Keywords
Health Services Research - Organisation studies - Health Care - Organisational Behaviour
in Health Care - Organisational Health Services Research
Introduction
Health Services Research (HSR) in Germany
In Germany, health services research (HSR) is a growing interdisciplinary
research field that began to develop in the late 1990s as a niche area within
the health sciences. Within the last 15 years, HSR has increasingly been
acknowledged as an important pillar of health research in Germany that is
expected to aid understanding and improve routine health care. Through the
increasingly acknowledged importance and increase of national research funding
for HSR, the field has grown substantially and strong research groups have
developed throughout Germany. Having developed mostly from the fields of
evidence-based medicine, medical sociology and medical psychology, HSR in
Germany was and is to a great extent institutionalised at medical faculties and
is thereby expected to deliver meaningful evidence and solutions to challenges
and phenomena close to clinical practice [1]. The institutionalisation at medical faculties let to close
collaboration with clinical fields, which can be regarded as beneficial in terms
of application-oriented research and practice translation. On the other hand,
this proximity might keep HSR in Germany from being able to thoroughly and
critically analyse health services [1]
and from utilizing the full potential of methods and theories from other
relevant disciplines.
The German Network of Health Services Research (DNVF)
The German Network for Health Services Research (DNVF) was founded in 2006 as an
interdisciplinary academic network and currently comprises more than 80
institutional members (professional societies, health authorities and industry),
more than 50 scientific institutions (scientific institutes and research groups)
and 354 individual members from research and health care institutions (as of
November 2023). The network’s aim is to connect health services researchers in
Germany and German speaking countries, health care practitioners and
policy-makers in order to facilitate the exchange of ideas and approaches for
designing health care. The 22th annual conference of the DNVF in 2023
was attended by more than 1,000 mostly national experts from research, health
care and health policy.
Organisational Health Services Research (OHSR) in Germany
The relevance of health care organisations in HSR was acknowledged at an early
stage of the HSR development in Germany. The working group ‘Organisational
Health Services Research’ (OHSR) – which the authors of this article are part of
– was founded as one of the first of currently 26 working groups within the
DNVF. In 2009, the working group published a first consensus paper
(‘memorandum’) on the concept and methods of organisation-focused HSR [2], which was updated and extended in
2019 [3]
[4]
[5]. In this conceptual paper [3] the research sphere of what we term organisational HSR includes
the following areas:
-
the environment (macro-level) in which health care organisations act and
their interactions with the individual (micro-level) and organisational
level (meso-level)
-
structures, processes and cultures in health care organisations
-
interactions within and between health care organisations
-
impact of the aforementioned factors on (patient-related) outcomes and on
the delivery of health care [3]
Links to Organisational Behaviour in Health Care (OBHC)
The terms OHSR and OBHC are sometimes used interchangeably in the German HSR
community, but the term OHSR is more commonly used [6]. Our understanding of OHSR might be
somewhat broader than what is usually defined as organisational behaviour, which
according to Borkowski is “the study of individual and group dynamics within an
organisational setting” [6]. Both
examine the meso-level of health care organisations, but also their interactions
with the micro-level (e. g., health care professionals, managers, patients,
relatives) and the macro-level (e. g., society, health care system, labour
market, regional networks) and therefore overlap in some topics. However, as the
term OHSR is commonly used in Germany, we use the term in the following.
Motivation for conducting this study
Literature research in the course of writing the latest consensus paper [3] revealed that OHSR in Germany can be
regarded as very heterogeneous in terms of research objects studied and as
conceptually fuzzy [7]. It was
observed that existing HSR studies deal with organisations, teams and
individuals in organisations, but only rarely formulate research questions with
an explicit organisational reference. Thereby, there is the impression that
health care organisations are in many cases seen as a study setting only,
without theoretically and methodologically acknowledging the organisational
nature of their research. The main motivation for this study is to refine these
preliminary hypotheses and to provide an overview of the field of OHSR in
Germany that can inform the further conceptual development of the field.
Aims and research questions
Aims and research questions
The aims of this study are two-fold:
-
to provide an overview on the field of OHSR in Germany
-
to systematically map original contributions on OHSR from Germany
Primary research questions are:
-
What is the scope of OHSR in Germany?
-
How many original contributions explicitly formulate the organisational
nature of their research?
-
How many original contributions implicitly do OHSR without referring to
it?
Secondary research questions are:
-
Which organisational forms are objects of research?
-
What is the main health care context that the research addresses?
-
Which research designs including which methods and methods mixes are being
used?
-
What is the purpose and objective of the research?
-
What level of primary outcomes or central variables of interest does the
research address?
-
Does the research explicitly have a theoretical basis?
Methods
We conducted a scoping review of the conference abstracts of the 19th German
Conference on Health Services Research, held in October 2020 [8]
[9]
[10]. With regard to the
PRISMA-ScR Reporting Guideline [11], the
methodological steps with reference to the search context, inclusion criteria,
screening and extraction of data are described below ([Fig. 1]).
Fig. 1 Methodological approach to the review including the steps of
screening, data extraction and mapping.
Information Sources, Search and Data Preparation
The German Medical Science-Portal (GMS) abstract database was searched for all
published conference abstracts [12].
The identified abstracts and data were imported into the literature management
software Citavi and were checked for completeness and correctness. For
screening, all complete abstracts were automatically imported into the screening
software Rayyan (https://www.rayyan.ai/) [13].
Inclusion criteria
Inclusion criteria were designed based on the conceptual definition of OHSR
described above [3]. Accordingly, an
abstract was included if it met at least one criterion for each of the following
two lists.
-
A health care organisation as an institution OR
-
subunits of a health care organisation (e. g., departments, teams,
nursing stations) OR
-
organisational processes in an explicitly named health care
organisation
were formulated as a focus of research within the research question,
objective, analysis, or reported results AND if at least one of
the five research perspectives in the conceptual definition of OHSR is
addressed:
-
the environment and conditions under which health care organisations act
OR
-
the interdependence between individual and organisational levels OR
-
the organisational structures, processes, and cultures of health care
organisations OR
-
the interactions within and between health care organisations OR
-
the impact of these factors on (patient related) outcomes and the
organisation of health care delivery
Screening the conference abstracts
First, a pilot run was conducted with a random sample of abstracts. From the
alphabetically sorted abstracts, every tenth abstract was selected and
independently reviewed by two reviewers. Disagreements and suggestions for
improvement were then discussed by the research group, after which the final
screening procedure was defined and the inclusion criteria were slightly
modified. Secondly, all identified conference abstracts were independently
reviewed by three reviewers each. Disagreements were discussed between the
reviewers and resolved by consensus.
Data extraction and mapping
Following Krippendorf [14], a content
analytic approach was conceptualised to enable categorical extraction and data
presentation of the scope of OHSR within the conference abstracts. Data were
extracted from all included abstracts using a self-developed and consented
detailed coding scheme. Given the research questions, the main dimensions of the
coding scheme were first created deductively. Based on this, the data extraction
was piloted in two rounds on a sample of the conference abstracts to refine
subcategories inductively and to test the extraction procedure. A hierarchical
coding tree including dimensions, categories, and sub-categories was created
(see [Tab. 1]), and a coding manual
was formulated (Online Supplement 1). Finally, the data were coded by four
researchers. The categorical data extraction was organised in Excel spreadsheets
and the data were analysed descriptively.
Tab. 1 Data extracted from the abstracts by content
analysis (N=138).
|
ORGANISATIONAL SETTING
|
|
|
|
Organisational form
|
N
|
%
|
|
Hospital
|
48
|
34.8
|
|
Inpatient rehabilitation clinic
|
5
|
3.6
|
|
Outpatient medical practice
|
26
|
18.8
|
|
Outpatient (therapeutic) non-medical practice
|
2
|
1.4
|
|
Practice networks
|
2
|
1.4
|
|
Ambulatory health care centre (MVZ)
|
1
|
0.7
|
|
Inpatient care facilities
|
15
|
10.9
|
|
Outpatient care services
|
3
|
2.2
|
|
Other organisational forms
|
10
|
7.2
|
|
Several organisational forms
|
16
|
11.6
|
|
Not clearly assessable
|
10
|
7.2
|
|
Main context of health care
|
N
|
%
|
|
Health promotion
|
5
|
3.6
|
|
Preventive health care
|
6
|
4.3
|
|
Curative care
|
39
|
28.3
|
|
Rehabilitation
|
6
|
4.3
|
|
Nursing
|
17
|
12.3
|
|
Palliation
|
13
|
9.4
|
|
Several of the above-mentioned care contexts
|
14
|
10.1
|
|
Not clearly assessable
|
38
|
27.5
|
|
RESEARCH DESIGN
|
|
|
|
Study type
|
N
|
%
|
|
Literature study
|
8
|
5.8
|
|
Conceptual-theoretical contributions
|
2
|
1.4
|
|
Observational study
|
82
|
59.4
|
|
Intervention study
|
31
|
22.5
|
|
Other study types
|
2
|
1.4
|
|
Several study types mentioned
|
11
|
8.0
|
|
Not clearly assessable
|
2
|
1.4
|
|
Data source
|
N
|
%
|
|
Primary data
|
96
|
69.6
|
|
Secondary data
|
22
|
15.9
|
|
Combination of primary and secondary data
|
14
|
10.1
|
|
Not clearly assessable
|
6
|
4.3
|
|
Research methods
|
N
|
%
|
|
Qualitative methods
|
34
|
24.6
|
|
Quantitative methods
|
45
|
32.6
|
|
Scoping review
|
3
|
2.2
|
|
Systematic review
|
3
|
2.2
|
|
Narrative review
|
2
|
1.4
|
|
Other methods
|
3
|
2.2
|
|
Combination of different methods
|
44
|
31.9
|
|
Not clearly assessable
|
4
|
2.9
|
|
RESEARCH OBJECTIVES
|
|
|
|
Research purpose and objective
|
N
|
%
|
|
Description/Explanation
|
68
|
49.3
|
|
Concept development
|
24
|
17.4
|
|
Evaluation
|
32
|
23.2
|
|
Implementation
|
2
|
1.4
|
|
Combination of above-mentioned research purposes
|
8
|
5.8
|
|
Not clearly assessable
|
4
|
2.8
|
|
Level of the reported primary outcome
|
N
|
%
|
|
Patient level
|
24
|
17.4
|
|
Employee level
|
26
|
18.8
|
|
Organisation level
|
44
|
31.9
|
|
Health system level
|
4
|
2.9
|
|
Multiple outcomes reported at different levels
|
34
|
24.6
|
|
Not clearly assessable
|
6
|
4.3
|
|
THEORETICAL FRAMEWORK
|
|
|
|
Explicit reference to theory
|
N
|
%
|
|
Yes
|
10
|
7.2
|
|
No
|
128
|
92.8
|
|
Organisational health services research
|
N
|
%
|
|
Explicit “Organisation”
|
24
|
17.4
|
|
Implicit
|
114
|
82.6
|
Note. Due to rounding, percentages might not add up to exactly 100%.
Results
Overall, 468 abstracts were identified for screening, all of which were written in
either German (n=393; 84.0%) or English (n=75; 16.0%). A total of 330 abstracts
(70.5%) were excluded because either the research question or objective was not
related to an OHSR topic (n=222; 67.3%) or because no OHSR topics were investigated
according to the inclusion criteria (n=108; 32.7%). After screening 29.5% (n=138)
of
these abstracts were ultimately included in the scoping review ([Fig. 2]).
Fig. 2 Flowchart for the inclusion and exclusion of abstracts in the
screening process.
The included abstracts were analysed with regard to the organisational setting, the
research design, the research objectives, and the theoretical framework. The results
are shown in [Table 1].
Organisational setting
The majority of identified abstracts reported on studies undertaken in hospitals
(acute care: n=48 (34.8%)), followed by studies focusing on outpatient medical
practices (n=26; 18.8%). The main body of identified studies in the nursing
setting revealed a strong focus on inpatient health care facilities (n=15;
10.9%) rather than outpatient health care services (n=3; 2.2%). Interestingly, a
considerable share of studies was based on an inter-organisational context
(n=16; 11.6%), i. e., studies investigated different organisational settings.
Other organisational settings such as outpatient therapeutic practices (e. g.,
physiotherapy and speech therapy) were barely considered. Although in 27.5%
(n=38) of the abstracts it was not possible to identify the main context of
care, the remaining abstracts focussed mostly on curative health care settings
(n=39; 28.3%). Notably, nursing care (n=17; 12.3%), palliative care (n=13; 9.4%)
as well as studies, where more than one main care context is studied, (n=14;
10.1%) were identified in a considerable part of included studies. Studies on
health promotion (n=5; 3.6%), prevention (n=6; 4.3%) or rehabilitation (n=6;
4.3%) were rarely the main context of health care studied.
Research design
The majority of included abstracts (59.4%; n=82) were based on observational
studies, and 22.5% (n=31) had an interventional study design. The main body of
studies used primary data (n=96; 69.6%), whereas secondary data was used in
15.9% (n=22) of the abstracts. Some abstracts drew on a combination of primary
and secondary data (n=14; 10.1%). Regarding the research methods, there was a
slightly higher use of quantitative (n=45; 32.6%) than qualitative (n=34; 24.6%)
research methods. A considerable part of studies combined different methods
(n=44; 31.9%). Hardly any abstract provided an indication of a ‘scoping review’
(n=3; 2.2%), ‘systematic review’ (n=3; 2.2%) or ‘narrative review’ (n=2;
1.4%).
Research objectives
Almost half of the abstracts reviewed were descriptive or explanatory (n=68;
49.3%). Other clearly classifiable abstracts focused on concept development
(n=24; 17.4%, e. g., developing an intervention) and evaluation (n=32; 23.2%)
rather than questions of implementation (n=2; 1.4%). Considering the studies
where the primary research objective was deducible from the included abstracts,
31.9% (n=44) had their research focus on a primary endpoint at the
organisational level, whereas research objectives at patient (17.4%) and
employee level (18.8%) and especially at the health system level (2.9%) were
less represented. Around a quarter, 24,6% (n=34) of the abstracts reported
several research objectives at different levels.
Theoretical framework
An explicit reference to theory was applied in 7.2% (n=10) of the included
abstracts, citing different theoretical approaches and not only organisational
theories. A total of 24 abstracts (17.4%) mentioned the term ‘organisation’ or
related terms (organiz* or organis*) explicitly.
Discussion
The results of the study provide a systematic but preliminary overview of the scope
to which HSR in Germany is currently addressing organisational research and also
highlight several theoretical and methodological challenges. The analyses support
the view that most organisational research within HSR is conducted in hospitals. The
most common context of health care was curing diseases. Most frequently used study
types were observational studies based on primary data, with a slight trend towards
quantitative empirical methods. However, we also found an increasing use of
qualitative and mixed-methods procedures to depict the complex contextual conditions
in OHSR. The most commonly cited research objectives were description and
explanation at the meso- and micro-level. The term “organisational health services
research” was never used, and the term “organization” or related terms appeared only
occasionally.
However, the reasons for a number of these findings remain unclear. Whether and to
what extent the results are due to conceptual reasons, such as the vagueness of our
underlying concept and the OHSR field as a whole? Do the results possibly reflect
preferences of researchers in dealing with the research funding system, especially
with the Innovation Fund (Innovationsfonds) as the largest funding program of HSR
in
Germany? Or do they reflect the strong institutionalization of HSR at medical
faculties in Germany and the associated research culture that is shaped by the
paradigm of evidence-based medicine rather than the social sciences? In addition to
the conceptual and methodological foundations provided by the consensus paper, the
next step in light of these ambiguous results is to conceptually sharpen the
research field of OHSR, raise awareness of organisational topics in HSR and develop
a research agenda that directs future research.
Based on our conceptual definition, most abstracts addressed OHSR issues only
implicitly and largely without reference to theory. A reflective use of
organisational theories was virtually absent in the abstracts we evaluated, although
a number of German and international textbooks on organisational theories are
available from the reference sciences of sociology, management, and psychology,
among others [15]
[16]
[17]
[18]. If the lack of theory
is not only due to the abstracts’ word limit, but reflects the lack of theory use
in
the respective studies, then this would hint at a low explanatory power of OHSR
studies. In this light, the goal should be to encourage health services researchers
to make greater use of organisational theory to advance knowledge in the field [19]. In this discussion, however, it should
also be noted that, firstly, the instruments of evidence-based medicine are in
principle capable of providing reliable results on effectiveness even without
explicit reference to a theory and, secondly, that this phenomenon generally
prevails in HSR as an implicit socialised guiding principle. However, since HSR is
expected to provide innovative solutions for health care problems, it would be
advisable to promote the consideration of theories and qualitative methods [20] in intervention studies to understand
and explain the occurrence of outcomes in a specific organisational context [21]. Particularly under the condition of an
uncertain environment characterized by rapidly changing situations, such as recently
experienced in the COVID-19 pandemic, Pfaff et al. recommend supplementing the EbM
approach with theoretical evidence to be able to inform politics in urgent
situations, where clear evidence in terms of EbM is lacking [22]. Due to their systemic nature, modern
social science organisational theories such as systems theories [23] , behavioural theories [24] or sociological neo-institutionalism
[25] can play a crucial role in
understanding and explaining the implications of the organisational context for the
effectiveness and, in particular, the effectiveness gap of a medical or
health-related intervention.
Due to a lack of clarity in the conference abstracts, both ambiguity and vagueness
in
the use of the term “organization” are evident, reflected in a lack of distinction
between ‘health care processes’ and ‘organisational processes’. For example,
although some abstracts on intervention studies conclude that the organisational
context had an influence on implementation, organisational determinants were not
explicitly and a priori covered in the study design. This ambiguity was not explored
further in this scoping review using a theoretical, epistemological lens [26] but it should rather be the subject of
a future sharpening of the conceptual and methodological foundations of OHSR in
Germany.
This leads to another challenge of OHSR in the German HSR context: there are few
tools that can help health services researchers that are not deep into organisation
studies to conceptualize organisational context and organisational determinants in
their studies. Developing a core set of organisational factors or determinants could
help researchers to explicitly consider “organization” when designing studies.
However, the risk that it leads to over-standardization and homogenization of the
HSR field needs to be considered and reflected upon [27].
Strengths of this scoping review are the robust evaluation and consensual exchange
among the reviewers, the systematic methodological approach [11], a pilot screening performed to create
a common understanding of inclusion and exclusion criteria and the use of structured
coding scheme for data extraction. However, the results of this paper are limited
to
a review of published abstracts from the 19th German Conference on Health
Services Research 2020, and as such provide only a ‘snapshot’ with limited
information. However, they provide a useful baseline for follow-up studies. We did
not evaluate the study quality and we did not review further materials and
publications on individual projects summarized in the abstracts. The limited
information summarized in abstracts led to missing information on some of the
categories of interest and it has to be considered that an extraction of full papers
of the presented studies would probably alter our results. Thus, it is possible that
OHSR has been considered in research projects, but has not been identified through
the screening procedure. It is also possible that our broad definition of OHSR, on
which we relied for inclusion and exclusion criteria, led to oversampling of
abstracts. It would therefore be desirable to validate the presented results by an
extended systematic review based on full texts of the original papers. However, the
availability of original research papers would have to be systematically researched
or the authors interviewed directly after publication, as these were not available
for the conference.
Conclusions
The results of this scoping review indicate that the theoretical and methodological
foundations of the OHSR concept in Germany need to be further researched and
developed (see Ansmann et al., 2024, in this issue https://doi.org/10.1055/
a-2326-6768). The refinement of the conceptual basis needs the involvement
of researchers from related disciplines beyond HSR that study health care
organisations from their respective fields (e. g., organisational sociology, health
care management). This also includes a critical review of terminology, especially
in
relation to OBHC. Within the HSR community in Germany and among research funders,
it
is important to create an awareness of the organisational nature of many pressing
problems in health care and, building on this, to sharpen and conceptually develop
the research field of OHSR in Germany.
