Creating organisational and practice change through the use of co-operative inquiry groups in healthcare settings

Co-operative inquiry groups

Inquiry groups are a core method in action research (Reason, 1999; Reason & Bradbury, 2008). Their purpose is to not only query, investigate or consider practice or social phenomena but also to connect to action in social settings (McArdle, 2002).Key aspects of the co-operative inquiry group include the building of skills, knowledge and action over cycles of inquiry and development of what Baldwin (2002, p. 291) describes as ‘owned and usable knowledge’, through an understanding of one’s practice. Wadsworth (2006) argues that an inquiry group should identify the interests of those who are meant to be served by the actions being planned, provided or otherwise being researched. Co-operative inquiry groups provide the opportunity to explore and respond to presenting problems within organisations, client groups and practitioner activities; offering a mechanism for understanding the problem or issue and then acting and reflecting on this emergent knowledge (Yorks & Nicolaides, 2007). Within health and social care settings, co-operative inquiry group approaches can also enable the researcher to consider complex ideas that HSCPs face in their interaction with clients (Baldwin, 2002). The validity of co-operative inquiry in healthcare settings often rests on the high-quality, critical, self-aware, discriminating and informed judgements of the co-researchers (Hummelvoll & Severinsson, 2005). Critical subjectivity is a core element (Reason, 1999) when utilising this approach involving self-reflexive attention to one’s basic beliefs, and the acknowledgement that there will be many versions of reality (Berring, Hummelvoll, Pedersen, & Buus, 2016).

Despite the potential of co-operative inquiry, a number of impediments affect its use in health and social care settings, including staff resistance to change, lack of long-term leadership support, insufficient funding, difficulties in securing appropriate training and problems in applying skills learned in training to work with real clients (Gotham, 2006). In their consideration of a co-operative inquiry process, Lavie-Ajayi, Holmes, and Jones (2007) highlight the confusion for practitioners in understanding the inquiry processes and ways of working such as group supervision and training which are often underpinned by similar values or work practices. The differences only became clear for one of the authors ‘when we were experiencing the tangible practice of CI’ (Lavie-Ajayi et al., 2007, p. 416). In order to promote sustainable changes in healthcare settings, Berring et al. (2016) argue there must be a long-term management strategy supporting organisational changes.

Successful co-operative inquiry groups can be fraught with paradoxes connected to issues such as power, authority, participation and decision-making (Ospina et al., 2004). Attending to power dynamics can often mean ascertaining and understanding why power is located where it is, while challenging and deconstructing power dynamics impacting on the research process. For instance, Lavie-Ajayi et al. (2007) found that the organisational power structures impacted negatively on clients and that by paying attention to these dynamics, this issue was revealed. Meanwhile, Ospina et al. (2004) maintain that successful co-operative inquiry groups require attention to roles, boundaries and the authority to act on behalf of the group in order to achieve tasks and embed action and emergent practices.

Quantifying in any concrete way the direct outcomes from any inquiry method can also be difficult, as processes are more focussed on not only the need to establish new skills and practices but also to internalise and enact new values and knowledge (Yorks & Nicolaides, 2007). Baldwin (2002) posits that the ending of the inquiry group process is key in embedding long-term organisational and practice change, maintaining that there must be an ‘event’ to evaluate the learning from the inquiry process. Using examples from practice, he proposes the sharing of learning back to the wider organisation as well as maintaining of notes and developed resources as ‘evidence’ of practice development. In reviewing an inquiry process within a mental health service, Patterson and Goulter (2015) found that while the approach identified important opportunities for practice improvement, lack of time and resources allocated to the inquiry group process and relationship meant that no actions were implemented.

Reflecting on co-operative inquiry processes

Reflexivity is central to action research; it is an integral part of the process and demands great self-awareness from the researcher (Eden & Huxham, 1996). However, translating healthcare practices into research and research issues into practice is not a static process, as it involves significant shifts in how we as actors interpret, construe and relate to each other within the research process (Julkenen, 2016). In this respect, the concept of reflexivity during data collection and analysis is crucial (Finlay, 2003). Reflexivity can be described as a strategy of monitoring how personal meanings and experiences creep into the process of inductively generating theory (Kuczynski & Daly, 2002). It is the awareness and recognition that our life experience and professional experience that will influence and shape our work as a researcher. This paper emanated from the reflexive practices of two researchers who were previously unknown to each other but had both utilised co-operative inquiry groups within different healthcare settings. Through colleague networks they met and began to discuss their experiences in action research, developing a working relationship based on peer support and mentorship (Furtatdo & Anderson, 2012) with the aim of understanding and developing their action research skills.

Both authors experienced different pathways into action research but, each sought to design and enact research methodologies that were reflective of their personal and professional values, especially with regard to health and social care practice. Importantly, they are committed to carrying out research using methodologies that sought to address traditional power hierarchies, bridging the gap between research and action (Gray, Sharland, Heinsch, & Schubert, 2015) as well as addressing issues of social justice that are identified or emerge within the research process (Cargo & Mercer, 2008). These reflexive and inquiring conversations (Bjørn & Boulus, 2011) took place over a six-month period, with a focus on understanding and learning from the different experiences of utilising co-operative inquiry groups within healthcare settings. Both authors drew from research notes and co-operative inquiry session notes to inform their conversations. The learning points and challenges that follow were developed from these critically reflective conversations and discussions.

Ethical considerations

The ethical issues that arise in research are similar to those that occur in the context of health and social care practice (Cohen, Manion, & Morrison, 2011). An ethic of care and a reflexive approach were embraced to counter difficulties and to strive for a more equitable process that would be mutually beneficial to all parties involved. Both studies were underpinned by a set of principles that attended specifically to the issues of competence, multiple relationships, avoidance of harm, confidentiality and informed consent. As the hospital study was completed as part of the author’s doctoral degree, full ethical approval was granted by the hospital. The study based in the domestic violence service was deemed not to require ethical approval by the participating agency that have supported the development of this article.

Participation and engagement in the inquiry processes

Within both projects, there were difficulties in securing and sustaining participation in the inquiry group processes. The researchers thus targeted their efforts to establish, build and strengthen relationships with the partners and used local level networking initiatives to promote and maximise participation in the early stages (Himmelman, 2001). The two projects illustrate different challenges in establishing and maintaining participation, with participation building over the duration of one project and waning over the duration of the other. Within the domestic violence project, a small number of practitioners who were strongly opposed to working with substance use issues attended sporadically, or not at all, in the early stages of the process. One explanation for this resistance is that, in Ireland, there are often strong normative beliefs about the impossibility of working with clients using drugs or alcohol until the client has hit ‘rock bottom’ and decided to change or address their addiction. Despite government policies to include harm reduction responses in agencies, these barriers often remain (Butler, 2016). This issue was evident in the inquiry groups where staff participated but had some reluctance about developing practice in this area.

There were a number of drivers that supported the engagement of the practitioners as a way of dealing with this resistance. The first of these was the support and encouragement of other team members and the open discussion at each inquiry group about the level of participation and what could be done. Rather than talk about the participation of individual group members, an exploration took place about what could be blocking participation and how this might be mirrored within wider inter-agency contexts. An understanding of the challenges to individual practitioner engagement can also provide insights as to why practitioners in other agencies did not wish to work with women who use substances. The second approach was in accessing support and input from other professionals who had addressed similar practice issues. The group decided to invite the coordinator of a local statutory substance use service to an inquiry group session to discuss how her agency had developed their practice using an abstinence based to a harm reduction approach. Her honesty in outlining the challenges for her staff team, and ultimate benefits to clients, further encouraged participation and attendance. Finally, the decision to include discussions on current client issues within the inquiry group sessions was a pivotal motivator for practitioners to attend and engage with the action research approach. Incorporating these practice issues into inquiry group discussions continually reinforced to practitioners the need to devise more appropriate responses to women using substances problematically. Combined these strategies maintained engagement and participation from the whole staff team for the duration of the inquiry group process. Interestingly, the exploration of the concerns of more resistant practitioners became pivotal in embedding practice changes across the organisation; some of these became the strongest advocates for practice and policy change.

In the hospital-based project, the establishment of the inquiry group process began with enthusiastic participation from all co-operative inquiry group members, helped in part by a strong ‘top-down’ organisational commitment and leadership from the medical consultants. The MDT co-operative inquiry group acknowledged that care planning meetings were a crucial part of multidisciplinary teamwork. From the start, it was evident that motivations to improve current practices and a general openness to a change process and engaging as co-researchers were important. These were expressed both at the beginning of the inquiry process and when the Cycle 1 findings were fed back to the group. Increased motivation may also have been fuelled and underpinned by organisational pressures at the time. There were institutional imperatives around discharge planning policies which often were the cause of ethical dilemmas and tensions for HSCPs in the hospital. Challenges were faced during Cycle 2, however, largely stemming from cuts to staffing levels resulting from the economic recession in Ireland which impacted on the ability of group members to engage in the inquiry process. This problem was somewhat modified, however, as the findings from Cycle 1 suggested Cycle 2 should focus on stroke patients which involved a smaller MDT cohort (n = 9) as co-operative inquiry group members. Hence, while the inquiry process continued for the duration of the project, the number of group members and the individuals involved differed which reduced the participatory aspect of the inquiry.

Concerns relating to the participation of MDT members as co-researchers were particularly heightened during Cycle 3 when ‘Best Practice Guidelines’ were being devised. The MDT co-operative inquiry group needed to be actively involved and ‘own’ this process; however, it became clear that the author as practitioner researcher would have to take responsibility to drive the initiative in order to achieve its aims. During the first co-operative inquiry group meeting which focussed on the development of the guidelines, group members explained that they wished for the author, within her practitioner research role, to take the lead. Yet the author was very aware that as an action research project, it was important that group members shared ideas and suggestions about what to include within the guidelines. Group members were frank and acknowledged that due to discharge planning pressures, they were no longer in a position to be involved in drafting the content for the guidelines. Instead, the co-operative inquiry group volunteered suggestions of what content should be included in order for the author to then write-up and compile draft guidelines. These were to draw strongly on the key practice implications that had arisen from research findings in Cycles 1 and 2. A reconfiguration of the co-operative inquiry group occurred whereby the MDT co-researchers became ‘secondary researchers’ during Cycle 3 but subsequently reassumed a more active role at the knowledge transfer stage of the project by implementing and embedding changes to practice based on the new research informed guidelines. It could be argued, however, that the co-operative inquiry process failed to achieve its objective in Cycle 3 as the process failed to engender ownership of the project by group members.

Power and decision-making

A common thread in action research is the issue of researcher power. The concept of ‘influence’ is at the heart of action in many different ways but particularly in terms of the ability of the researcher to successfully encourage co-inquirers to think and act differently in relation to issues of personal and social change (Mc Niff and Whitehead, 2009). This was a central discussion point for both researchers who had long established relationships with each of the organisations and had a well-established frontline practice with the client groups involved. This is not a point addressed substantially within the literature, but both researchers felt that such practice experience and wisdom was critical in building trust and confidence between the researcher and the co-operative inquiry group participants. Beyond having a thorough practice knowledge of the client group, both researchers felt that the co-operative group members responded to the researchers’ commitment and passion for change and development. Furthermore, the positioning of both researchers as reflexive, innovative and questioning of institutional responses also aided in developing a functioning, inquiring and action focussed process.

The co-operative inquiry group processes, with its deliberate attention to creativity and multiple viewpoints (Yorks & Nicolaides, 2007) opened up new avenues for practice and organisational responses in both projects and helped to minimise any perceived/existing power differentials. For instance, in the domestic violence organisation, a key issue emerged in relation to women’s misuse of prescription medication that had not been identified as a substantial concern at the initial stages of the co-operative inquiry group. As this issue was worked with, the group members discovered, through the application of new screening questions, that the misuse of medication as a coping mechanism for stress and trauma was a significant issue for up to one third of their clients. It was felt by the practitioners that this knowledge would not have emerged within their normal work practice discussions and team meetings.

In the hospital-based project, much of the attention on the care planning meeting process arose from ethical concerns expressed by MDT members about how older people were increasingly being discharged to nursing home care with little or no consultation. This institutional response in dealing with limited acute hospital beds was having a significant negative impact on the clinical practice of both the researcher and the co-operative inquiry group members. This helped create an implied trust and commitment to the participatory action research approach generated by a shared practice dilemma. The research focus and action research cycles were therefore grounded in the ongoing narrative of professional roles of practitioners within the hospital. The act of creating these narratives helped to offer clues to the kinds of cultural values affecting professional judgements associated with ethical dilemmas faced by the practitioners. This in turn helped co-operative inquiry group members to explore how they could be empowered to identify changes required at a wider hospital level. For example, through engaging in the process of analysing data from the group discussions, MDT members were able to move out of their disciplinary silos to collectively adopt a solution focussed approach. Thus, micro level practice changes to care planning meetings could act as a starting point to wider organisational and systemic changes.

Both projects were characterised by a commitment to consensus, debate and democratic group decision-making processes where power was held by ‘the group’ and co-operative inquiry group members were viewed as the ‘expert’ decision makers. In practice, however, the reality did not always meet these aspirations given the variety of dynamics of participation and power playing out in each of the projects. In the hospital project, pronounced power differentials emerged, in particular, when the medical consultants infrequently attended meetings, preferring to be involved by email. This served to disempower the other MDT members who felt aggrieved that the consultants did not attend, yet expected to be viewed as co-researchers in the same way as other group members. This example illustrates how hierarchies of power, which were deeply embedded within the hospital structure, began to be mirrored and replicated within the action research process itself. It could be argued this signified that the co-operative inquiry process had failed to meet all of its intentions. On reflection, it appears that both projects required significant cultural shifts in how people engaged, made decisions and practiced in order for the inquiry group process to be successfully embraced and sustained. It can be argued that successes in this area were underpinned by the long-standing relationships both researchers had with individuals within the organisations and the organisations themselves.

Influence of organisational structures, practice and policy changes

It has been argued that, in many social service organisations, practice decisions and approaches to complex client work are often constrained within hierarchal and procedural-based systems (Onyx, Cham, & Dalton, 2016). Both organisations reported in this paper were struggling to deal with the aftermath of the recession and subsequent fiscal retrenchment. High client caseloads and reduced resources also pushed practitioners towards conservative and minimalistic client responses (Fursova, 2016), as neoliberal discourses took hold, with emphasis on individualism, value for money and concrete outcomes (Burkett, 2011).

When action research projects are focussed on improving or developing practice responses to clients, a tension can exist between the co-operative inquiry group discussions and other organisational structures such as case management meetings. In both projects, the practitioners at times questioned how these processes should be differentiated. Decisions were made in both cases studied to not discuss individual clients but to encourage the exploration of trends and issues arising from individual client or caseload work, with a view to having a ‘wider lens’ on practice issues (Morton & Hohman, 2016). The responsibility was therefore placed back onto the practitioners to think critically about the dynamics and implications of practice experiences. For teams to move beyond repetitive practices whose value is reinforced by their familiarity requires an awareness of the alternative discourses created by the team and a critical examination to take place (Opie, 1997). Patterson and Goulter (2015) characterise such processes in terms of a ‘risk adverse’ culture, where there is a fear of developing new and innovative practice, particularly, if it requires a shift towards granting service users greater autonomy but with potential ‘negative outcomes’ for the client. These more radical perspectives seem important at a time when neoliberal orthodoxies tend to demand increased managerialism and bureaucracy (Rogowski, 2013). These were important considerations for both projects where client groups often experience differentials of power and practices that often reinforce dependence rather than independence. For example, within the medical model, older people are often treated in a paternalistic manner impacting on their opportunities for decision-making autonomy in relation to their discharge arrangements. The co-operative inquiry space then became the place where the expectations and beliefs service providers have about their clients can be challenged and reframed.

For the domestic violence service, developing new practices and responses that centre-staged the woman’s expertise required a paradigm shift in the practitioner’s thinking, challenging the internalised belief that women who use substances were impaired in their thinking and decision-making (Butler, 2002). By agreeing different ways to ask and explore women’s substance misuse experiences, some new understandings emerged. The practitioners realised that many of the women understood their substance use as a form of medication to alleviate pain and trauma symptoms, for example, opening up new avenues for conversation and therapeutic work. It also appears that the strategy to embed the co-operative inquiry process into day-to-day practice such as team meetings and supervision while also incorporating clinical practice into the inquiry process had the desired effect of improving and sustaining participation by inquiry group members.

For the hospital setting, practitioners gained valuable insights about the disconnect of being able to identify changes to practice which would empower older patients within their care planning meetings and challenge practitioner’s own risk adverse attitudes preventing changes to practice. An example of this is where there was the inclusion of all older people in meetings despite vulnerabilities due to cognitive and or communication difficulties. It was only when a wider lens was adopted, and best practice guidelines developed for the wider hospital, that practitioners were finally able to implement and embed real and visible practice change. It would appear that understanding key areas of change management and how to avoid obstacles are critical to the success of action research projects (Khresheh & Barclay, 2007).

Significant practice changes did occur in both settings; however, the process by which this occurred, and the level to which the changes were sustained, varied. Within the domestic violence service, practitioners began to address and respond to client’s substance use between inquiry groups and then discuss these forays into new practice areas, debating their interventions, responses and how these could be improved. Direct feedback from clients on these changes were sought and also discussed at the inquiry group. As the organisation already had policy and practice guidelines in place, these provided a framework for interventions and the recording of practice outcomes. The action research inquiry process became the mechanism by which the practitioners discussed, developed, tested and sought feedback on their emerging practice on addressing problematic substance use, in the aftermath of a long process of training and policy development. The domestic violence agency has now become established as the sole women’s refuge that accommodates women actively using substances, and staff have presented on the challenges and approaches to their integrated domestic violence and substance use work in a range of education, social work and academic settings, both nationally and internationally,

Within the hospital setting, this change process was inverted. Despite inquiry group members having reflected on current practices and developing their own recommendations as to how care planning meetings could be improved, there appeared to be a disconnect for group members between reflection and translation into action. The action research inquiry process in many ways therefore began to parallel some of the tokenistic practices in care planning meetings that group members wished to change; members could identify what they were doing wrong but struggled to implement the group’s agreed changes to their practice. It was the development of best practice guidelines in Cycle 3 and a formal launch of the study at a wider organisational level that ultimately was the pivotal factor in embedding practice change. This was most strongly evidenced by the hospital’s commitment to a policy stating that all older people regardless of their perceived level of cognitive impairment should participate in their care planning meeting. The implementation of this policy was helped by external drivers, namely, the Nursing Home Support Scheme (2009), which legally required that all older people were actively involved in any decision-making relating to discharge to nursing home care mandating their routine inclusion in all care planning meetings.