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Table 2 OPR summaries illustrating each of the four ideal-types of OPR and their combination

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

Illustration of OPR ideal type 1: Basic OPR

 This 10-month project sought to examine the process of change when developing a preparation programme for patients awaiting Total Knee Replacement (TKR) Surgery in an outer London acute NHS hospital. The researcher initiated and facilitated the project which involved ‘back office’ activities of organisation and encouragement. A Project Management Group (PMG) was established consisting of orthopaedic consultants, nursing staff, physiotherapists, occupational therapists, managers and service, users who were patients who had had Total Knee Replacement surgery at the project site, and the university researcher who was a nurse practitioner within the organisation. Nine monthly PMG meetings held between January and October, with the aims of planning and reviewing the action cycles related to the development of the Knee Clinic and information booklet, and reflection on the progress of the project, including the change process. The researcher took notes during PMG meetings which were distributed to PMG members for checking and correction.

 PMG members were involved in the action cycles to varying degrees. They worked within the meetings to plan, discuss, analyse and refine the test cycles. They decided which test cycles should continue and which should not be pursued. They participated in the test cycles themselves in various roles including data collection, participation in the Knee Clinic, and administrative tasks. Ultimately, the PMG developed into an effective team, demonstrating the behaviours of good communication and adaptability.

 Some of the PMG members believed the project was well-managed and that this was a factor in its success. Some staff did not have high expectations of the project but nevertheless participated. It appeared that this participation modified their behaviour in that they continued to provide support to the Knee Clinic after the project ended. For the service users the project provided the environment for them to share and use their experiences of TKR surgery with staff and other patients. They helped to shape the direction of the project and changed the environment through the decision to set up a service user group for others to share their experiences of surgery after the project ended.

Illustration of OPR ideal type 2: Sparks

 In 1989 a three-year study began in a substance abuse inpatient unit in a large university teaching hospital in the UK, to generate a description of the substance abuse inpatient program, define and prioritize target areas for change, implement and evaluate change efforts, and provide an opportunity for staff participation and input into the change process. The nurse, medical, and unit directors, and other key staff members (e.g., admitting nurse) formed the team bringing nursing, medical, and psychosocial staff members’ perspectives to meetings. Other staff members volunteered to form various subcommittees that developed and implemented changes (e.g., revision of criteria and procedures for monitoring patient progress in treatment, provision of written policies addressing major issues). All action followed a developmental process in which committees circulated drafts for staff feedback, thereby insuring that staff members were informed and invited to participate in all change efforts. The unit director’s role was that of facilitator, providing encouragement, process monitoring, and feedback. The director relied heavily on group facilitation skills to achieve consensus among staff members. However, this consensus seeking did not occur overnight and actually involved several months of discussions. Through the group process, opinions were voiced resulting in all staff members supporting clinically sound changes that were consistent with the unit goals and philosophy. Changes were assessed by surveys and results were provided to the inservice staff to plan and implement adjustments and, then, re-assess. Administrators’ support was readily forthcoming by including some in the action research process and by keeping others informed through the distribution of survey forms and committee and evaluation reports.

 The use of the action research model employing staff participation increased the effectiveness of this multidisciplinary inpatient unit. Benefits include: a) an observed increase in staff morale, b) improved staff relations (e.g., good-natured teasing and humor compared to sarcasm and blaming readily observed in meetings prior to the project), c) lower staff turnover, d) more open intradisciplinary and interdisciplinary communication (e.g., staff members now openly support each other, ask for assistance from staff members in other disciplines, and collaborate on problem solving), e) new skills (e.g., team problem identification, decision making, cooperation, leadership), and f) staff appear willing to take more risks in making suggestions, confronting issues, and encouraging and supporting others.

Illustration of OPR ideal type 3: Replication

 The aim of this study was to embed the theoretical tenets of the Canadian Model of Occupational Performance and its structures in a way that was appropriate to, and would be used by, all staff within an integrated health and social care setting. Initially enthusiasts were called upon to work in the localities and join a short-term steering group. This small group of self-selecting members of the service and the university lecturer, soon grew to include representatives from all geographical areas and services within the trust (n = 16–20). It was non-hierarchical and disseminated the notes of its meetings to the whole service through individual ‘champions’ of the model’s implementation. Despite the attempt to include all staff in the action phases of the research (led by their own representative on the action research steering group), the steering group was a large group and, not all the members were present at all the reflection cycles, but they were crucial to the research’s action phases.

 The steering group recognised their supervisory and influential role but did not want staff to feel the model was being imposed upon them. The group discussed what resources were required to assist staff confidence and keep the momentum going. Given staff criticisms of communication and dissemination of up to date information the steering group recognised the need to engage both occupational therapists and the managers in the different organisations, and that management and senior occupational therapists needed to support and help maintain enthusiasm for the model within their teams. Thus issues, concerns and good practice were brought to the steering group meetings, and over time tools and materials were developed to help staff in the sharing of good work and solutions to issues and concerns.

 The collaborative way of carrying out the research ensured the workability of the action. For instance, the steering group member who had previously experienced the dilution of the model’s theory by its paperwork being implemented too early influenced the steering group to delay paperwork implementation. At the same time, other staff members were clamouring for its creation. The result following was that staff in their own settings began to create their own paperwork, which was then brought back to the steering group for further reflection and consequent action. The assessment and planning paperwork that has evolved through this process is now almost countywide, applicable to most areas, firmly embedded in the theory of the model. Another example concerns training. Champions in the acute hospitals produced a training package on the model’s theory and use and the steering group became aware that other areas were keen to use this or a similar package and recognised that the training package was a good way of a team working together to strengthen understanding of the model, share how it could be practically adopted in individual clinical areas and address any issues or concerns. The steering group realised this sharing of knowledge would not have happened if the information had not been taken to a group steering the implementation of the model.

 The steering group was critical in guiding the model’s implementation, in sustaining motivation and energy across the service, and for communicating information across a wide staff group on an ongoing basis. Many heated discussions occurred, and all members of the group found that their thinking about occupational therapy practice developed and changed. The group has continued to have an important role in making decisions and recognising when staff needed re-energising. The process so far has taken 4 years and is ongoing.

Illustration of OPR Ideal-Type 4: Initiation

 When this project began, although the local staff were helpful, they did not envision how the study would be useful and they went along with the initial steps of data collection and analysis passively. One of the major tasks in data analysis was the regrouping of individual diagnoses into manageable categories. Through repeated discussions, among groups composed of Guatemalan and Tulane physicians and epidemiologists, consensus was achieved in developing clinically and conceptually meaningful diagnostic groups. After data processing had been completed, a series of two meetings were held in Guatemala for interpretation of the information generated. The Tulane staff had prepared charts and graphs of the results on a large drawing pad. When staff saw the graphs and tables, the level of enthusiasm rose markedly. They began to participate actively in data interpretation, better understand what Tulane staff were doing, what the results would look like, and how the study could be helpful to them in operating the clinical or preventive sectors of their facility. Interpretations of the data were developed primarily by the three hospital staff physicians through group discussions. They frequently argued about the results, but usually they eventually achieved group consensus regarding their interpretations. By creating a structured and supportive environment for data interpretation, the study reduced their fear. As they became more familiar with the charts and graphs, they began to look at data as a basis for decision making. Within several months of the completion of the data analysis, the findings were being used to identify areas of research and to improve health education and outreach programs. Thus, this project provided a learning experience that afforded an opportunity to become familiar with how data can be useful. The second educational outcome of the joint study was the emergence of a stronger awareness of public health problems. During the data interpretation activities, the physicians moved from a classical medical orientation of the individual as the unit of analysis to examining disease patterns in the population. The physicians also began to move from an exclusively curative orientation to disease to a more preventive one.

 As a result of the hospital study, the health education staff already plan to focus on alcohol abuse in those communities which seem to have an elevated problem. Tuberculosis has emerged as a second area of outreach program development. The Foundation’s board of 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 highlighted a need for larger population based epidemiologic studies to examine relationships between sociodemographic characteristics, cultural beliefs and health practices. To assess the impact of community participation in water projects, the extension staff are now collecting baseline data through a “community diagnosis” instrument. The staff are also participating in a second record study. Preliminary discussions about the establishment of an information system which could be used for program monitoring and impact assessment are also underway.

 In Summary, the authors believe that the study had two major impacts: (1) the hospital physicians developed a stronger data orientation in studying hospital policies and services and (2) they gained an increased awareness of public health issues.

Illustration of a Combination of the Four Ideal-Types

 The purpose of this part of the project was to improve patient information before and at admission for trans-urethral resection and to explore the effect of the changes in the information practices as perceived by the patients. The highly supportive head-nurse selected nine enthusiastic nurses judged to have the necessary professional background and interest to work on the project. Two work-groups were formed, each group a mix of experience and expertise. The nurses identified the problem to be solved and were active participants in the process of change as equal partners with the researcher who had the role of facilitator who used a non-threatening, supportive, and accepting mentoring style and gave credit, guided and advised throughout. The researcher was responsible for the agenda and the minutes from project meetings. All met frequently to collectively discuss the work of each group. They developed a welcome brochure the use of which for all patients admitted to the ward is now regular practice, and other brochures that are sent patients when they receive their date for admission, also now regular practice. Indeed, admission of patients by one nurse each day is now a well-established practice with benefits for all patients, not only the trans-urethral resection -patients. Additionally, guidelines were necessary to ensure that all patients got a certain amount of information at discharge. To evaluate the changes, given no adequate instrument was found, the researchers worked with the nurses to develop an instrument, reaching consensus on topic, readability (literacy level), relevance, and ease of use for the patient. Guidelines for administering the data-collection were established and nurse was designated to do this. The hospital financed a course in SPSS for this nurse, who then was able to participate in developing codebooks and to carry out data-entry.

 The pace of the study was slower than anticipated given a lower than usual admittance rate of trans-urethral resection patients. This affected the implementation that had been planned to coincide with the merger between the project ward and another urology clinic. The issue of ownership was an important concern. By the end of 2000 most nurses on the ward had not been part of the processes the year before. They received information informally by the nurses closely involved in the project and formally by the nursing professor who met with smaller groups of staff to inform and include them in the ongoing processes.

 Positive outcomes have resulted for patients and staff through the project. The new brochures improved the patient information, and patients valued the nurses’ interaction and approach, and appreciated the correspondence between the information in the brochures and what went on while in the hospital. Re-designing the brochures benefited staff as well. Structuring the admission talk created a clearer, concise and consistent approach for imparting information. Moreover, as the discussions about the discharge talk evolved, the nurses recognised other areas that needed attention. They identified a need for standardisation of the nurses’ talk with patients on admission and subsequently developed guidelines for this event.