Table 5 Barriers and facilitators to achieving the NIHR principles of co-production [3]
From: Approaches to co-production of research in care homes: a scoping review
NIHR principle | Barriers | Facilitators |
|---|---|---|
Sharing power | Burden of supporting resident involvement on care staff [39, 41] Recruiting and gathering perspectives of residents during the research placed additional pressure on care home staff. This limited resident involvement Care home staff and health professionals supported recruitment of residents into some research studies and likely influenced who had access to opportunities to be involved Ethical procedures [17] Ethical processes, such as formal signed consent, may have reinforced power imbalances and restricted or deterred resident participation in co-production Delineating roles in the research process [17, 39] Involving stakeholders in different roles, such as panel members, peer researchers and research participants, created hierarchies among those involved in co-production and sometimes led to ambiguity about ownership of the research | Creating opportunities to challenge dominant views [17, 18, 39] Opportunities and positions were created which supported marginalised groups, such as residents, to challenge dominant views and helped reduce hierarchies. This was achieved through the creation of expert roles, safe spaces for non-judgemental dialogue and through the ethos of co-design in general Reflexivity of project leads and researchers [18] Project leads and research teams who exhibited reflexivity were responsive to the perspective of stakeholders and able to relinquish control of the project despite the uncertainty that this created |
Including all perspectives | Not enough involvement of key stakeholders [18, 31, 41, 42] Key stakeholders were sometimes not involved early enough, in large enough numbers, or at all Pressures on care home staff and healthcare professionals [18, 37,38,39] Seeking perspectives of busy care home staff and healthcare professionals was challenging. This was due to the daily pressures of their roles and the complex nature of the contexts they work in, where staff, priorities and organisational structures change frequently and unpredictably Care home resident characteristics [37, 39] Characteristics specific to care home resident populations were identified as barriers to recruitment and opportunities to share perspectives. This included having a diagnosis of dementia, fatigue and reduced concentration Limited depth of discussion [31, 37] The depth of discussions and insight into perspectives was sometimes limited due to lack of time available or inexperience of student facilitators Difficulties with stretching perspectives [18, 34] It could be challenging for stakeholders to consider other perspectives that were different to their own, or to see the bigger picture | Stimulating experiences [29, 40] Stimulating experiences supported involvement from a wide range of stakeholders. Bringing a range of stakeholders together in a creative, unfamiliar environment facilitated an enjoyable experience. Connecting objects and handling materials helped to stimulate participation from people with dementia Care home staff’s willingness to participate [18, 38] Care home staff were willing to contribute their views and engage in conversations about sensitive topics. Buy-in from senior managers supported staff to be involved in all stages of the research Flexible approach [18, 34, 40] Flexible and iterative approaches facilitated deeper understanding of perspectives, incorporation of different methods and expertise, and the development of outputs that met the needs and preferences of the end-users |
Respecting and valuing knowledge | Lack of self-confidence [18, 30, 37] Care home staff, residents and stakeholders representing residents described a lack of confidence in their ability to contribute to the co-production process Balancing different forms of knowledge [28, 37] Sometimes different knowledge led to “trade-offs”, such as balancing the researcher’s knowledge of the evidence-base with practical considerations of care homes, and developing strategies based on resident preferences which are also feasible to deliver | Involvement across design stages [42] Involving care home staff throughout all the design stages helped staff feel that their knowledge was valued and see the contribution that they made to the process Recognising and utilising different forms of expertise [17, 18, 29, 31, 40, 42] Projects that recognised different forms of knowledge and expertise used this to shape the research and develop resources that were useful and accessible in care home contexts. This included utilising experiential, subject-specific, organisational and political knowledge |
Reciprocity | Potential harms of participation [17, 18] Participating in co-production could cause memories of painful experiences to resurface and evoke anxiety when challenging the views of other stakeholders. Some were cautious about voicing their perspective due to potential negative consequences of doing so | Providing support [18] In one study [18], advisors were provided with emotional and practical support by the project leader and by working in pairs with another advisor Providing learning opportunities [18, 28, 35, 40] Stakeholder learning was supported as part of the process, through structured activities, trying out new ideas in their care home, or learning from the expertise and experiences of other stakeholders Clarifying expectations [38] Being clear about expectations, including short- and long-term outcomes, was important to avoid issues later down the line |
Building and maintaining relationships | Relationships with management [18, 31, 41] Making initial contact and maintaining relationships with care home managers could be difficult. Sometimes management or ownership of the care home changed during the study which led to changes in organisational priorities Optimising links with wider stakeholders [37, 39] Links with wider stakeholders and partners, such as NHS PPI structures and community organisations, were not always well-defined and there may have been missed opportunities for collaboration Differences between stakeholders [18, 31, 35, 37, 39] Stakeholders often had different beliefs, cultures and organisational norms. This created difficulties with communication, sharing opposing views and developing understanding between stakeholder groups Practical challenges [18, 31, 39] Practical aspects of the projects, including short project timescales, de-prioritisation of reflection and difficulties planning engagement activities, presented challenges to building report and maintaining stakeholder motivation throughout the project | Building and utilising existing partnerships [38, 39] Investing in building relationships and utilising existing partnerships helped to engage stakeholders in conversation and in the research process Regular meetings and dialogue [18, 31, 39] Having regular meetings was important for facilitating dialogue and building connection between stakeholders. Regular meetings were also helpful for research teams working across large research programmes Establishing ways of working [31, 39, 40] Recognising different ways of working and developing acceptable approaches which accommodated individual preferences facilitated collaboration between stakeholders Project leadership [31, 35, 37, 39] Leaders, including named project leaders, programme research managers, champions in care homes, and students, acted as knowledge brokers who helped to facilitate dialogue with stakeholders and resolve problems. Projects led by researchers with past experience of working in the care sector enabled rapport to be built with care home staff Connection through creative approaches [29, 30] Creative approaches enabled relationships between residents and staff to shift and build through the slow pace of creative activities. In one study, continued engagement was facilitated through displaying the finished tapestry in the care home29 Sustaining relationships through participatory approaches [39] The participatory approach itself, such as appreciative enquiry or co-design, was reported to have a positive impact on future interactions between stakeholders and sustaining relationships |
Other | Feasibility of scaling co-production [41] It may not be feasible to co-produce interventions or deliver co-produced outputs on a larger scale | Logistical arrangements [18, 31, 39, 43] Resources, such as time and funding, were required to conduct co-production activities. Maintaining autonomy of projects within programmes of research and immersion of the researcher in the process enabled projects to be responsive |