Patient and public engagement in healthcare system policy: An integrative review
Caryl Harper, RN, BA, BSN (Distinction) UVIC ID: V00243084
A project submitted in partial fulfillment of the requirement for the Degree of Masters of Nursing from the University of Victoria, School of Nursing Faculty of
Human and Social Development.
Supervisor: Marjorie MacDonald, RN, PhD, Professor, School of Nursing, University of Victoria Committee Member: Lenora Marcellus, RN, BSN, MN, PhD, Associate Professor,
School of Nursing University of Victoria October 23, 2015
Abstract
The need for greater patient and public engagement (PPE) in policy-making in the healthcare system has garnered significant attention from governments (Lewin, Lavis & Fretheim, 2009). Patient and public involvement (PPI) has been at the core of the United Kingdom’s (UK) British National Health Service (NHS) and was accelerated by the Health and Social Care Act 2001 (Tritter & Koivusalo, 2013). In the UK PPI is implemented to create a national mechanism for holding policy-makers in governments and health-care provider organizations accountable for planning and delivering health services. One of the ongoing challenges of engaging the public or patients is how best to involve patients and the public in health policy and decision-making (Thurston, et al., 2005). In this paper, I explore the findings from my review on PPE policy to understand if PPE policy makes a difference within the healthcare system. I have included qualitative and secondary sources, grey literature, and mixed methodology literature published between 2002 and 2015 (January to March). I conducted an integrative review and organised the findings using the Services Management (SM) and Service-Dominant (SD) Theory (Osborne, Radnor & Nasi, 2012). The following three themes were identified in the findings benefits of PPE policy, challenges for policymakers, and governments’ role in PPE policy. An analysis of the key themes revealed a number of policy challenges and recommendations for policy makers, healthcare and nursing leaders specific to PPE. The Advanced Practice Leadership (APL), Master of Nursing, University of Victoria program includes policy competencies. I developed an Integrated PPE Framework for Public Service and Nurse Leaders that includes APL competencies, theoretical concepts and the findings in this review. Future efforts in PPE should include research on how PPE is linked to accountability, translated into policy and practice, and evaluated using standardized, valid, reliable, and appropriate measurement systems.
Acknowledgement
I would like to extend my sincere gratitude to Dr. Marjorie MacDonald (supervisor) and Dr. Lenora Marcellus (committee member) for their support. Their guidance and expertise in scholarship have inspired me to improve my critical thinking and writing during an extended effort to complete this project. Most importantly, I thank God. I also thank my sister Bettyanne, friends, physicians, colleagues, and patient partners in B.C. for without their love, support, inspiration, and continual encouragement this project would never have come to fruition.
Table of Contents
Abstract...2
Acknowledgements...3
Purpose/Aim of the project...6
Background and Significance...7
Statement of problem...9
Methodology...10
Problem identification ...10
Literature search ...10
Inclusion and Exclusion Criteria...11
Data evaluation...13
Data Analysis...15
Data reduction...16
Data display...17
Data comparison...17
Conclusion drawing and verification...19
Presentation...20
Findings...20
Discussion...29
Strengths and limitations...42
Significance of the findings for: Advanced Practice Nursing Leaders...44
Nursing Educators ...48
Public Service Professionals and Policymakers...50
Recommendations from the findings for Future Research...51
Conclusion...52
References...54
Appendix A. Interchangeable terms and common elements for the concept of patient and public engagement...65
Appendix B. Patient and Public Engagement Frameworks...67
Appendix C. Guiding framework for critiquing qualitative literature...68
Appendix D. Guiding framework for critiquing secondary/grey literature...69
Appendix E. Summary and Data Extraction of the Sources...71
Appendix F. Mind Map: Interconnections – Patient and Public Engagement Policy...99
Appendix G. Data display of the patient and public engagement influencing factors, levels of engagement and policy...100
Patient and Public Engagement in Healthcare System Policy Purpose/Aim
The purpose of this project is to gain a better understanding of the existing knowledge about patient and public engagement (PPE) within the context of healthcare system policy. In this project, I critically review and analyse literature from 2002 to 2015 (January to March) on PPE that holds relevance for policymakers, nurses, and healthcare leaders. My overall purpose is to position nurses, healthcare leaders, researchers, policy makers, and patients and families to work together to co-create a sustainable healthcare system. In addition, I chose to do this integrative review to further my understanding as a novice Masters-level researcher in furthering my understanding of the policies, concepts, and the existing evidence on PPE policies. This integrative review has allowed me to explore various PPE policies in the context of healthcare.
I selected the integrative review as the most suitable method for this project for three main reasons. First, I wanted to develop a PPE policy framework and by definition, integrative review is “a form of research that reviews, critiques, and synthesizes representative literature on a topic in an
integrated way such that new frameworks and perspectives on the topic are generated” (Torraco, 2005, p. 356). Second, I was interested in gleaning a more comprehensive understanding about the challenges and successes of PPE in the context of health policy and policymakers, and the integrative review method “summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a particular phenomenon” (Whittemore and Knafl, 2005, p. 546). Third, as a novice Masters-level
researcher, I believe that this review process supports my learning needs. The specific question I am asking is “Do PPE policies make a difference in the healthcare system?”
The goals of this integrative literature review will focus at the policy level to
1. Explore, describe, and synthesise the existing knowledge about what healthcare leaders and policymakers need to know and do to ensure successful PPE in healthcare system policy;
2. Develop a conceptual framework that can inform the future design of PPE in healthcare system policy; and,
3. Identify areas to inform advanced nursing policy, practice, and research. Background/Significance
Patient engagement in healthcare policy, practice, and research is commonly believed to be a key ingredient in high-quality health care systems (Barello, Graffigna & Vegni, 2012). Moreover, patient engagement in policy (frequently described as “citizen or “public” engagement) helps ensure that the healthcare system writ large is oriented around and responsive to patients’ and the public’s perspectives (Carmen et al., 2013). National Health Service Scotland health boards and Foundation Trust boards in England support the tenet that patients must be involved at all levels in health governance including an emphasis to involve patients and carers in the design, delivery, and evaluation of services (Forbat, Hubbard & Keamey, 2009). Additionally, the patients’ involvement in designing, delivering, and evaluating services provides the context for substantive policy and organizational development (Forbat, Hubbard & Keamey, 2009).
From a Canadian perspective, I am encouraged about the leadership and collaboration shown between the Canadian Nurses Association and the Canadian Medical Association 2012 Primary Health Care Summit. Specifically, the Summit Report identifies priority areas for action included building professional and inter-sectoral partnerships for advancing primary health care transformation and ensuring
that the public is included in the partnerships at the local, regional, provincial, and national levels for system re-design (Lankshear, 2012).
To set context for this review, there are two specific areas that warrant further explanation. First, I need to explain the meaning of the term patient and public engagement because it is often confused due to different authors using different terms to refer to the same thing. I also wanted to make sure my search strategy for this integrative review incorporated multiple terms for PPE to ensure that a thorough and successful search approach was used in my integrative review. Second, I will elucidate the different levels of PPE. The levels of engagement are important because I wanted to focus this integrative review on papers reporting higher levels of engagement from a policy systems’ perspective rather than at an individual level where engagement is typically between a patient and a healthcare provider.
First, although the concept of patient engagement is increasingly accepted and valued among health care stakeholders (Gallivan, 2012), there is often confusion about its meaning because, as noted above, different authors may use different terms to refer to the same thing. For example, in a scoping review, Kovacs Burns, Bellows, Eigenseher, and Gallivan (2014) found 15 synonyms for patient engagement in 26 different sources. These terms are often used interchangeably. By contrast, I found twenty 20 interchangeable terms and common influencing factors for the concept of PPE (see Appendix A). The most common interchangeable terms were used in the search strategy for sources included in the integrative review.
Second, there are factors that influence PPE, such as (1) ongoing engagement mechanisms that support patients and the public to participate in societal decisions, priority setting, and healthcare system policy development; and, (2) different levels, forms, and settings of engagement throughout the healthcare system (see Appendix B). The levels, forms and settings of engagement can be described along a
continuum (Carmen, et. al., 2013). For example, on the lower end of the continuum, engagement could involve policymakers and/or healthcare providers/leaders informing or educating patients or members of the public individually on a direct care basis (e.g., self-management, healthcare information). The higher end on the engagement continuum could involve policymakers and/or healthcare leaders engaging patients and/or the public in co-creating or sharing power in decision making at healthcare system policy levels. Lower and higher levels of engagement on the continuum are characterized by lower and higher levels of patient or public decision making or responsibility. Although there is “the possibility that a greater impact could be achieved by implementing interventions across multiple levels of engagement” (Carmen, et al., p. 227), I limited this integrative review to include only those sources related to higher levels of engagement at the policy healthcare system. I limited the scope to higher levels of engagement was to keep the focus of this integrative review on organizational and system levels of engagement. Individual-level engagement (e.g., interaction between healthcare provider and patient) is often associated with lower engagement levels.
Statement of Problem
John Doyle, former Auditor General of British Columbia, argued that in order to get public participation right, there needs to be the correct balance amongst the competing priorities of government (British Columbia, Office of the Auditor General, 2008). Doyle cautioned that getting public participation wrong frustrates all participants — government and the public —and when participation is not successful, it takes time to rebuild trust for successful engagement (British Columbia, Office of the Auditor General, 2008). Moreover, citizen participation, including public participation in policy-making processes, is now formally mandated by policy in many economically-developed countries (Martin, 2009). Martin also emphasized that the public is now more demanding and knowledgeable about policy, so it is important to
understand their needs and desires. Nurses are well positioned within and outside of government to
leverage their collective voice to ensure successful PPE policy at multiple levels. Thus, an examination of the factors that influence PPE in healthcare policy is needed to better understand how PPE can be
supported and promoted within this context of healthcare system policy. This understanding may help leaders in public service including nurse leaders, researchers, patients, and the public to develop more effective policies to achieve improved governance accountability and increased diversity of perspectives on policy issues.
Methodology
In this project, I followed the five specific stages of the integrative review methodology outlined by Whittemore and Knafl (2005). These include (1) Problem Identification, (2) Literature Search, (3) Data Evaluation, (4) Data Analysis, and (5) Presentation.
Stage 1: Problem Identification Stage
Although I have identified the problem of this project in the previous section, I also want to emphasize that, despite the acknowledgement of the importance of public involvement in healthcare policy, there has been very modest inquiry in policy and academic discourse into the purpose of PPE and how the success or limitations of policy might be assessed (Mullen, et al., 2011). My intention in this project was to be rigorous enough to provide insight into the current knowledge about PPE at the healthcare system policy levels. This information may inform government policy makers, nursing, and other healthcare leaders and researchers about PPE at various policy levels. My intention was also to draw the attention of policymakers, nurses, and other healthcare leaders to the importance of PPE, specifically the benefits, successes, challenges, and gaps in knowledge about PPE in healthcare system policy.
Stage 2: Literature Search Stage
Whittemore and Knafl (2005) advise that developing a strategy for literature searching is crucial to avoid bias or inaccuracies in the selection of studies. In order to capture a maximum of eligible sources for this integrative review I used the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL) database (Advance Search); Google Scholar; Medline Ovid; AbiInform Business Source Premier (EBSCO); College of Registered Nurses of British Columbia (CRNBC) EBSCO; and Web of Science. Whittemore and Knafl also advise using two to three search strategies. I used three search strategies. First, I retrieved sources from the above databases using the following search terms: engagement, patient and public engagement, patient and family engagement, client engagement, public participation, citizen engagement, patient and public involvement, patient involvement, citizen
involvement, citizen participation, health policy, healthcare system, health research, and health reform. These terms were the most common terms found in Kovacs Burns, et al.’s (2014) scoping review and the interchangeable terms that I located (see Appendix A), which are described in a previous section of this paper. Any of these terms were present either in the title or the abstract. Second, I also applied an
ancestry search approach to broaden the search of the topic. The ancestry search approach that I used was inclusive of authors’ recommendations within the literature, and/or was obtained through the
bibliographies of articles meeting inclusion criteria for this review. Ancestry searching refers to reviewing citations from earlier studies cited in references of published articles (Conn, et al., 2003). Third, secondary sources such as grey literature, reports, white papers and documents from health authorities, government, universities, and colleges were also searched using ProQuest, open grey, Grey Matters, and government sites.
Inclusion and Exclusion Criteria. After conducting the literature search and reviewing the sources, only the sources that met the inclusion criteria were selected for this integrative literature review project. The following inclusion criteria were applied: sources published between 2002 and 2015 (January-March), English only, and only those sources in which patient and public engagement occurred within a healthcare policy context at either the regional, provincial, or national level. To keep the volume of literature manageable, excluded sources were those published before 2002, and those that focussed on healthcare provider engagement, patient and/or provider engagement supporting self-management, and patient and public engagement focussed on unique specific diseases, conditions, or cultures. I also excluded patient and public engagement policy sources focused on mental health and substance use, HIV Aids, and methadone maintenance treatment. They were beyond the scope of my project and could be considered for further research. A total of 3777 sources were found using the above listed databases. Six articles were located via an ancestry search that met the inclusion criteria. Fourteen sources from the grey literature met the inclusion criteria.
The abstracts, executive summaries, and/or introductions of the 3777 were reviewed to determine whether they met the inclusion criteria of the review. Through this process, 317 sources were selected based on the abstracts, executive summaries, and/or introductions. A second screening was conducted and the full texts of the 317 sources were reviewed resulting in the selection of 39 sources that met the
Figure 1. Identification of eligible studies
Stage 3: Data Evaluation Stage
Descriptive information on the selected sources. The 39 sources addressed existing knowledge about patient and public engagement at the policy level. After critiquing all sources (explained in the next section) 2 were screened out leaving 37 sources remaining for the integrative review. Although there were 3 mixed method studies, there were no quantitative studies screened in for this review and this may have some implications for future research. The 37 sources are listed in Figure 2.
3777 Sources
1st screening: abstracts, executive summaries/introductions and articles based on the inclusion criteria
3460 sources excluded 317 sources included
2nd screening: full texts reviewed based on inclusion
280 sources excluded 39 sources included
Databases search using keywords
2 screened out leaving a total of 37 sources included
Figure 2 Descriptive information of the thirty-seven selected sources
Grey Literature N=15
Government Reports or Documents: (n=6) British Columbia Office of the Auditor General, 2008; House of
Commons, The Public Administration Select Committee, 2013; House of Commons, The Health Committee,
2007; Patient and Public Experience & Engagement Team, 2011; Government of Newfoundland and
Labrador, n.d.; Directorate Office of the Chief Medical Officer, 2007
Government Policy and/or Procedures: (n=3) Lenihan, 2012; Capital Health, 2014; State of Victoria, Department of Human Services 2006
Government Frameworks: (n=2) Canadian Institute for Healthcare Research, 2014; Queensland Government,
2012
Government Briefing Document: (n=1) Institute for Public Administration, MNP & Fasken Matineau, 2013 Government Handbook: (n=1) Sheedy, 2008
Evaluation Guide: (n=1) Warburton, Wilson & Rainbow, 2011 Government Action Plan: (n=1) Scottish Government, 2007
Qualitative Research N=17
Case Studies: (=6) Mullen, Hughes, Vincent-Jones, 2011; MacKinnon, 2003; Kovacs-Burns, Bellows, Eigenseher & Gallivan, 2014; Ansari & Andersson, 2011; and Bovaird, 2007; McCaffery, K, J., Smith, S., Shepherd, H, L., Sze, M., Dhillon, H., Jansen, J., Juraskova, I., Butow, P, N., Trevena, L., Carey, K., Tattersall, M, H, N., & Barratt, A. 2011.
Literature Reviews: (n=2) Carmen, et al., 2013; Tritter & McCallum, 2006.
Systematic Reviews: (n=2) Oxman, Lewin, Lavis, & Fretheim, 2009; Martin, 2009. Systematic Scoping Review: (n=1) Conklin, Morris & Nolte, 2012.
Historical: (n=4) Hogg, 2007; Church, Saunders, Wanke, Pong, Spooner & Dorgan, 2002; Martin, 2008;
Tritter & Koivusalo, 2013.
Ethnographic: (n=1) Meads, Griffiths, Goode & Iwami, 2007.
Comparative Study: (n=1) Legare, Stacy, & Forest, 2007.
Secondary Sources N=2
Literature Reviews: (n=2) Cavaye, 2004; Edgaman-Levitan, Brady, & Howitt, 2013
Mixed Methodology - Qualitative and Quantitative N=3
Comparative Quasi-experimental Design: (n=1) Abelson, Forest, Eyles, Casebeer, Martin & Mackean, 2007; Randomized Trial Process Evaluation: (n=1) Boivin, Lehoux, Burgers & Grol, 2014.
Grounded Theory with quantitative analysis: (n=1) Thurston, MacKean, Vollman, Casebeer, Weber, Maloff, & Bader, 2005.
Quality and Relevance Assessment. I used and adapted two evaluation frameworks to evaluate and score all of the 39 sources: first, Coughlan, Cronin, and Ryan’s (2007) framework for critiquing qualitative research; and second, McCaston’s (2005) evaluation guide for critiquing secondary sources including grey literature (in respective order see Appendix C and Appendix D).
I followed the steps in critiquing the qualitative sources outlined by Coughlan et al. (2007) for qualitative research to evaluate each element assigning each question one point for a maximum total of 39 points and a minimum total of 26 points (see Appendix C). Similarly, I followed the steps in critiquing the grey literature and secondary sources outlined by McCaston (2005) for secondary sources to evaluate each methodological element assigning each question one point for a maximum total of 35 points and a minimum total of 25 points (see Appendix D).
Scoring is recommended to help evaluate the rigor of the sources, rather than for the purpose of exclusion from the review; moreover, as Whittemore and Knafl (2005) highlight, the score, whether high or low, can be used to measure the magnitude of the source’s importance to the review in the analysis stage. Based on quality scores there were only two sources that were excluded. Of the 37 sources that were included, 20 were qualitative sources or mixed methodology that scored a minimum of 26 points (moderate quality) and a maximum of 39 (high quality); 17 were secondary or grey literature sources that scored a minimum of 25 (moderate quality) and a maximum of 35 (high quality). Therefore, 37 sources were considered of sufficiently high quality to be included in this integrative review project.
Stage 4: Data Analysis
The main goal of the data analysis stage is to synthesize the evidence into an innovative interpretation (Whittemore & Knafl, 2005). The data analysis stage is divided into four phases: Data reduction, display, comparison, and conclusion drawing and verification (Miles & Huberman, 1994).
Prior to outlining the four phases of the data analysis in the next section, I will explain two overarching analytical approaches that I used throughout the integrative review project that helped inform and influence my thinking from the research and sources in this review.
First, I used the Constant Comparison Method (CCM). The CCM and theoretical sampling form the core of qualitative analysis in the grounded theory approach and in other types of qualitative research (Boeije, 2002). Comparison is the main principle of the CCM analysis process and includes a multitude of different aids (e.g., close reading and rereading, coding, diagrams, data matrices) to enable the principle of comparison. I used a number of these aids to convert extracted data such as close reading and
rereading, coding, and construction of data matrices to support the principle of comparison. Second, I used the contrasting notions of convergence and divergence as an analytical method to draw out the key themes (Hewison, 2008). According to Hewison, the application of this analytical method is essential in framing policy discussions and therefore pertinent to this project. Examples of how I applied this method included reviewing the synthesis, implications and recommendations of each source to identify themes and sub-themes (convergence); and, reviewing each individual source several times to identify broad patterns (divergence) in applicability, similarities, and differences specific to PPE policy.
I compared similar data (point by point) and grouped categories in preparation for coding. Next, the coded categories were compared in order to advance the analysis and synthesis processes.
Subsequently, data were extracted and coded from primary, secondary, and grey literature sources to simplify, abstract, focus and organize data into an appropriate matrix to assist with my ability to compare and theme data.
Phase 1: Data Reduction. Whittemore and Knafl (2005) posit that data reduction is a necessary process in an integrative review because it will simplify, focus, and organize data into a manageable
system. For this phase I summarized each of the sources included in the integrative review into a one page document. The headings of each one page document included (a) number of the article, (b) author and country, (c) subject of the article/source, (d) method and setting (regional, provincial, national), (e) findings, (f) engagement levels (individual, community, and system), (g) limitations, and (h) implications and recommendations. This approach assisted me with organizing and systematically comparing the sources of literature on the components of healthcare policy focussed on patient and public engagement at various jurisdictional and policy levels.
Phase 2: Data Display. The next step, data display, involved converting the extracted data from individual sources into a display (see Appendix E) that further synthesized the data from multiple
primary, secondary and grey literature sources around levels of engagement, and levels of setting (e.g., regional, provincial, national). Data were displayed according to the same headings used in the one page data summary explained in the data reduction section above. These displays enhanced the visualization of patterns and relationships within and across primary, secondary, and grey data sources and served as a starting point for interpretation of the relationships, applicability, similarities, and differences.
I developed a Mind Map (see Appendix F) of the Interconnections – Patient and Public Engagement (PPE) Policy that was helpful in focussing on the multiple interconnecting elements that influence patient and public engagement policy. The map is intended to graphically show barriers, challenges, factors, and concepts that influence patient and public engagement policy. It also provides a visible map to readers of this review.
Phase 3: Data comparison. To examine data displays (see Appendix G) of primary and
secondary sources and identify patterns, themes, or relationships, I grouped the factors influencing PPE according to broad headings and sub-headings. I developed the broad headings and sub-headings for the
influencing factors of PPE policy and by reading and re-reading primary, secondary, and grey data
sources and constantly comparing the patterns and relationships within and across the sources. In addition to the number of the source and the citation, there were four broad headings and twenty four
sub-headings. These included (1) multiple stakeholders - influencing factors for PPE (patient/public; provider(s)/organizations; academics/researchers/university; policymakers / administrators; and, mechanism for ongoing PPE); (2) the reasons healthcare policymakers engage in PPE (improve
collaboration and/or knowledge sharing; accountability; reduce health delivery fragmentation or improve effective health system; ensure equity; patient centered care; more diverse ideas, perspective, suggestions; policies more accessible and responsive to citizens; better informed decisions; limited resources’
available; inform healthcare system policy; social capital; improved governance, accountability; citizens’ rights; and democratic legitimacy); (3) levels of engagement (community/organization; and system partner, leadership co-design, shared decision making); and, (4) policy levels (policy at the regional, provincial, county or national/federal level). I developed a coding scale (see Figure 3) to evaluate and analyze the influencing factors for PPE policy from the research, secondary, and grey literature sources and identify patterns, themes, or relationships. After I coded each source based on four broad categories (and sub-categories) I compared influencing factors per geographic representation (See Appendix G) and explored further characteristics such as patterns, themes, relationships, or conclusions.
Figure 3 Five Point Coding Scale PPE/Policy Influencing Factors Category Points Awarded Elements PPE Influencing Factors 4 (1 point each)
Multi-pronged engagement with patients; provider(s) organizations; educators/ researchers; policymakers/ health administrators
5 points awarded for mechanism
Mechanism for ongoing patient and public engagement
Reasons healthcare policy makers are engaging patients and the public
Maximum 14 points (one point each)
Improve collaboration, knowledge sharing and accountability, reduce health delivery fragmentation, ensure, equity, patient centered care services, effective healthcare system. More diverse ideas, perspectives, suggestions, policies more accessible and responsive to citizens, better –informed decisions, with limited resources available. Inform healthcare systems policy: social capital, improved governance
accountability, citizens’ rights, and democratic legitimacy Levels of
Engagement
3 points Level of Engagement at the Community/Organization (e.g., organizational design, governance
5 points Level of Engagement at the System Partner (e.g., leadership, co-design, shared decision making)
Policy Levels (Legislation- Legs; Regulations – Regs)
3 points Policy at the Regional level
5 points Legs/Regs Policy at the Provincial level
5 points Legs/Regs Policy at the National/Federal level
Phase 4: Conclusion Drawing and Verification. Whittemore and Knafl (2005) state that this final phase of data analysis includes a shift from efforts to interpret the description of patterns and
relationships to an elevated level of abstraction, thus allowing findings to be generalized. This final phase comprised reviewing data, isolating patterns and processes, and identifying the common themes and differences among the elements, which highlight the challenges and successes PPE policy (Whittemore & Kanlf, 2005). Moreover, this process is a gradual elaboration of a small set of generalizations that
encompasses a subgroup of the entire integrated review. Miles and Huberman (1994) suggest conclusions or models are developed via a continual revision process to help ensure the inclusion of as much of the
data as possible. Additionally, in order to ensure accuracy, this stage included validating the conclusions with all of the 37 sources in my integrative review and reading and re-reading sources.
In the final part of the data-comparison stage of my integrated review I synthesize the significant elements of the conclusions of each subgroup into an integrated summation of the elements that influence patient and public engagement policy (Whittemore & Knafl, 2005)
Stage 5: Presentation. The final phase of the integrative review process included the presentation of the review findings and discussion section. The final phase has five sections. First, I summarize the findings of my analysis from sources selected for this literature review. Second, I identify an appropriate theory that will help interpret the findings. Third, I discuss the integrative review findings that help to provide a better understanding of the existing knowledge about patient and public engagement within the context of healthcare system policy. Fourth, I present an integrated framework for policymakers, public services, and nurse leaders specific to critical aspects of patient and public engagement healthcare system policy. Lastly, I present the strengths and limitations of the study and recommendations for future
research and nursing leaders.
Findings
The findings of the integrative review for this project show that there are benefits for government and public citizens in PPE policy. There are also challenges and specific roles for government to play in promoting or facilitating PPE policy. Three themes emerged from the findings reviewed in this project. The three themes are presented below to help illuminate the findings: (1) benefits of PPE policy (2) challenges for policymakers (3) governments’ role in PPE policy. I will describe the first theme, the benefits of PPE policy, and then talk about the other themes in the order listed above.
government policy makers and public citizens benefit from PPE in policy making. I will explain the benefits with examples to show why they are perceived as benefits.
From a public service perspective, improved governance is seen to be a key benefit of PPE in the policy process. Before I discuss improved governance I will provide a very brief explanation to set the context about why governance within public service needs to improve.
Traditionally, healthcare system policy within the public sector has been a top down driven process reserved for policy-makers and high level decision makers. More recently, a strategic direction in the policy process incorporates a more prominent role for users and other members of the public in healthcare policy, decision making, and outcomes and uses a top-down – bottom-up driven process (Bovaird, 2007; British Columbia Office of the Auditor General, 2008; Capital Health, 2014; Legare et al., 2007; Lenihan, 2012; Oxman, et al., 2009; Sheedy, 2008; Tritter & McCallum, 2006). The main premise of the top down and bottom up combined approach versus a top down approach to policy making in the context of PPE is that citizens and the public are viewed as full interactive partners in governance instead of being seen in the traditional view of passive recipients of healthcare policies and services (Lenihan, 2012; Legare, Stacy, & Forest, 2007).
One of the main benefits of effective PPE policy is improved democratic legitimacy, which can improve governance (Warburton, et al., 2012). Democratic legitimacy can help to validate accountability and citizen rights, which is a reason for government(s) to embed PPE in the policy process. Some
examples may help to provide further understanding. The NHS Scotland’s Better Health Better Care Action Plan describes their aim to have a more inclusive relationship with the Scottish people in which members of the public are affirmed as partners rather than recipients of care. The ownership and
Scotland are co-owners with both rights and responsibilities. Further, in both Scotland and Ireland’s NHS, collaborative and integrated approaches have the benefit of strengthening public ownership in the culture of their healthcare systems (Scottish Government, 2007; Directorate Office of the Chief Medical Officer, Northern Ireland, 2007).
Benefits of engaging citizens in policy or program development can, from the public’s point of view, increase citizens’ sense of responsibility and understanding for complex issues (Sheedy, 2008). From the public service point of view, engaging citizens in policy or program development can be an important mechanism to clarify citizen’s values, needs and preferences, allowing public servants to understand how the public views a public concern and what is most important to them, what information the public needs to understand, and how to best present or speak about an issue (Sheedy, 2008).
Similarly, public engagement in policy making enables decision makers in the health system to address the right issues, help design programs, and improve policy implementation (Kovacs-Burns, et al. 2014; Oxman, et al., 2009).
An important benefit from the Patient and Public Involvement (PPI) policy perspective is that peoples’ experience of services and the quality and safety of care is changed. Further, PPI can also increase service responsiveness and accountability to local communities and the wider population by involving them in the deliberations and decisions about service provision. Thus, staff morale and
satisfaction can also improve when staff realize they are providing a responsive service that is valued by individuals and appreciated by the wider public (Directorate Office of the Chief Medical Officer,
Northern Ireland, 2007). Furthermore, the House of Commons Public Administration Select Committee (2013) reported that engaging the public and experts in debates about policy and in the policy-making
process and establishing new relationships where citizens become valued partners lead to new thinking and proposed new solutions to challenges.
In summary, from the perspective of policy makers, government leaders, patients and the public there is a range of PPE policy benefits. The range of benefits from the policy makers and government leaders’ view includes improving democratic legitimacy, governance, policy implementation and staff morale. The range of benefits from the patients and the public view includes improving peoples’ experience with the healthcare system and knowledge of complex issues, increasing citizens’ sense of responsibility, and incorporating citizen’s values, needs and preferences in the policy process.
Challenges for Government(s) and Policymakers. The findings in this integrative review show there are many challenges for government(s) and policymakers related to successful PPE policy. The findings were organized around three main challenges. One of the challenges is that “doing” PPE wrong can have multiple negative repercussions. The second challenge that emerged from the findings related to internal barriers within the government environment. The third challenge emerged from PPE policy and legislation that appeared to have decreased the engagement processes and may have negative outcomes from the public point of view. The three challenges will be discussed in this section.
When government(s) and policymakers “do” PPE incorrectly, the negative repercussions from the public can be significant. I will discuss three main points to set the context of this challenge. First, government PPE policy is typically vulnerable to accusations about trying to manipulate the public using cynical efforts to garner support rather than enhancing a participatory democratic process (Hogg, 2007). Second, autonomous mechanisms for PPE (e.g., Community Health Councils in the NHS, UK) were set up by the government but were later criticized for the Councils’ inconsistent and variable performance due to the lack of accountability. Third, when the government “gets” PPE wrong there is a further loss of
public good will and the perception of wasted public resources (British Columbia, Office of the Auditor General, 2008; Hogg, 2007). Moreover, where there is engagement that is not done correctly by
government (e.g., a decision has already been made so there is no need for public engagement) public cynicism towards government generally ensues. Engagement done wrong frustrates everyone and takes a significant amount of time and effort to rebuild public trust (British Columbia, Office of the Auditor General, 2008). Similarly, the Government of Newfoundland and Labrador (n.d.) caution that the costs associated with not conducting public engagement appropriately may arise from actions needed to respond or mitigate public lobbying, lack of buy-in from stakeholders, or loss of credibility with the public.
The potential negative outcomes of “doing” PPE incorrectly in the government policy process that are described above should be of concern to current government policymakers and decision makers. Future research in this area may warrant attention, particularly the cost of “doing” PPE incorrectly in the government policymaking process or not doing PPE at all. There may also be more research needed to confirm that PPE improves governance, or has other benefits.
Next, I will discuss the internal government challenges that I identified in my review findings. These challenges were located in the intra-organizational (within government) context. Policymakers are required to manage the policy process and achieve political objectives within intense, pressured, and uncertain timelines generally due to overriding urgent priorities within government (Church, et al., 2002). In my previous experience as a government policy analyst and also within the scope of my nursing
practice as the provincial director of Patients as Partners strategy in the B.C. Ministry of Health, I found that urgent competing strategic priorities within government are routine in this environment and attending to required legislative actions would over-ride other services. Adding to this complex system is the policy
process itself that is neither rational nor linear; to be more precise it is influenced by a multitude of internal and external factors (Ableson, et al., 2007). Many governments, such as Australia, UK, and provinces and territories in Canada, have moved toward engaging public and community in policy processes. The question or challenge is - how can government(s) create a more flexible system to allow for effective PPE within a “pressure cooker” environment (Cavaye, 2004)? The following examples from the findings may provide some answers and will be discussed in the next section.
I will discuss the context of the third challenge then I will explain the specific criticism. The third challenge from the findings about policy and legislation emerged from the United Kingdom (UK) NHS experience. This may have been because Patient and Public Involvement (PPI) and/or patient led health services in the UK have existed since 1974 (Hogg, 2006). Thus, the focus on UK NHS legislation in the research may have emerged because of their extensive experience specific to PPI policy and legislation over a longer period of time than other jurisdictions. UK legislation and policy was changed from including extensive PPI to a narrower scope with less inclusive PPI and this change was one of the main challenges that emerged in this review (House of Commons, Health Committee, 2007; Public and Patient Experience and Engagement Team, 2011; Tritter & Koivusalo, 2013). Nevertheless, other countries (such as Canada) with less patient and public engagement type legislative and policy experience may not have experienced challenges yet. However, Canada and other countries could be well positioned to learn from the extensive NHS experience.
The main criticism found with the UK policy/legislative change was a shift in direction that involved narrowing the scope of public involvement to two specific areas. First, individual involvement regarding choice about care; and second, access to a mechanism for advocacy regarding complaints (e.g., healthcare services experience was unsatisfactory). Whereas previous legislation included extensive
public involvement and consultation in the health system policy process at multiple levels, new legislation appears to have reduced engagement opportunities. The shift in policy direction is a challenge for
policymakers because of negative public accusations about government rhetoric regarding their pledge “that patients must be at the heart of everything we do, not just as beneficiaries of care, but as participants, in shared decision making” (Tritter & Koivusalo, 2012, p. 118).
Findings from this review are that there are challenges for government(s) and policymakers not only to enact PPE legislation and policy but also to implement PPE correctly throughout the process. Notwithstanding, the potential negative outcomes from these challenges and barriers may also be seen as motivation for governments and policymakers to “do” PPE correctly. Further, despite the aforementioned challenges there are also positive examples of PPE government policies and legislation that were
discussed in the first section of these findings.
Government(s) Role in PPE Policy. The government(s) role in PPE policy is the third theme that emerged in the findings. There were two main points in this theme: first, provide leadership and second, ensure there are formal PPE mechanisms, accountabilities, and responsibilities. I will discuss these points beginning with leadership.
To set context specific to government leadership in PPE it may be helpful to state, at the outset, that one of the leadership roles of government in healthcare is to set direction through legislation, regulation, and policies for service delivery partners such as health authorities. For the purpose of this section I will use the overarching term policies to refer to legislation, regulations, and policies.
Findings in this review show a range of diversity in PPE policies from detailed multiple
requirements to very minimal requirements. Examples of multiple requirements include Canadian PPE policies enacted in Nova Scotia, Ontario, Manitoba, and the Yukon. These policies require regional health
organizations to plan and implement thorough engagement and consultation processes with the public in establishing health priorities and/or plans (Institute of Public Administration of Canada, et al., 2013). In contrast, a minimal policy (related to patient and community engagement) enacted in British Columbia (B.C.) only requires regional health organization boards to conduct board meetings that are open to the public – unless there are mitigating interests that outweigh public disclosure (Institute of Public
Administration of Canada, et al., 2013). Another example of government leadership that provides
extensive direction, accountabilities, and expectations in PPE policy is from Australia. The Victoria State Government Doing it with us not for us participation policy describes in detail the actions, rationale, objectives, priorities, outcomes, and the expectation of collaboration (people working together) to achieve better health and better healthcare through public participation (Department of Human Services, Victoria Government, 2006).
These policy examples are from provincial or state regions, and it is important to realize that the NHS UK example mentioned in the previous section is from a national perspective. Thus, it is difficult to make comparisons between provincial/state versus federal, particularly when in Canada, the provinces have jurisdiction over healthcare policies including PPE.
The second point that emerged in the government leadership role theme is about ensuring there are formal PPE mechanisms, clear accountabilities, and responsibilities. It may be helpful to first explain what is meant by PPE mechanisms. PPE mechanisms in this context mean structures such as
organizations, networks, forums, and health regions that usually have accountabilities and responsibilities to provide healthcare services. In Canada, the provinces of Alberta, Quebec, and, Ontario are required by provincial governments to establish PPE mechanisms. For example, in Alberta, the engagement
Integrated Health Networks (LHINs). The people and organizations involved are held accountable and responsible for engaging representatives and organizations that reflect the population and are also held responsible for involving the public in local health system planning on an ongoing basis.
It is important for government leaders to recognize the need for involving diverse stakeholders in the policy process. Currently, the need to involve diverse stakeholders (e.g., patients, public and
communities) in solutions to complex problems is being recognized by governments (Martin, 2008). Some governments have radically reinterpreted the policy making process from an excluded process reserved for policy makers and top decision makers to a process whereby negotiated outcomes involve many interacting policy systems and co-production among citizens and multiple stakeholders (Bovaird, 2007).
Leadership from an internal government perspective emerged as important in the findings and will be discussed next. Decision makers and leaders in government organizations have a critical and central role within which they operate in shaping public participation (PP) implementation processes (Abelson, et al., 2007). Boviard (2007) proposed that a new type or role of public service professional is needed (e.g., coproduction development officer) who can act internally within government and externally with partners to produce strategic direction of the system. Specifically, expertise in partnering (e.g., or
co-producing) is needed within and external to government between traditional service professionals, service managers, and the political decision makers who shape the strategic direction of the service system.
Government leaders have substantially increased Public and Patient Involvement (PPI) in policy decisions and have invested significant public resources in setting up long-term mechanisms (local partnerships) to one off events such as citizens’ juries (Ansari & Andersson, 2011). In Capital Health (2014) in Nova Scotia, government leadership is required to report back to the public and participants in a
timely manner to ensure accountability and compliance is aligned with their policies. Government leadership in Scotland and Ireland’s NHS, use a collaborative and integrated approach that includes strengthening public ownership in the culture of their healthcare systems (NHS Scottish Government, 2007; Directorate Office of the Chief Medical Officer, Northern Ireland, 2007).
In summary, the findings in this integrative review of the published and grey literature provided a glimpse of the complexity of PPE in health care policy processes. The findings depicted a range of benefits of PPE policy and various challenges and roles for policymakers to consider. The discussion section introduces a theory that I chose to help interpret my findings.
Discussion
The discussion section is presented in three main parts. In the following two parts (1) identify and provide a rationale for choosing an appropriate theory to interpret my findings and introduce the theory and its four concepts; and (2) discuss my findings and how they are situated within the context of the Services-Management and Service-Dominant (SM and SD) Theory and the framework that I developed. Theory Identification, Introduction to the SM and SD Theory and Four Concepts
In the first part of the discussion section I will discuss two points. First, I will discuss the process of identifying and the rationale for choosing the SM and SD theory; second, I will introduce the theory and its four concepts.
Process of Theory Identification and Selection. To interpret and discuss my findings, I considered using complex adaptive systems theory, organizational readiness for change theory, and services management and service-dominant theory because aspects of each of these are related to my findings. I selected the services management and service-dominant (SM and SD) theory (Osborn, Radnor & Nasi, 2012) as the most appropriate framework for this integrative review for the following reasons.
The rationale for selecting this theory was that the theory focussed on citizen and public engagement throughout the process of policy development. The other two theories are more general theories are more general theories not specific to the topic of PPE. Thus, SM and SD seemed most appropriate.
Additionally, I found the terminology (e.g., titles of the concepts) to be easily adapted to align with my review findings and the APL competencies (see Table 1).
Introduction to SM and SD Theory and Theoretical Concepts. This theory was developed because Osborne, et al. (2012) believed that traditional public management theory was outdated, what was needed was a theory based on the current reality of public service delivery. The origins of public
management theory evolved conceptually from management research conducted in private manufacturing. However, most public services such as health care, education, social services are all services rather than manufactured “public products” – thus they are generally services to “support and enable the delivery of intangible and process-driven public services” (Osborne, et al., 2012, p. 136). Moreover, traditional public management theory is based on intra-organizational processes (e.g., internal processes), when the current reality of public service delivery is based on inter-organizational processes (e.g., cross-sectoral relationships and multiple systems of public service delivery).
The four main concepts in the SM and SD theoretical approach are (1) strategic orientation of Public Service Organizations (PSOs), (2) role of marketing in public services, (3) co-production of public services, and (4) the operational management of these services. I will briefly describe each concept.
The strategic orientation concept situates both the citizen and the user as key stakeholders of the public policy and public service delivery processes whereby their engagement in the processes adds value to both (Osborne, et al., 2012). Moreover, strategic orientation is also about understanding the needs and expectations of citizens and service users. From a service-dominant approach, Osborne et al. (2012) posit
that strategic orientation requires citizen engagement and user involvement at all phases of a (public) service lifecycle – including policy development. Furthermore, PSOs in this context incorporate public engagement as a core dimension in strategic orientation and implementation. Further, as a result of the interactivity between PSOs and the public, valuable information is generated to support policy
formulation and implementation in the current and future state.
The second concept, the role of marketing public services is twofold. First, a marketing approach helps to transform the intent of public service strategy into a commitment or promise – in other words, fulfilling public service commitments. Second, what is essential about the role of marketing is that the intent of a marketing approach is to maintain collaborative relationships and build trusted partnerships between service users and PSOs (Osborne, et al., 2012).
The third concept, co-production, situates the service user experiences and knowledge at the heart of effective public service design and delivery (Osborne, et al., 2012). For example, the service user knowledge is encouraged and used to improve or develop new or existing services (Osborne, et al., 2014). The concept of coproduction does not mean that PSOs and staff are excluded – rather, the insight(s) from both user and public service is combined.
The fourth concept, operations management, focuses on Relationship Management (RM) as an imperative. RM is described as increasing trust in on-going relationships and demonstrating genuine interest in the welfare of others (Osborne et al., 2012). The fourth concept also includes quality
improvement methodologies such as “lean.” Lean is an operational management methodology originating from the Toyota Motor Corporation and has been implemented into health services. Lean methodology seeks to reconfigure internal organizational processes to reduce waste and improve internal efficiencies (Osborne et al., 2012). Lean reform has been implemented in healthcare services and public services and
achieved internal efficiencies. However, lean reform has failed in terms of meeting external effectiveness and meeting the needs of external service users, citizens, and local communities (Radnor & Osborne, 2013). Osborn et al., (2014) argue “lean” continuous process improvement methodology is preoccupied with internal measures of efficiency and satisfying internal customers rather than including external public and value. Although there may be other quality improvement methodologies that include external
efficiencies and effectiveness this is outside the scope of this review.
This brief introduction to the SM and SD theory and its four theoretical concepts provides a summary of the main points that are related to my review findings. Examples from the findings related to the concepts included engaging citizens at all phases of policy development, maintaining collaborative relationships and building partnerships, using citizen knowledge in co-producing improved public
services, and ensuring that there are ongoing relationships between internal government and organizations external to government. I have re-named the four concept titles introduced above to align better with my findings in this review. I also maintained the intent of each concept as described above and as outlined by Osborne et al. (2012). The four concept title changes included, strategic orientation re-titled PPE in policymaking; the role of marketing public services renamed public service collaboration; co-production changed to PPE policy implementation; and operations management renamed interactive leadership for PPE.
Discuss Findings, SM and SD Theory, and Introduction to the Framework.
In the second part of the discussion section I review the findings in the context of the SM and SD theory and present the framework that I developed entitled, Integrated PPE Policy Framework for Public Service and Nurse Leaders, hereafter referred to as the Framework (see Table 1). This section will be presented in four parts that correspond with the four concepts of the theory, common influencing elements
of PPE (identified in Appendix G) and, themes and findings from this review. I will discuss the relationship of these concepts to the competencies from the University of Victoria, APL Masters of Nursing Program in the significance of the findings section that follows. As previously mentioned I changed the titles of the four concepts. The new titles, as reflected in Table 1 are PPE in policymaking, public service collaboration, PPE policy implementation, and, interactive leadership for PPE policy. Table 1. Integrated PPE Policy Framework for Public Service and Nurse Leaders
# Theory Concepts Theory Elements
PPE Policy influencing factors from the findings
PPE Policy Themes Examples from the findings
University of Victoria: Masters of Nursing Advanced Practice
Leadership
Competencies and Indicators 1. PPE in Policymaking Government Role 1.0 Understand the needs and expectations of citizens and service users
Improve collaboration and knowledge sharing
Recognize that the immense knowledge gleaned from public will lead to better policies and decisions will strengthen democracy.
3. Advances professional nursing practice. (Nurses/Nursing Sphere) 3.1 Role models relational integrity, ethical component and a commitment to scholarly inquiry and lifelong learning. 1.1 Users as key stakeholders Patients/Public Engagement Legislation, regulation or policy requirements for health authority
accountability to
demonstrate community consultation.
1. Demonstrates knowledge of and engagement with leadership theories.
1.1 Articulates possibilities for nursing leadership in 5 spheres of influence: patient/client, nurse and practice, interprofessional/ inter-sectoral health,
organizations, and health systems/health policy. 1.2 Engagement adds
value to policy and service delivery processes Policies / Service delivery process is more accessible and/or responsive to citizens
Provides government with justification for public spending and
strengthening the publics’ voice in decisions and health service deliver.
1. Demonstrates knowledge of and engagement with leadership theories.
1.3 Analyzes the influence of the social, political and economic environment and prominent discourses / practices (such as corporatization) on health care, health policy, and nursing practice.
1.3 Users involvement at all phases of policy cycle Inform healthcare system policy throughout policy process
PPE enables decision makers to design policy and programs tailored to public needs; achieve better results; and validate outcomes.
3. Advances professional nursing practice. (Nurses/Nursing Sphere) 3.2 Creates a culture of learning in a focused area of nursing practice that fosters a spirit of inquiry.
2. Public Service Collaboration Concept
Benefits and strategies of PPE policy 2.0 Fulfilling public service commitment(s) Governance, accountability and democratic legitimacy, mechanisms for ongoing PPE
Gain valuable knowledge through public
engagement that can lead to better policies and decisions and democracy.
4. Fosters collaborative working relationships with diverse
stakeholders. 4.1 Promotes
interprofessional and inter-sectoral communication to enhance patient and staff safety, foster client-centred, ethical and culturally safe practices, and build collaborative teams and coalitions. 2.1 Maintaining collaborative relationships Improve collaboration, knowledge sharing Include actions to strengthen public ownership by embedding patient experience
information in the system.
4.2 Communicates within nursing, inter-professionally, and across sectors in a timely, frequent, accurate,
succinct manner to create a climate of shared goals and mutual respect. 2.2 Building trusted partnerships System Partner (e.g., leadership, shared decision making, co-design) Challenge for policymakersRecognize the impacts of not engaging the public such as increased costs due to stakeholder lobbying and loss of public credibility.
4.3 Participates in, or leads, diverse teams to improve client experiences or outcomes and to initiate and/or support evidence-informed policy changes.
2.3 Co-creating joint improvement More diverse ideas / perspectives/ Suggestions Government Role
Acknowledge the value of the engagement process.
4.5 Articulates an advanced nursing perspective to diverse stakeholders (colleagues, decision makers, public, etc.) to address client needs, support nursing decisions, and optimize health-care provision.
3. PPE Policy Implementation Concept
Government Role in PPE Policy 3.0 Innovation includes seeking user service knowledge Better informed decisions, communication,
Incorporate shared policy agenda setting to ensure that policy proposals and
2. Demonstrates leadership abilities in an area of nursing practice or health care delivery. (Patient/Client
to improve or develop services
and more diverse ideas.
decisions are co-jointly created.
Influence) 2.1 Conducts systematic and comprehensive assessments based on the integration of theory, evidence, research, and differing perspectives, as a foundation for advanced reasoning and/or decision-making.
3.1 Puts service user experiences at the heart of public service design Patient centred care and Citizens’ Rights Challenge for policymakers
Challenge for government to incorporate PPE into a policy process.
5. Fosters innovation to create effective work environments (Organizations Sphere) 5.6 Participates in the design and implementation of new models for nursing and/or healthcare delivery in an area of practice.
3.2 User is at the heart of the process (social inclusion)
Patient centred care
Government Role in PPE PolicyEnsure PPE as a key strategic direction for ensuring decisions and priorities reflect the needs of the citizens.
1. Demonstrates knowledge of and engagement with leadership theories.
1.1 Articulates the possibilities for nursing leadership across 5 spheres of influence: patient/client,
nurses/nursing practice,
interprofessional/ inter-sectoral health, organizations, and health systems / health policy.
4 Interactive
Leadership for PPE policy
Government Role in PPE Policy 4.0 Interactivity between internal/ external stakeholders: public service transformation Engage multiple stakeholders at all levels of the policy process.
Ensure public is involved in forming legislation for durable decision-making. Public’s are typically more supportive of government decisions if they know their views were considered.
6. Demonstrates leadership within complex health systems (Systems/ Policy Sphere)
6.6 Participates in the development and implementation of institutional, local, provincial, or national health policy. 4.1 Relationship Management Social Capital, Democratic Legitimacy Challenges for policymakers
Efforts need to be made to raise patients’ awareness about PPE benefits, and support patients increasing role in leadership.
4. Fosters collaborative working relationships with diverse
stakeholders. (Interprofessional/ Inter-sectoral Sphere) 4.2
Communicates within nursing,
interprofessionally, and across sectors in a timely, frequent, accurate,
succinct manner to create a climate of shared goals and mutual respect. Adapted from the Services Management and Service-Dominant Theory (Osborne, et al., 2012)
(i) PPE in Policy Making Concept. The main premise of this concept is engaging the patients and public in decision making throughout the policy process. I will first list the four elements in this concept and then discuss relevant findings from this review. The four elements are (1) understanding the needs and expectations of citizens and service users, (2) situating service users as key stakeholders, (3) recognizing that engagement adds value to policy and to service delivery processes, and (4) involving service users in all phases of the policy process. PPE in policymaking concept is congruent with the findings in this review and I believe is very relevant to understanding how healthcare policy leaders and decision makers support and value PPE in healthcare policy.
The first element in this concept is understanding the needs and expectations of citizens and service users. The findings show that the PPE process in policy provides an effective way for
governments to better understand the needs and expectations of citizens and service users. Moreover, governments can utilize the immense knowledge gleaned from the public through engagement for developing better policies and decisions and to strengthen democracy (Department of Human Services, Victoria Government, 2006; Edgaman-Levitan et al. 2013; Institute of Public Administration of Canada et al. 2013; Kovacs-Burns et al. 2014; Sheedy, 2008).
The second element is situating service users as key stakeholders. The findings indicate that governments are starting to hold to account health authorities, who are responsible for delivering healthcare services, for implementing community consultation processes in the development of health plans, strategic directions, and policy development (Directorate Office of the Chief Medical Officer, Northern Ireland, 2007; House of Commons, Health Committee,2007; House of Commons Public Administration Select Committee, 2013; Institute of Public Administration of Canada et al. 2013; Public and Patient Experience and Engagement Team, 2011; Scottish Government, 2007). These processes
situate service users and the public as key stakeholders at multiple levels and are an example of how policy leaders within government support PPE in healthcare policy.
The third element is recognizing that engagement adds value to policy and to service delivery processes. The findings show that by engaging citizens and the public in the policy process it can lead government decision makers to make better decisions (Ansari & Andersson, 2001; Bovaird, 2007; Cavaye, 2004; Lenihan, 2012; Scottish Government 2007; Sheedy, 2008). For example, government decisions makers may not understand potential social or ethical implications of their decisions and by engaging such populations they would have a greater understanding, thus leading to better informed decisions (Sheedy, 2008).
The fourth element is involving service users in all phases of the policy process. The findings indicate that by embedding PPE throughout the phases of the policy process, health system decision makers are likely to address the right issues in an appropriate way and design programs, policy and planning activities that closely align with the public needs (Kovacs-Burns, et al, 2014; Directorate Office of the Chief Medical Officer, Northern Ireland, 2007; Warburton, et al., 2012).
In summary, the PPE in policy making concept is about PPE providing effective ways for governments to understand the publics’ healthcare needs and expectations. Findings show that it is important for government(s) to support PPE processes to ensure the user and/or public is a key
stakeholder at multiple levels throughout the policy process. The findings show that the benefits of PPE policy included government leaders having a more comprehensive understanding of the issues about populations that are affected by decisions and as a result lead to better informed decision making. Finally, embedding PPE in the policy process healthcare decision makers may develop policy that is well aligned with the public needs.
(ii) Public Service Collaboration Concept. The main premise of this concept is fostering collaborative working relationships with diverse stakeholders (including interprofessional and inter-sectoral spheres). Developing collaborative ongoing relationships between government and organizations and/or health users helps to develop trust and impact strategic decision making (Osborne, et al., 2012). The four elements in this concept are building trusted partnerships, maintaining collaborative
relationships, co-creating joint improvements, and fulfilling public service commitments.
The findings in this review highlighted the importance of partnerships between the public and the government public service in co-producing effective health service policy (Bovaird, 2007; Carmen, et al., 2013; Cavaye, 2004; Department of Human Services, Victoria Government, 2006; Directorate Office of the Chief Medical Officer, Northern Ireland, 2007; House of Commons Public Administration Select Committee 2013; Lenihan, 2012; Scottish Government, 2007; Oxman, et al., 2009; Tritter & McCallum, 2006). Moreover, citizens and the public are viewed as partners who are “situated as essential
stakeholders of the public policy and public service delivery processes and their engagement in these processes adds value to both” (Osborn, et al., 2012, p. 143).
Findings show that public engagement, building partnerships, and collaboration are required to solve complex issues in healthcare policy (Directorate Office of the Chief Medical Officer, Northern Ireland, 2007; Lenihan, 2012; Scottish Government., 2007). Neither governments nor any one
organization alone can provide effective solutions to healthcare in isolation. Lenihan (2012) suggests that governments’ current multi-stakeholder environment requires high levels of collaboration across
organizational boundaries. The following example from the findings in this review show how
governments incorporate engagement in policy guiding documents. In Northern Ireland, the Department of Health, Social Service and Public Safety circular document entitled, Guidance on Strengthening
