some would health OPR in diverse types of healthcare organizations. argue is necessary for its uptake and use [68, 69]. The Moreover, this review overcomes issues previously re- model is thus a significant contribution of our work. ported regarding attributing organization members’ par- The four ideal types illustrate features of learning organi- ticipation in research to particular outcomes [3, 14, 15] sations such as open systems thinking, building individuals’ since we selected studies based on a precise definition of capacities, sharing knowledge, and learning collectively OPR and excluded those that did not make an explicit [70]. Our synthesis illustratesthatwhile OPRisameansto link between OPR processes and outcomes [3, 14, 15]. achieve study objectives (basic OPR), it may also lead to Similar to all literature reviews, our work is limited by any combination of (a) outcomes unrelated to the study, or publication bias. As found in previous reviews [15, 16], ‘random sparks’ as described by H Atlan [71](OPRideal the challenges of OPR (i.e., negative outcomes), and type 2), (b) replication of outcomes (OPR ideal-type 3), or means to mitigate with them (processes), were rarely re- (c) initiation of new OPR or activities (OPR ideal type 4) ported in the included studies and are, thus, not covered [72]. Replication was also a finding of one OPR review that in this article. Our practical experience, however, sug- reported effects beyond the location in 13% of included gests that OPR can be quite challenging. A primary studies (n =4) [3]. Moreover,thisisinlinewith the capacity study to identify challenges OPR stakeholders face and building and sustainability literature [73, 74] which suggests describe how they deal with them would be a valuable change is more likely to endure if it spreads or multiplies. contribution to the literature. Thus, OPR as we have operationalised it in our model, can be a means for academic and organization stakeholder to Conclusion co-create lasting change. Our findings are in line with a With this review, we have broadened the understanding of CBPR review [29] found that community-based OPR and the value of this research approach by Bush et al. BMC Health Services Research (2018) 18:992 Page 13 of 15 identifying and illustrating sequences of OPR the data extraction forms, interpret the findings and draft the manuscript. All authors read and approved the final manuscript. process-outcome sequences. Specifically, our results sug- gest that OPR stakeholders form a WG and hold meetings Ethics approval and consent to participate where they collectively determine the research objectives, None required. analyse the data and interpret the results and decide how Consent for publication to use them. Throughout these research phases, commu- Not applicable. nication, relationships development, commitment, and Competing interests collective reflection should be maintained. These pro- All co-authors declare they have no competing interests. cesses contribute to knowledge, attitude and behaviour changes in the stakeholders and the healthcare Publisher’sNote organization. Since our analysis is based only on OPR pro- Springer Nature remains neutral with regard to jurisdictional claims in cesses that were explicitly linked with OPR outcomes, we published maps and institutional affiliations. assert that these are the key processes to follow when con- Author details ducting OPR. Moreover, as per the four ideal types of OPR, 1 Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, we submit that when these processes are followed, OPR Suite 300, Montréal, Quebec H3S 1Z1, Canada. Department of Family Medicine, Sherbrooke University, 150 Place Charles Lemoyne suite 200, teams will achieve their objectives, and may also achieve Longueuil, Quebec J4K 0A8, Canada. Institute for Social Health, Catholic one or more extra benefits in the form of sparks, replication University of Applied Sciences Berlin, Köpenicker Allee 39-57, 10318 Berlin, or initiation. Overall, this review provides operational guid- Germany. Special projects, Canadian Pharmacists Association, 1785 Alta Vista Drive, Ottawa, ON K1G 3Y6, Canada. West Island YMCA, 230 Brunswick Blvd, ance to help OPR stakeholders collaboratively address Pointe-Claire, Quebec H9R 5N5, Canada. Mental health research institute, organizational issues and achieve desired outcomes and 7 University of Montreal, Montreal, Canada. CIET/Participatory Research at more. McGill (PRAM), 5858 Cote de Neiges, 3rd floor, Montreal, Montreal, QC H3S 1Z1, Canada. Additional files Received: 2 May 2018 Accepted: 28 November 2018 Additional file 1: Search strategies. This documents provides the References detailed search strategies for each bibliographic data base we searched. 1. Cargo M, Mercer SL. The value and challenges of participatory research: (PDF 195 kb) strengthening its practice. Annu Rev Public Health. 2008;29. Additional file 2: Data extraction form. This Excel form used for all 83 2. Green LW, George MA, Daniel M, Frankish CJ, Herbert CJ, Bowie WR, O'Neill studies included in this review. (XLSX 12 kb) M. 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