Accepted Manuscript Involving Undergraduate Nursing Students in Participatory Health Research: Implications from the Netherlands
Gideon De Jong, Ellen Meijer, Gert Schout, Tineke Abma PII: DOI: Reference:
S8755-7223(17)30362-9 doi:10.1016/j.profnurs.2018.04.001 YJPNU 1138
To appear in:
Journal of Professional Nursing
Received date: Revised date: Accepted date:
5 September 2017 23 March 2018 18 April 2018
Please cite this article as: Gideon De Jong, Ellen Meijer, Gert Schout, Tineke Abma , Involving Undergraduate Nursing Students in Participatory Health Research: Implications from the Netherlands. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yjpnu(2017), doi:10.1016/ j.profnurs.2018.04.001
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Involving undergraduate nursing students in participatory health research
Perth /Amsterdam, 23rd March 2018
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Implications from the Netherlands
Full title Involving undergraduate nursing students in participatory health research: Implications from the Netherlands
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Running title Undergraduate nursing students as co-researchers
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Author details GIDEON DE JONG, Ph.D., R.N. Senior researcher and lecturer, School of Nursing and Midwifery, Edith Cowan University, Perth Gideon de Jong recently defended his PhD thesis entitled ‘Family Group Conferencing in public mental health care: A responsive evaluation’ at the VU University Medical Centre in Amsterdam. He holds a Bachelor’s degree in Nursing and a Master’s in Educational Sciences. Over the past decade he has been working as a nurse in different psychiatric settings, combining this job with a position as a university teacher and researcher. Since February 2016 he is appointed as a senior researcher and lecturer in mental health nursing to the Edith Cowan University in Perth, Australia ELLEN MEIJER, M.Sc. PhD candidate, department of Medical Humanities, EMGO+, VU University Medical Centre Amsterdam, the Netherlands Ellen Meijer is a PhD candidate at the VU University Medical Centre in Amsterdam. She holds a Bachelor’s degree in Psychology and a Master’s in Sociology. Since 2013 she has been researching Family Group Conferencing in coercive psychiatry. GERT SCHOUT, Ph.D. Senior researcher, department of Medical Humanities, EMGO+, VU University Medical Centre, Amsterdam
ACCEPTED MANUSCRIPT Over the past decade, Gert Schout has been involved in the research and development of (public) mental health care in the Netherlands. He has written books and published in various journals on topics dealing with care for socially vulnerable people. In 2007 he received a PhD degree at the University of Groningen on a study into the interplay between care avoidance and care paralysis. His recent articles and research focus on the application of Family Group Conferencing in (public) mental health. Professor, department of Medical Humanities, EMGO+, VU University Medical Centre, Amsterdam Tineke Abma is professor Participation & Diversity and research director at the department of Medical Humanities, and senior researcher at the EMGO+ research institute, VU University Medical Center in Amsterdam. Her research projects are embedded within the Quality of Care programme of EMGO+. Formerly she was appointed as associate professor at the department of Health, Ethics & Society at Maastricht University and research institute Caphri, and assistant professor at the institute for Healthcare Policy & Management of the Erasmus University in Rotterdam.
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Corresponding author Gideon de Jong Tel: +61 863043490 Email:
[email protected]
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TINEKE ABMA, Ph.D.
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Address Edith Cowan University School of Nursing and Midwifery Building 21, Room 21.423 270 Joondalup Drive Joondalup WA 6027 Australia
Acknowledgment The research group consisted, besides Gideon de Jong, Ellen Meyer (both research supervisor), and Gert Schout, Ph.D. (research project leader, former Professor of Public Mental Health Care at the Hanze University of Applied Sciences) of Marjolein van Dijk, M.Sc. (research supervisor) and Elleke Landeweer, Ph.D. (research supervisor), all related to the Department of Medical Humanities of the VU University Medical Centre.
ACCEPTED MANUSCRIPT We are grateful to dr. Sara Bayes, associate professor of midwifery at the Edith Cowan University, for the English proofreading of our manuscript. Conflict of interest There are no conflicts of interests to be reported. Word count Full article (including references and keywords):
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7671 (27 pages)
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Involving undergraduate nursing students in participatory health research
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Implications from the Netherlands
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Abstract
Internationally, there are increasing initiatives that involve undergraduate nursing students as
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co-researchers. This paper discusses the inclusion of final year undergraduate nursing students as co-researchers in participatory health studies. It reports on a large-scale study (2009-2015)
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on the process and outcomes of Family Group Conferencing in mental health care that demonstrates how undergraduate students in the Netherlands got involved as co-researchers
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and how their contribution was optimally utilised. The project revealed that the benefits for students participating in a large-scale, participatory health research are twofold. Firstly,
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students could conduct a research thesis tailored to their studies where they learn from experienced supervisors through demonstration and the transference of tacit knowledge.
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Secondly, they meet real clients and gain insights and ideas for transferable skills to meet changing demands in the nursing profession such as activating self-care and social resilience, utilising social resources and supporting near communities. From a broader perspective, the project demonstrated sensitivity to the needs of different spheres (professional care, education, civil society) so that these can learn from each other and enrich interim study findings with different viewpoints. Highlights
ACCEPTED MANUSCRIPT There are increasing research initiatives that seek for collaboration with undergraduate nursing students A Dutch study project demonstrates the engagement of undergraduate students as coresearchers The research process enabled both students and research groups to reflect on routines,
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interpretations and power relationships
Students can participate in relevant research with a high learning potential while developing and refining research outcomes
Simultaneously students generate a large capacity for data gathering and analysing
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social networks, to learn from each other
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The collaborative research process enabled researchers, educators, students, clients and their
Key words
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Co-researchers, Family Group Conferencing, undergraduate nursing students, participatory
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health research, student-to-student mentoring, non-linear knowledge development and
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transformation
ACCEPTED MANUSCRIPT Introduction In the last decade research professorships (‘lectoraten’) have been created at schools of nursing, part of universities of applied sciences, in the Netherlands with the aim to include students as co-researchers in large-scale studies. One means to an end for these universities is their role in
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practitioner-based and participatory health research. This has led in recent years to multiple initiatives, such as the development of new research modules for final year baccalaureate students (Van der Donk & Van Lanen, 2015) and workplace learning opportunities in clinical placements where students participate in care innovation projects established between care organisations and nursing faculties (Snoeren, Volbeda, Niesen, & Abma, 2016). From 2009 to
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2015, we gained experience as a research professorship with engaging final year undergraduate students of nursing, social work and applied psychology as co-researchers in a large-scale study
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on the process and outcomes of Family Group Conferencing in mental health care. The purpose of this paper is not to report on the findings of this research project, but to describe the
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experience of involving undergraduate students in participatory health research and illustrate
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their added value as co-researchers.
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Participatory health research
For decades, knowledge transfer in health care was largely passive and linear “where research
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funding (inputs) enabled design of research protocols and interventions (activities) leading to papers (outputs) and new or improved services (outcomes) producing better health and reduced mortality (longer term impact)” (Abma, Cook, Rämgård, Kleba, Harris, & Wallerstein, 2017, p. 3). According to Abma et al. (2017), until the 1990s, health scientists were inclined to know what was best and did not take the practical knowledge of professionals and the lived experiences of patients into account. Since the new millennium, voices are raised for the inclusion of a varied group of stakeholders in health research, among them health professionals and patients. Practitioner-based and participatory health research is of importance here, as it takes place within the context of a professional practice, is conducted in corporation with health
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professionals and patients, and aims for the improvement of this practice (Abma et al., 2017; Van der Donk & Van Lanen, 2015). In here, there is a continuous systematic interaction with the environment to answer questions that emerge during the distinctive phases of the research cycle. Participation of various stakeholders is an important value in this type of research. Undergraduate students, however, are not always considered as stakeholders or co-researchers
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in participatory health research, while their inclusion could diminish the theory-practice gap as knowledge and practice are systematically integrated into research, education and services. But also because the research agenda is not dominated entirely by scientists and the perspectives of a varied group of stakeholders are taking into account (Abma et al., 2017). Students as participatory (co-)researchers are, in the words of Abma et al. (2017), ideally positioned to
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support “reflection and dialog to enable critical awareness of hierarchies and of power relations that otherwise are taken for granted” (p. 14). This is especially important when doing research
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with disadvantaged groups, such as those who are confronted with coercive measures in psychiatry and other forms of disempowerment and paternalism (Authors’ Own). Participating
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in such a study guides students how to act as advocates for people who struggle with ongoing mental health issues (in this paper termed as ‘mental health consumers’ or ‘consumers’) and
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their families once they are graduated.
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In our participatory research project, we included and worked together with students as coresearchers. Around 160 final year undergraduate and 10 postgraduate students participated in
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this study as research team members; participants were enrolled in a range of Bachelors and Masters’ programs, such as nursing, social work, (applied) psychology and sociology. Many (around 70) were students finishing their Bachelor degree in nursing. We trained them to encourage mental health consumers and their network to share their perceptions on a social intervention, Family Group Conferencing (FGC), where up to the implementation of the project just little knowledge was gained in mental health care. FGC, in its very essence, aims for the democratisation of decision-making in care and social welfare practices. It was therefore selfevident that a collaborative and participatory research design would be the best fit to evaluating FGC when this would be organised for people with a history of disempowerment and
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marginalisation. The aim of our project was to shape a research practice with various stakeholders and evaluate in what kind of situations and under which circumstances in mental health care FGC could be deployed. In this paper, the experiences with these students are used to address the question of how to collaborate with students in a large scale, participatory health
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research and illustrate their added value as co-researchers.
Improving the research capacity of undergraduate nursing students
Since the new millennium, several nursing faculties have introduced research modules in their undergraduate courses. In the Netherlands, as in other countries in the European Union (Gallart, Bardallo, de Juan, Rodríguez, & Fuster. 2015), the bachelor thesis is the mandatory conclusion
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of studying an undergraduate degree at a school of nursing. The process of developing a proposal, gathering and analysing data, and finally writing a thesis, lasts a period of 20 weeks
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during which students work full time (40 hours a week without being enrolled in other courses) on their research subject. Various scholars (Bailey, Zanchetta, Velasco, Pon, & Hassan, 2015;
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Borglin & Fagerström, 2012) argue that undergraduate nursing students are traditionally not equipped with the right tools to develop these skills in their taught program. Undergraduate
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students often perceive research as difficult and complicated (Ax & Kincade, 2001; Christie,
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Hamill, & Power, 2012; Kessler & Alverson, 2014; Niven, Roy, Schaefer, Gasquoine, & Ward, 2013; Spatz, 2008), and therefore develop negative attitudes towards it (Halcomb & Peters,
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2009) or lack to see its relevance and cannot connect it to the practice of nursing (Sheriff & Caney, 2006). Schools of nursing, therefore, are increasingly emphasising the ability of research and academic writing in their undergraduate curriculum (Borglin, 2012; Halcomb & Peters, 2009; Johansen & Harding, 2013; Latham & Ahern, 2013). In most European countries, this capability must be reflected in students’ bachelor thesis which is the final output of their 4 year undergraduate degree. Lundgren and Robertsson (2013) argue that writing a bachelor thesis generates transferable knowledge and skills useable in nursing practice. Successfully completing a research project with a well-written thesis is the ultimate demonstration that students can think critically about and deploy the best possible research methodology to address
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problems in their field of practice, evaluate theoretical assumptions, construct arguments and support these with insights from the academic literature, and present their thoughts logically (e.g. Bailey et al., 2015). Recent evidence from Turkey also suggests that writing a thesis has a positive effect on how nursing students perceive research and how it evokes awareness of the essence of evidence-based practice (Toraman, Hamaratçılar, Tülü, & Erkin, 2017).
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As Halcomb and Peters (2009) on the basis of their thorough literature review conclude, there is a lack of rigorous evaluation of effective strategies for engaging undergraduate nursing students in research. The examples that are available report on the positive experiences that students gain by contributing to research initiated by faculty nursing staff, such as learning that research can be exciting and relevant, being involved in every phase of the research project,
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gaining a greater knowledge of a particular nursing intervention, and the improvement of patient care, (see Abbott-Anderson, Gilmore-Bykovskyi, & Lyles, 2016; Ayoola, Adam, Kamp,
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Zandee, Feenstra, & Doornbos,, 2017; Greenawald, 2010; Jamerson, Fish, & Frandsen, 2011; Kessler & Alverson, 2014; Jansen, Jadack, Ayoola, Doornbos, Dunn, Moch, Moore, & Wegner,
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2015; Morrison-Beedy, Aronowitz, Dyne, & Mkandawire, 2001; Niven et al., 2013; Ravert, Boyer, Harmon, & Scoffield, 2004; Sheriff & Chaney, 2006; Snoeren et al., 2016; Taber, Taber,
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Galante, & Sigsby 2011; Thompson, McNeill, Sherwood, & Starck, 2001). These initiatives
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lead to an increased number of recent graduated students who aim for a career in nursing science (Slattery, Logan, Mudge, Secore, Von Reyn, & Maue, 2016) and also provide opportunities for
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PhD candidates to act as nurse faculty mentors for students (Abbott-Anderson et al., 2016). In recent years voices have been raised that call for more creative and interactive strategies to make science relevant to the practice of nursing, such as the embedding of research throughout curricula apart from the separate research classes (Christie, Hamill, & Power, 2012) and the inclusion of students as research assistants (Burkhart & Hall 2015). Various scholars (Abbott-Anderson et al., 2016; Burkhart & Hall, 2015; Cepanec, Clarke, Plohman, & Gerard, 2013; Kessler & Alverson, 2014; Jansen et al., 2015) have recently reported on initiatives in US-based schools of nursing where undergraduate students work as co-researchers in faculty research rather than carrying out small-scale bachelor thesis research. In European countries
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too, there are increasing initiatives to involve undergraduate nursing students in large-scale health research, but evidence for their efficacy is meagre. This demonstration and discussion paper is based on experiences we have gained with including final year undergraduate nursing students in a large-scale study conducted by a research professorship in the Netherlands. Central to this paper is describing how undergraduate
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students can get involved in participatory health research and how their contribution could be optimally utilised. Literature was sought which reports on participatory health research initiatives and, more in particular, the role of undergraduate nursing students as co-researchers
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herein, to provide an extra layer of understanding.
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Description of the research project
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Family Group Conferencing is an approach which aims to bring the informal system of people
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and their social network together with the formal system of the government and care agencies (Pennell & Anderson, 2005). Consequently, both systems have hold on each other’s information
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and can make the best decision on how to solve a problematic situation. Different actors participate in a family group conference. Not only the central person and his or her family are present, even friends, neighbours and colleagues can participate, together referred to as ‘primary group’ (Authors’ Own). The ‘heart’ of the conference is the private time where the primary group develops a plan on their own which in cases of threatening measures is reviewed by professionals on practicability and achievability. It is the aim in FGC that all participants can share their ideas for viable solutions, but are also given voice to express their dissatisfaction and grievances (Holland & Rivett, 2008). The plan describes the roles and responsibilities of the different actors.
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From 2009 to 2015, we examined the practice of FGC in mental health, first through a research professorship related to the School of Nursing of the Hanze University of Applied Sciences in Groningen, and since 2013 as part of the Department of Medical Humanities of the VU University Medical Centre in Amsterdam. The research project consisted of three parts. We started in 2009 with an exploratory study into the opportunities and limitations of FGC in public
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mental health (Author’s Own). Then, from 2011 to 2013, 41 family group conferences were studied in a public mental health setting in the north of the Netherlands, while from 2013 until 2015 we examined 41 conferences in three regions (Groningen, Noord-Holland-Noord, Eindhoven and its surroundings) as a means to avert coercive measures in psychiatry. Altogether, 82 case studies were carried out to evaluate the process of FGC and their outcomes
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in terms of strengthening mental health consumers’ capabilities, mobilising social support, improving their living conditions, and reducing the risk of coercive measures. We made use of
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mixed methods: qualitative methods (semi-structured interviews, observations, [group] member checks) were deployed to gain an understanding of how the family group conferences
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proceeded, while quantitative methods (10-point scales) were used to examine the effects of the conference. We interviewed around 600 participants (consumers, their family, friends,
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neighbours and colleagues, health and social professionals and FGC coordinators) who had
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experienced FGC. The research project, therefore, is the world’s most in-depth study on FGC for adult care recipients.
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In the case studies, we collaborated with multiple stakeholders. We invited people from various backgrounds to assist in the formulating of research questions and methods. These stakeholders were linked to mental health consumers’ and family movements, professionals working in mental health care and nursing academics. A continuous collaboration with consumers, their families and mental health providers was initiated. Besides, the Dutch organisation responsible for conducting FGC (De Eigen Kracht Centrale), was included as a stakeholder. All these stakeholders had their own interests in the implementation of the research project. The involved students needed to act in this dynamic field and were responsible, together with their research supervisors, for the evaluation of a single case study.
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The study was conducted in accordance with the Declaration of Helsinki, and the study protocol was approved by the Ethics Committee of the Hanze University of Applied Sciences
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and the VU University Medical Center (EMGO+).
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The research cycle
The collaboration between students and supervisors
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An important pillar these days at Universities of Applied Sciences in the Netherlands is to stimulate an inquiring attitude in their students. The relevant schools therefore questioned
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whether this objective was within reach when students would participate in a predetermined group project. That students would participate in such a large-scale study was new for nursing
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schools and therefore a little uncomfortable for them. Would students be given the freedom to
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shape their final research project at their own discretion, as long as the requirements of their school programmes were followed? Was the research protocol as it was prescribed from the
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research group not too much of a straitjacket? Without the students we would have never been able to carry out such a thorough study; simultaneously we offered them the opportunity to take part in a large-scale study where their critical and reflexive thinking about a relevant nursing issue was developed, however we had to ensure that their involvement allowed them to uphold the rules governing their thesis study. On the other hand, there were also goals beyond academic writing skills at stake in this project. These goals referred to the broader aim of this project, namely to establish together a practice with students, mental health consumers, families, near communities, professionals and municipal services, who altogether tried to minimise coercion and restore relationships.
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The students were supervised by four experienced researchers (supervisors) who were employed at the aforementioned research professorship. Two of them worked part-time as mental health nurses, while the other two had gained significant knowledge on coercion and family involvement in psychiatry through former studies they participated in. At the same time, these mentors themselves were supervised by senior faculty staff (their PhD supervisors) that,
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in line with Abbott-Anderson et al. (2016), were “[…] responsible for overseeing the research endeavours of the entire team, while junior faculty [the supervisors] take on the task of directly mentoring of students” (p. 422).
The recruitment and training of students
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Prior to the start of their bachelor research, students were recruited to work on the study through the digital communication channels of their university schools. An appealing title about doing
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research into the practice of FGC in mental health care, and an accompanying text proved to attract interest among students. Students were then invited for an interview guided by one of
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the supervisors to ascertain their level of interest and research capabilities. The supervisor would also be the assessor of their graduation and as such would evaluate the student’s thesis
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together with a second assessor. These second assessors were lecturers employed in the
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involved schools who had experience in supervising undergraduate students throughout their bachelor theses. They were responsible for a second review of the students’ proposal and thesis.
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Because the supervisors were trained in the undergraduate curriculum of the schools and took part in peer-review sessions with the second assessors, they could simultaneously supervise the students in the merit of the research project as well as addressing the requirements of their school programs. After the supervisors and students had decided to engage in the process, students were asked to present their research questions and objectives. Students were encouraged to independently come up with a research proposal that would fit into the framework of the research project. Once students had gone through this process, they received the standardised research protocol with the request to use it to document their plan. The final proposal was the best of both worlds:
ACCEPTED MANUSCRIPT students’ own opinions and ideas, and the requirements of the research group and their university schools received equal priority. Most students realised that this approach was necessary to achieve unambiguous study findings, and therefore had no problems with the research protocol as guiding principle:
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We also made use of the research protocol which we received from the research group. This was given to us after we had first written our own research method strategy and had already thought about it. After our research strategy was approved, we received the protocol from our supervisor. Using this protocol ensured that the different case studies were carried out in the same way, so that
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they are comparable and reliable. [FGC-case 31, Student 1 & 2]
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A single student, however, had her doubts about this approach for understandable reasons:
We were ‘stuck’ as a couple within a strict research protocol. I was not aware of this enough during
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the start of the research. That’s too bad. I wanted to invest more of myself in this research. The strict research protocol, however, was understandable. That’s why I could also comply with that. Another
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reason for complying with this study was the bond I felt with the client group where our research
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focused on. [FGC-case 26, Student 1]
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The next step was to train the students in approaching the participants of the FGC and doing the interviews. Niven et al. (2013) describe that undergraduate nursing students usually perceive research as difficult. They therefore propose a “one step at a time” approach when training in all stages of the research process (p. 67). Although the schools of the students involved in our research project offered courses on qualitative research, the training that we provided was specifically aimed at preparing them for doing a qualitative case study (Stake, 1995) using responsive evaluation methods (Abma, 2005) and 10-point scales, not only to measure the effects of the family group conference but, in line with solution-focused therapy (Bannink, 2007), also to reflect more in depth on these outcomes. Besides general research
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skills (gathering and analysing data), nursing competencies such as empathy, perseverance, and dealing with challenging and unpredictable behaviour (see Author’s Own), ethical awareness (the assurance of preserving anonymity and confidentiality) and a sense of self-confidence and self-protection (e.g. Blenkinsop, 2003; Lundgren & Robertsson, 2013) were central to this training. During the interviews students needed to be able to bring attention to the topics
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mentioned in the protocol, but simultaneously to be open to new insights that could come to the surface. Awareness was built on the iterative process of interviewing (e.g. Merriam, 2009). Students considered the extra research training by their supervisors valuable:
We followed one tutorial [offered by their school] before we started with our case study, but actually
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consulted our supervisor more often. He was aware of all the criteria that were demanded by our
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school and could tell us a lot about the design of this specific case study. In each new phase, for example before we had to write the research design or before we started analysing the data, he gave us information and we could ask questions. […] For us this was a pleasant way to be supervised.
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[FGC-case 31, Student 1 & 2]
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We were confident because the supervisor had experience with guiding students in similar research.
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The last training session consisted of a two-hour session on data analysis using the software programme ATLAS.ti (Friese, 2014). This programme is a useful tool in structuring interview
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data where the answer on a particular question in every interview can be given at a different time, and helped in finding a ‘red thread’ running through the diverse stories that the students gathered from their respondents. This ‘red thread’ enabled the process of the conference to be described, including all the specific twists and turns within it.
Conducting the case study
ACCEPTED MANUSCRIPT This study followed a Rortyan, pragmatic theory of truth (Authors own; Rorty, 1991).1 Students in this project were trained to gather information on what works for the participants of the FGC, to derive from each conference a narrative on the problematic situation prior to the conference and the plan that got established to address it. The students worked in pairs, which meant they could reflect on each other’s work and
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counteract individual biases. A possible downside to this approach was that students with a stronger personality may have influenced more passive students. However, we mainly saw that students had different qualities and competences, and that they actually encouraged each other to make use of their particular strengths and therefore complemented each other.
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Already from the start of the research design it became clear to us that we possessed different
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qualities that perfectly matched each other. Where I could get to the core of the literature and interviews easier, A was better able to formulate well-written sentences. Logically, we have taken these qualities into account when allocating the tasks. In this way I started to focus more on the
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literature study, the Results chapter and the elaboration of the focus group, and A was more concerned with the formulation of the Method chapter, Discussion, Conclusion and
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Recommendations. [FGC-case 52, Student 2]
For example, we saw with several student pairs that one of them had a keen sense of how to
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make contact and gain the trust of suspicious respondents so that the interviews could go ahead, while the other student had the capacity to think critically so that the insights from the interviews could result in a comprehensive thesis:
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In line with the American philosopher Richard Rorty (1991), a central goal of our study project was to understand
the process and outcomes of FGC in mental health care. Rorty viewed knowledge not as getting a reality right, “but rather as a matter of acquiring habits of action for coping with reality” (as cited in Leigland, 1999, p. 485). What does count in Rorty’s view is how language and vocabularies represents reality. The one vocabulary in its own right is not necessarily a better representation of the truth than the other.
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During the case study there was a clear division of roles and we used each other’s qualities to arrive at the thesis that is now available. This division actually emerged during the course of our research and became clearer and clearer. J’s qualities lie in structuring, analysing and reporting. K’s qualities lie precisely in social interaction. All contacts with respondents were established by K. In this, K used his conversational techniques and was therefore able to plan the interviews. During the research
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we have emphasised the need to keep each other up to date and to think along with each other’s tasks. Because of this we were involved in every part of the research. [FGC-case 34, Student 1 & 2]
We supplemented each other, especially during the interviews. J and I are very different. I would like to get to the point as soon as possible and I want to get everything as concrete as possible. He
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is precisely the one who during the interviews ensured that there were silences, so that the
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interviewees had time to think. He also took care of the depth by asking questions to deepen topics. In that case I made sure that we did not lose track. [FGC-case 45, Student 1]
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Students were especially trained in reflecting on new insights that would emerge during the interviews (iterative reflection); this helped in understanding why the conference had succeeded
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or failed. The supervisors provided close oversight of the students’ work prior to the start of the
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research up to collecting and analysing the data, and finally writing the case study report (their bachelor thesis), and therefore encouraged academic writing and critical thinking.
deployed:
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Students appreciated the intensive involvement of the supervisors in the case studies they
I was extremely happy with the collaboration with our supervisor. He was very involved during all phases of our case study. We were always able to reach him by email or telephone. We were also able to meet him in his office whenever we felt it necessary. When he had time, he was always willing to answer questions or to talk about our research. In this way our supervisor could share new insights when we were stuck. In addition, his involvement encouraged our motivation to write the best possible report and learn as much as possible during the case study. [FGC-case 52, Student 2]
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The same student also shared a critical note about this intensive supervision:
A downside to this involvement is that you sometimes get too many guidelines on how to shape your research. In this way, as a student, you can easily take the role of follower rather than stipulating
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your own research plan. On the other hand, it has increased the quality of our case study and we have been able to challenge ourselves more in other areas. [FGC-case, Student 2]
Whether students were too restrained was also a critical observation that the schools made. However, students were free to discuss the research protocol with their supervisor and deviate
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from this if they had good reasons for doing so. They were also challenged to use their qualities in other areas. As the students were in their final year, they were trained in conversation skills
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which they already had applied in various nursing settings. These skills helped in establishing
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contact with and gaining the trust of an otherwise difficult to reach group (Author’s Own).
Although I had learned a lot about the client group of the public mental health care when conducting
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the literature review, I was still surprised how difficult it was to establish contact with the family [in
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the studied case]. I had to step over my own thresholds by constantly calling them and explaining the importance of their participation in this research. As soon as we had a foot between the door,
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thanks to the mother, it immediately went a lot smoother. By diving into their life world, I gained a comprehensive impression of this case. During the interviews it was rather difficult to gather the required information. This had to do with the fact that the conference got organised a long time ago, but also because the topics we discussed raised a lot of emotional tension. During our study we learned to ask open questions but in this research asking closed questions and paraphrasing were the most important tools to come to the core of the family group conference. [FGC-case 45, Student 1]
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This quote is illustrative for the role of the student investigators in our research project, namely that of the ‘concerned outsider’ who combined empathy and critical reflection with a nonjudgmental attitude. Students conducted the semi-structured interviews at sites designated by respondents (at their home, at work, or in a neutral environment) and at moments convenient to them (both
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during daytime and in the evening, during weekdays and in weekends). They also maintained a memo list on specific twists and turns during the data collection and analysis. In the interviews, students asked respondents to reflect retrospectively on the process of the conference. Qualitative topics of the interviews were the perceptions of mental health consumers, members from their social network, professionals and FGC coordinators on the
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entire process of the family group conference (referral, preparation, the conference itself, implementation of the conference plan). Several subtopics were included such as a description
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of the problem situation, expectations prior to the conference, the decision-making process during the conference, and the role of the FGC coordinator. Further on, students tried to capture
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if the social network alleviated the work of professionals and if the conference reinforced the cooperation between consumers, their network and professionals.
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The semi-structured interviews were recorded, transcribed verbatim and analysed with the
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help of ATLAS.ti. In addition to the training that the students completed, they made use of free, digitally available manuals (see www.atlasti.com) and followed the guidelines for narrative
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coding in qualitative research (Silverman, 2013):
As far as concerning the interviews, I have mainly focused on the coding using ATLAS.ti. I learned quickly how to use this programme. [FGC-case 22, Student 1]
Interim findings from the interview analysis were shared with respondents in group member checks (see Guba & Lincoln, 1989), first to validate these findings, and second to provide new insights about the process and outcomes of the conference. These meetings were organised at a time when most respondents could be present, with the proviso that in any case the central
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person would have the opportunity to reflect on the findings. The group was asked to exchange views on the actual developed plan and the plan that should have been developed to better address the problem. This method yielded experiential knowledge, both for the family group, the professionals, the FGC coordinator, and the student researchers. These group meetings were not always easy for students to chair; many cases were characterised by high conflicts between
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participants where students almost had to fulfil a mediating role:
Through this case study we met two parties that had ended up in a long-term conflict and were still full of emotions towards each other. As outsiders we increasingly gained a clear picture of how this conflict had originated and proceeded. The reactions of the main persons were sometimes quite
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intense and emotional, but we were aware that this vehemence was not aimed at us. During this
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process we did not choose sides. [FGC-case 31, Student 1 & 2]
The advantage of the group member checks was that the student investigators stayed close to
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the data so that they could validate findings and check interpretations:
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During the group meeting there was room for additions to our conclusions and new insights. P and
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I tried to take a leading role in this meeting. This was sometimes difficult because some participants also tried to take the lead. Based on the group meeting, we revised our conclusions. [FGC-case 26,
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Student 2]
Biases and variations that emerged during the group member checks were in this Rortyan approach input for discussion leading to a narrative that works for the group. A report of each case study was written wherein the process of the conference and seminal moments were described, as well as the outcomes of the conference and the insights that arose during the member check. For most students, this formed their bachelor thesis. The purpose of each case study was to explore if the family group conference in the given situation had a
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positive effect or not and what the specific patterns were that helped in understanding its success or failure.
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Discussion Working together with different stakeholders was fruitful and challenging. As around 80 student pairs had helped us carrying out the 82 case studies, it was possible to reach every participant for an interview. We were therefore able to conduct around 600 semi-structured interviews with an average length of 60 to 90 minutes. Without the commitment of the students,
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we would not have been able to carry out this study at such a large scale. Below we will share the major lessons learned from our research project that could have exemplary value for other
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schools who aim for the implementation of similar projects with a prominent role for undergraduate students.
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Participatory health studies, such as this research project, are shaped bottom-up and give voice to needs, insights and results of multiple stakeholders (Abma et al., 2017). The reflection
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on this type of collaboration yields added value for all stakeholders. In the process of the family
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group conferences, respondents were confronted with questions like “How do I want to relate to my relative, neighbour or friend?”, “What are my responsibilities?” or “How can we divide
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tasks?” and learned to address them. The knowledge institutes (universities and their schools) facilitated this process; staff and students learned to promote self-activation and social resilience. In the illustrated research project, students demonstrated a critical view on power relations, on the conduct of family group conferences and the role of the various participants (mental health consumers and their family, mental health professionals and FCG-coordinators) herein. These skills are beneficial for students in their future practice as a mental health practitioner as they are well-aligned with actual developments in this field, such as giving a voice to disempowered people and their families by encouraging supported decision-making and the favouring of recovery over curing.
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Working together with students from different disciplines was valuable; it enriched data collection and analysis by adding perspectives from the fields of nursing, social work, sociology and psychology. It also prevented dominance of the preferences and perceptions of individual researchers or the drawing of narrow conclusions – students came up with fresh perceptions that we as supervisors alone never would have thought of. In the words of Morrison-Beedy et
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al. (2001), students “[…] can substantially enrich the research project” (p. 292). On the other hand, including a large group of students as co-researchers holds the risk of inconsistent data collection (Thompson, McNeill, Sherwood, & Starck, 2001). The limitations of our study were mainly located in the interview skills of the students and their experiences with and capabilities of analysing qualitative data. This was addressed by the supervisors who managed the whole
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research cycle of the project. During their case study, each student pair had been guided intensively through the whole research process.
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When implementing participatory health research, a ‘click’ between students and supervisors is important, as both parties would engage in an intensive process together (e.g. Abbott-
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Anderson et al., 2016; Burkhart & Hall, 2015; Lundgren & Halvarsson, 2009; Taber et al., 2011). The benefits of students mentored by experienced researchers is emphasised by various
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nursing scholars: working closely together with a mentor allows students to gain first-hand
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knowledge and nursing research skills (Burkhart & Hall, 2015; Jamerson et al., 2011; Lev, Kolassa, & Bakken, 2010; Ravert et al., 2004), encourages their self-efficacy on how to deploy
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these (Lev et al., 2010), and generates a better translation of research findings into practice (Abbott-Anderson et al., 2016). Besides being experienced researchers, another advantage in the described project was that two of the four supervisors were trained themselves as mental health nurses, while the other two supervisors had extensive experience in issues related to family involvement in psychiatry. Therefore, they were also ideally positioned to demonstrate students how to make contact and gain trust of people who can frequently act suspicious towards representatives of the professional society (Authors’ Own). Our study made clear that faculty research staff not only may evoke an interest in research among undergraduate students but can also act as role models in handling challenging situations (e.g. Ayoola et al., 2017).
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Conclusion This paper seeks to inspire schools of nursing to engage their students as co-researchers in large-
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scale health studies conducted by research professorships. Its purpose was to describe how undergraduate students could be included as co-researchers in large scale, participatory health research. The project Family Group Conferencing in Mental Health Care demonstrated that the benefits of having undergraduate students participating in large-scale studies are twofold. Firstly, students could conduct a research thesis tailored to their studies where they implement
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theoretical knowledge and skills they have acquired during their studies and learn from experienced supervisors through demonstration and the transference of tacit knowledge.
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Secondly, they gain insights and ideas for transferable skills to meet changing demands in the nursing profession such as strengthening mental health consumers’ capabilities, activating self-
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care and mobilising social support. Additionally, this process prevents the conduct of smallscale bachelor theses that after completion would gather dust on the shelves.
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From a broader perspective, a participatory health research, such as the one illustrated in this
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paper, distributes its benefits among all stakeholders. First, mental health consumers and their network are recognised and acknowledged as equal partners, and therefore can enrich
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conclusions with different viewpoints and thus prevents premature closing and one-sidedness. Second, students can meet real people, with real problems. They can also apply innovative research methods and get involved in knowledge development. Universities of applied sciences and their schools are given tools to close the gap between theory and practice and to meet the complexity of social problems with the contribution of diverse actors in the research process. And finally, for all actors together, large-scale, participatory health research can effectuate the partnership between universities, schools, practice institutions and citizens. In other words, such a project is sensitive to different spheres of action, like civil society and education, to interact and form partnerships with.
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In conclusion, if schools of nursing want to contribute to solving social issues, the dialogue between different forms of knowledge, different disciplines and stakeholder groups is of significant importance. Forming communities of practice wherein students, teachers,
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researchers, nursing practice and citizens all have a role, could be a way to start this dialogue.
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