[Mixed Methods Studies in Health Services Research: Requirements, Challenges and the Question of Integration - a Discussion Paper from the Perspective of Qualitative Researchers]. / Mixed Methods-Studien in der Versorgungsforschung: Anforderungen, Herausforderungen und die Frage der Integration ­ ein Diskussionspapier aus der Perspektive qualitativ Forschender.

With this discussion paper, the subgroup Mixed Methods of the working group Qualitative Research Methods in the non-profit organization German Network Health Services Research (DNVF) is taking up the topic of three previous discussion papers on the significance and potentials of qualitative research methods in health services research. Mixed methods are being increasingly used and demanded in health services research. However, there are also areas of conflict in the planning and implementation of mixed methods studies, and these are addressed in this paper from the perspective of qualitative research. Special attention is given to the aspect of integration as the fundamental signature of mixed methods research. With this discussion paper, our aim was to stimulate critical as well as constructive exchange of ideas on what constitutes high-quality health services research characterised by a diversity of methods and the framework conditions under which this can succeed.

Work-related psychosocial demands related to work organization in small sized companies (SMEs) providing health-oriented services in Germany - a qualitative analysis.

BACKGROUND: Micro, small and medium-sized enterprises (SMEs) represent the majority of businesses in the EU. Little is known about psychosocial demands faced by company owners, managers, and employees in SMEs, especially in the health and service sector. The current study aimed to identify which psychosocial demands related to work organization are reported by managers and employees in the health and service sector, and if managers and employees differ in their perspective on these psychosocial demands. METHODS: We conducted nine single interviews and two focus group discussions with seven company owners and managers as well as eleven employees from six different German companies between January and February 2020. The psychosocial factors of the psychosocial risk assessment of the Joint German Occupational Safety and Health Strategy (GDA) served as a framework for data collection and analysis. The interview material was analysed using Mayring's method of qualitative content analysis. RESULTS: We identified four prevailing work-related psychosocial demands related to work organization among managers and employees: (1) possibilities and time for recovery after work, (2) communication and cooperation, (3) work intensity, and (4) interruptions, and prioritization. According to the managers, they were confronted with a lack of possibilities and time for recovery after work. They report issues related to inadequate communication and cooperation affecting the entire company team, and also face high work intensity and frequent interruptions and prioritization. Employees reported a clearer division between work and private life. However, they also face periods of high work intensity, frequent interruptions and the need for prioritization. CONCLUSION: Managers and employees in SMEs in the health and service sector would benefit from evidence-based and evaluated tailored interventions and approaches for improved work organization. Further studies are needed to support managers and employees in SMEs in the health and service sector in facing and handling work-related psychosocial demands like lack of possibilities and time for recovery after work, high work intensity or frequent interruptions.

Feasibility, psychological outcomes and practical use of a stress-preventive leadership intervention in the workplace hospital: the results of a mixed-method phase-II study.

OBJECTIVES: Hospitals are psychologically demanding workplaces with a need for context-specific stress-preventive leadership interventions. A stress-preventive interprofessional leadership intervention for middle management has been developed. This phase-II study investigates its feasibility and outcomes, including work-related stress, well-being and transformational leadership. DESIGN: This is a mixed-methods study with three measure points (T0: baseline, T1: after the last training session, T2: 3-month follow-up). Additionally, focus groups were conducted to assess participants' change in everyday work. SETTING: A tertiary hospital in Germany. PARTICIPANTS: N=93 leaders of different professions. INTERVENTION: An interactive group setting intervention divided in five separate sessions ((1) self-care as a leader, (2) leadership attitudes and behaviour, (3) motives, needs and stressors of employees, (4) strengthen the resource 'team', (5) reflection and focus groups). The intervention was conducted between June 2018 and March 2020 in k=5 runs of the intervention. OUTCOME MEASURES: Feasibility and acceptance were measured with a self-developed intervention specific questionnaire. Psychological outcomes were assessed with the following scales: work-related strain with the Irritation Scale, well-being with the WHO-5 Well-being Index and transformational leadership with the Questionnaire of Integrative Leadership. RESULTS: After the intervention at T2, over 90% of participants reported that they would recommend the intervention to another coworker (92.1%, n=59) and all participants (n=64) were satisfied with the intervention and rated the intervention as practical relevant for their everyday work. Participants' self-rated cognitive irritation was reduced, whereas their well-being and transformational leadership behaviour were improved over time. Focus group discussions revealed that participants implemented intervention contents successfully in their everyday work. CONCLUSIONS: This intervention was feasible and showed first promising intraindividual changes in psychological outcomes. Participants confirmed its practical relevance. As a next step, the intervention will be evaluated as part of a multicentre-randomised controlled trial within the project SEEGEN (SEElische GEsundheit am Arbeitsplatz KrankeNhaus).

Reflection on leadership behavior: potentials and limits in the implementation of stress-preventive leadership of middle management in hospitals - a qualitative evaluation of a participatory developed intervention.

BACKGROUND: Mental health and stress prevention aspects related to workplace in hospitals are gaining increasingly more attention in research. The workplace hospital is characterized by high work intensity, high emotional demands, and high levels of stress. These conditions can be a risk for the development of mental disorders. Leadership styles can hinder or foster work-related stress and influence the well-being of employees. Through leadership interventions, leaders may be encouraged to develop a stress-preventive leadership style that addresses both, the well-being of the leaders and of the subordinates. A comprehensive qualitative description of leaders' experiences with interventions on the topic of stress-preventive leadership is yet missing in the literature. Therefore, we address leaders of middle management regarding the development of stress-preventive leadership styles through supporting interventions. The research questions are: How do leaders of middle management perceive their leadership role in terms of effectiveness in stress prevention? Which potentials and limits in the implementation of stress-preventive leadership are experienced? METHODS: The study follows a qualitative research design and content analysis. We conducted individual interviews with leaders of middle management (n = 30) of a tertiary hospital in Germany for the participatory development of an intervention. This intervention, consisting of five consecutive modules, addressed leaders of middle management in all work areas within one hospital. After participation in the intervention, the leaders were asked to reflect on and evaluate the implementation of the contents learned within focus group discussions. Overall 10 focus group discussions with leaders (n = 60) were conducted. RESULTS: The results demonstrate that leaders of middle management perceived potentials for a stress-preventive leadership style (e.g., reflection on leadership role and leadership behavior, awareness/mindfulness, and conveying appreciation). However, limits were also mentioned. These can be differentiated into self-referential, subordinate-related, and above all organizational barriers for the implementation of stress-preventive leadership. CONCLUSIONS: Some of the organizational barriers can be addressed by mid-level leadership interventions (e.g., lack of peer-exchange) or possibly by adapted leadership interventions for top management (e.g., lack of stress-preventive leadership styles in top level management). Other organizational limits are working conditions (e.g., staff shortage) that can only be influenced by health policy decisions.

Psychosocial demands and resources for working time organization in GP practices. Results from a team-based ethnographic study in Germany.

BACKGROUND: General practitioners (GPs) are challenged, e.g. by long working hours, and as employers they are responsible for the creation of working conditions that prevent work-related psychosocial risks. Leadership behaviour plays an important role within the working conditions of employees, thus we focused on two research questions: To what extent and how do GPs fulfil their role as entrepreneurs and leaders responsible for occupational safety and health of the team members in the organization of working time of the employees? What psychosocial factors result from the way of organization of working time for the practice team? METHODS: Data was collected by participant observations, individual interviews with six GPs, and five focus group discussions with 19 members of the practice staff in total. We gained access to five general practices through a teaching network associated with the Institute for General Medicine, University Hospital Essen (Germany). The analysis was carried out according to the Grounded Theory approach. RESULTS: GPs have several roles and related tasks to fulfil in the organization of working time. This can lead to perceived psychological stress. With regard to the organization of predictable working hours, vacations and sickness absence, the GPs determined the scope of action of the practice assistants. The delegation of these tasks took place to varying degrees and resulted in different work-related resources and stressors. CONCLUSION: We described transactional and transformational leadership behaviours which are all related to specific psychosocial demands and resources and may overlap on site. Leadership training seems recommendable as part of the training of GPs and other future leaders of micro-enterprises to promote self-reflection by the entrepreneurs and leaders and strengthen occupational health of leaders and staff.

Work-Related Psychosocial Demands and Resources in General Practice Teams in Germany. A Team-Based Ethnography.

General practices are established microenterprises in Germany providing a variety of preventive and therapeutic health care services and procedures in a challenging working environment. For example, general practice teams are confronted increasingly with work-related demands, which have been associated with poor psychological and physical outcomes. It is therefore important to gain a better understanding of issues related to occupational health and safety for personnel working in the primary care setting. This study aims to gain an in-depth understanding of psychosocial demands and resources in the primary care setting. We applied an ethnographic design, comprising a combination of participating observations, individual interviews with general practitioners (GPs) (N = 6), and focus group discussion with practice assistants and administrative staff (N = 19) in five general practices in Germany. A grounded theory approach was applied to analyze all data. Our results identified psychosocial demands and resources exemplified mainly along two typical tasks in GP practices: the issuing of medical prescriptions and blood sampling. Main psychosocial demands included factors related to work content and tasks, organization of work, and the working environment. For example, daily routines across all practices were characterized by a very high work intensity including disturbances, interruptions, delegation, and the division of labor between GPs and practice staff. Work-related resources comprised the staff's influence on aspects related to work organization and social support. The triangulation of methods and data formats allowed the disclosure of interconnectedness between these factors. Although work processes in general practices are complex and required to comply with legal regulations, there are opportunities for practice owners and practice teams to establish working procedures in ways that reduce psychosocial risks and strengthen work-related resources.

Exploring Drivers of Work-Related Stress in General Practice Teams as an Example for Small and Medium-Sized Enterprises: Protocol for an Integrated Ethnographic Approach of Social Research Methods.

BACKGROUND: An increasing shortage of skilled personnel, including medical personnel, has been reported in many postindustrial economies. Persisting and growing trends in absenteeism and incapacity to work due to mental disorders are concerning and have increased political, economic, and scientific interest in better understanding and management of determinants related to the work environment and health. OBJECTIVE: This study protocol describes an integrated approach of social research methods to explore determinants of work-related stress in general practice teams as an example for micro, small, and medium-sized enterprises (SMEs). METHODS: The methods applied will allow an in-depth exploration of work practices and experiences relating to psychological well-being in general practice teams. An ethnographic approach will be used to develop an in-depth understanding of the drivers of work-related stress in general practice teams. We will combine participating observation and individual interviews with five to seven general practitioners (GPs), and five to seven focus group discussions with the nonphysician staff (3-4 participants per group) in approximately four GP group practices and one single practice in Germany. Data collection and analysis will follow a grounded theory approach. RESULTS: The Ethics Committee of the Medical Faculty, University Hospital of Tuebingen, Germany, has approved this study (reference number: 640/2017BO2). Recruitment has commenced with study completion anticipated in mid-2020. CONCLUSIONS: The data from this project will be used in follow-up projects to develop and test an intervention to reduce and prevent work-related stress in GP practices and other SMEs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15809.