THEORETICAL CONSIDERATIONS OF DELIBERATIVE DIALOGUE : CONTRIBUTIONS FOR NURSING PRACTICE , POLICY AND RESEARCH

Objective: this paper will discuss and reflect on the use of deliberative dialogue’s theoretical and methodological conceptions and its contribution for nursing practice, policy, and research. Method: a theoretical and reflective study was conducted on the methodological approach of deliberation process and on its theoretical conceptions. This paper also provides an overview of key characteristics and fundamental steps that can be used to guide the development of a dialogue session. Results: deliberative dialogue involves purposeful, facilitated discussions among stakeholders to achieve consensus about health services priorities and to collectively decide on action strategies using synthesized research evidence and contextual experience. It is a knowledge translation strategy that involves individuals, communities, and institutions taking up scientific knowledge into reasoned changes. Key characteristics of this method include careful selection of participants, development of a background document with evidence synthesis, skilled and neutral facilitation, use of innovative approaches for group activities, and data analysis with integrated methods. Conclusion: deliberative principles have been used more for health policy decision-making, with little use in nursing care. Their use may be a unique experience for the nursing field, contributing to change in nursing practice and policy. They can also be used as a tool for data collection in qualitative research, as a new way to build scientific knowledge. Deliberative dialogue is an innovative approach that can facilitate having more critical-reflexive nurses, more evidence-based practices, and better health outcomes. DESCRIPTORS: Community-based participatory research. Decision making. Evidence-based nursing. Evidence-based practice. Policy making. CONSIDERAÇÕES TEÓRICAS DO DIÁLOGO DELIBERATIVO: CONTRIBUIÇÕES PARA PRÁTICA, POLÍTICA E PESQUISA EM ENFERMAGEM


INTRODUCTION
Over the last two decades, academics, providers, and policy-makers have highlighted the need for healthcare practices as well as organizations and systems to be evidence-informed. 1 By reducing the gap between research and practice it is possible to achieve optimal care, leading to more effective health service delivery and improved health outcomes. 23] For example, a systematic review concluded that nurses' use of research evidence in decision-making is not as ideal as it should be. 4 the Brazilian context, there are few experiences and models to support evidence-informed interventions in healthcare policy and practice.A recent study reported the importance of further research in focusing on innovative approaches to improve the uptake of research results. 3Over the past few years, an increased interest in knowledge translation strategies is clearly apparent among Brazilian academics. 1,5owledge translation is defined as a set of actions and strategies to develop and disseminate relevant knowledge and facilitate uptake of research results. 6Fundamentally, it is essential to use research results in decision-making on problems or issues affecting the health system.There are several knowledge translation theories and strategies described in the literature; 2,7 the majority of them highlight the importance of involving stakeholders and knowledge-users from the beginning of the research process.The input of providers' knowledge and experiences may offer approaches that are feasible, acceptable, and potentially effective in real-world practice settings. 8powerful strategy to engage stakeholders and the community in planning and developing policies and services is deliberative dialogue.This method involves purposeful, facilitated conversations among diverse groups of stakeholders who are invited to consider empirical evidence in the context of their experience and tacit knowledge. 9While it is recognized as a knowledge translation strategy, 10 it also has the potential to be an approach to data collection in qualitative research. 9veral studies have documented that deliberative dialogue can significantly contribute to change practice and policy, [11][12][13] overcoming challenges such as irrelevant evidence and access to scientific knowledge, and making research evidence easier to use in decision-making. 10][13][14] Deliberative processes are well suited to the health field because they can meet the broader objectives of stimulating debate, improving the understanding of complex issues, and encouraging consensus about health services priorities. 15owever, there has been very limited experience in nursing with deliberative dialogue.Up to now, much of the use of the method has been focused on macro-level policy formulation in some countries such as Canada, [16][17] the United States, 18 and Australia. 13Some attention has been given to its use as a qualitative data collection method, particularly in Canada. 9Surprisingly, there is little or no research using deliberative dialogue for nursing practice, policy, or research.
Considering the lack of familiarity with knowledge translation strategies and deliberative dialogue methods, as well as the growing need to improve nurses' use of research evidence, a theoretical and reflection study may more broadly contribute toward the development of relevant knowledge in nursing and health care.This paper's aim is to discuss and reflect on the use of deliberative dialogue's theoretical and methodological conceptions and its contribution to nursing practice, policy, and research.The reflection is based on the methodological approach of deliberation and on previous experiences using this method.It also provides an overview of key characteristics and fundamental steps that can be used to guide the development of a dialogue session.

T H E O R E T I C A L C O N C E P T I O N S O F DELIBERATIVE DIALOGUE
:263 What distinguishes deliberation from a generic group activity is the act of considering different points of view and arriving at a reasoned decision.Deliberative dialogue approaches are conceptually different from deliberative discussion regarding the co-creation of solutions.Deliberative discussion focuses on the process of informing and discussing the topic of interest, 19 not arising with a decision for action as in deliberative dialogue.
Deliberative approaches are grounded in the philosophy of deliberative democracy, a specific area of political science and political philosophy that involves giving members of the public the opportunity to learn more about a topic, engage in debate, and collectively decide on what policy should entail. 20Democratic practices such as public participation and consultation have a powerful influence in this theoretical approach.There is an interest not only in the product that comes from discussion, such as a decision or set of recommendations, but also in the process through which the product is developed. 15 addition to deliberative dialogue, there is a broad grouping of other deliberative approaches that include citizens' juries, consensus conferences, and deliberative polling.These methods differ with respect to specific features, but they all coincide with regards to the deliberative component where participants receive scientific information about the specific issue, discuss and consider each other's views, and together develop a final decision or recommendation for action. 15Thus, deliberative dialogue is a powerful tool to engage the community in the planning and development of policies and services through collaborative sense-making about pressing issues, deliberate priority setting, and developing concrete proposals that can be adopted by policy-and decision-makers. 13,15comprehensive discussion of the principles of deliberative dialogue has been presented in the literature. 10,21The key characteristics, as well as descriptions and goals, are summarized in table 1. Provide participants with common ground and ensure that relevant evidence will be taken into account.

Meeting environment
Appropriate venue and facilities.Ensure that the meeting environment is conducive to deliberation, enabling free-ranging discussion.

Confidentiality
Content of the dialogue session cannot be repeated to people outside the group.Also, participants or identifiable characteristics cannot be included in dialogue reports.
Guarantee confidentiality of dialogue content as much as possible in order to establish safe ground for the open exploration of ideas and values, as well as to promote trust among participants.

Facilitation
Facilitators should be skilled, knowledgeable, trained, and neutral.Co-facilitators may be helpful when meeting activities include small group discussion.
Ensure a safe deliberation, assisting participants in expressing their ideas and ensuring the opportunity for all to contribute .

Techniques during the session
Innovative approaches, dialogic and transformative educational and community building pedagogies Elicit participants' deeper views on issues and provide a way for people to see themselves as actors to critically transform reality.

Data analysis
Data often include multiple sets of materials, requiring integrated methods that balance analytical strategies with interpretive lenses.
Provide a credible method to analyze data generated through deliberative dialogue session(s) considering it as a complex process.Evaluation Rigorous evaluation of representation, procedures of the session, with evidence synthesis provided, as well as the impact on outcomes and decisions arising from the meeting.
Document what results were obtained and discuss lessons learned and recommendations for future effective deliberation processes.
It is important to note that although there are a number of characteristics of deliberative dialogue, hallmarks include an appropriate mix of participants, appropriate use of research evidence, and an appropriate meeting environment with adequate resources, participant commitment, and a skilled facilitator. 10In the next section, key steps for implementing a deliberative dialogue and strategies to ensure its features will be presented.

PLANNING AND IMPLEMENTING A DELIBERATIVE DIALOGUE SESSION
Application of deliberative dialogue as a method for change is a complicated process and requires significant planning and time to be conducted effectively.Work is required before, during, and after the session.Key steps to the development and implementation of a deliberative dialogue are outlined in figure 1.

Planning the session(s)
The literature recommends rigorous selection of participants for fair representation of all relevant interests, ensuring that all affected will be considered. 10,22It is necessary to first recognize the full array of interests involved as well as the key stakeholders that are influential or affected by the issue, categorizing them into groups of similarities.If stakeholders span different geographies or organizations, it is important to ensure representation from each different geographic area or organization.Following this comprehensive analysis, a balanced range of individuals from these groups is carefully selected. Evidence for a background reading document clarifies what is known about the issue and describes the options available to solve the problem. 12vidence synthesis can be drawn from a variety of sources including the peer-reviewed literature, grey literature sources, and primary data collection.Modes of data collection such as interviews, surveys, and photos may be chosen to provide an understanding of the current local state.All evidence should be provided in an easy to read format, understandable to a broad audience, and not be too long to ensure that dialogue participants will review the same prior to attending the session. A space that is easily accessible for all participants should be selected.The space should have room to conduct large and small group activities, enabling participants to move around.A knowledgeable and well-trained dialogue facilitator should be chosen.The facilitator will need to be able to work with power differentials among stakeholders groups, drawing out the quieter members of the group and dealing with those who dominate discussion, ensuring all perspectives are heard.A toolbox of activities is required to move the dialogue process from consideration of the evidence through deliberation and discussion and the co-creation of solutions.The facilitator is one of the key determinants of the success of a quality deliberative dialogue.Organizers need to work closely with the facilitators to develop activities that will engage participants, promote sharing of perspectives, develop actions, and set priorities.If small group work is to be completed, small group facilitators will also be needed.These may be chosen from a group of staff involved in the dialogue and can be trained by the overall facilitator.Note-takers and other roles should be assigned as needed.
An agenda for the session(s) will need to be developed.It is important to consider the timing, as deliberative dialogue can occur over a single session or multiple sessions. 13This will depend primarily on the setting, but also the topic may lend itself better to more than one session, where participants may need to reflect on discussion and reconvene for further deliberation and decisions on a topic.More often, though, the timing and amount of time available is dependent on the setting.A busy hospital unit may not have large blocks of time available; therefore shorter, for example, several one-and-a-half to two-hour blocks may be more feasible in these situations.Facilitators may also wish to consider a follow-up dialogue (e.g., six months later) to assess actions and outcomes achieved and reevaluate actions and adjust if necessary.

During the session(s)
At the beginning of the dialogue session, it is important to review confidentiality with participants.They should be asked to respect confidentiality principles, assuring that nothing said in the meeting will be repeated and they will not share who participated in the session. 10Comments will not be identified by a person's name, organization, or position in the final report in order to facilitate a trusting environment.
A variety of activities may be useful to engage participants in discussion and maximize deliberation.Dialogic and transformative educational and community building pedagogies may be used as means to facilitate discussion based on evidence. 9nnovative approaches to group facilitation, such as the World Café methodology and flip charts, motivate participants to critically reflect and propose actions to transform reality.It is recommended that participants first complete activities to discuss the background evidence, contextualizing and defining the issue. 20Engagement activities may then be developed to share and elicit participants' experiences and deeper views about the issue.Finally, brainstorming actions, recommendations, and strategies to put into practice can be completed.Depending on the number of recommendations raised, an exercise to set priorities may be necessary.Although dialogue techniques must be well planned, they should be flexible to maximize deliberations.Consideration should also be given to the number of participants and the meeting objective.Usually, small group activities are designed to encourage discussion, followed by large group feedback. 13,24  lead facilitator and small group facilitators need to track the conversation, assisting participants in expressing their ideas and ensuring that everyone is involved and contributing. 10They should not intervene or influence the discussion.However, the facilitator should continuously assess the discussion to ensure that it moves forward and meets the deliberative dialogue objectives.
For reporting purposes, the meeting can be video recorded, audio recorded, or photographed (with consent from the participants).Flip charts and other products from the meeting should be collected for later analysis.Facilitators and observers can take notes during the entire session, which will be included in the material for analysis.

After the session(s)
Prior to the session, it is important to schedule time to debrief following the dialogue session between facilitators and note-takers.If there is more than one session, debriefing should be conducted after each session.Sufficient time should be available to discuss overall impressions of the dialogue, what worked well, what did not work as well and, if further sessions are to be held, what changes should be made.It is also valuable to discuss the equity of voices at the session, as this information is important to consider in the analysis of the data.Finally, discussion on key ideas of content can be helpful and provide a beginning point for data analysis.
Deliberative dialogue uses a collective approach, contemplating the evidence, interpretation, and the creation of further data through discussion, setting priorities, and co-creating solutions.Understanding of the evidence and further data generation are influenced by stakeholders' tacit knowledge, which contributes to the overall interpretations of the data.The goal in a deliberative dialogue approach is to achieve comprehensiveness of the data versus saturation. 9Analysis of dialogic data is a cyclic process of data generation and synthesis, with further data being generated followed by further synthesis within and outside of the dialogue itself. 9liberative dialogue generates a variety of types of data.Notes from note-takers, flip charts and any other handwritten notes along with audio recordings should be transcribed.Once all dialogic data have been transcribed, rounds of analysis and interpretation are conducted by research team members.Using an integrated framework for analysis, there are three readings of the data.The first reading is to have a general scope of the data.Then, analytical strategies are used to categorize, code, and connect data.Third, interpretative notes can be produced via memos in contemplation of the analysis. 9final report of the dialogue proceedings is created and circulated to all participants for their validation and feedback.Accuracy of the interpretations by the research team is sought from participants and additional feedback is incorporated as data.Once the report has been finalized it can be used for broader circulation, dependent on the stipulations of the study and the broader approaches being used for knowledge translation.
Evaluation of the deliberative process is another important component of this stage.Data from initial evaluation of processes will already have been gathered in debriefing sessions immediately following the group session(s).Further reflection on the transcripts by research team members will provide additional information on the effectiveness of the process.6][17][18][19][20][21] Impact and outcomes from the meeting may also be evaluated by the participants.These data provide a comprehensive picture of the effectiveness of the dialogue.

C O N T R I B U T I O N S T O N U R S I N G PRACTICE, POLICY AND RESEARCH
Deliberative dialogue can be used in various settings for a variety of purposes to facilitate policy reform, practice change, and research.Since it engages people in generating new understandings and producing collective decisions from knowledge exchange, 9 it can be beneficial for nurses when empirical evidence and tacit knowledge need to be connected with action.Deliberative approaches have been used in the health services field, but are still a relatively new method in nursing.The experiences of health services can provide guidance for its use in a variety of areas of nursing.
Deliberative dialogue has most often been used for policy development and change.The process lends itself to gathering input with dialogue in the policy arena.The McMaster Health Forum, which is the World Health Organization (WHO) Collaborating Centre for Evidence-informed Policy, conducts both stakeholder and citizen dialogues to inform healthcare policy issues.Recent dialogues conducted by this group focused on improving cancer pain and symptom management 25 and strengthening care for people with chronic disease. 26Other deliberative dialogues that were successfully conducted for policy development included issues such as the ethics of human tissue biobanking, 20 family violence prevention 27 and rapid-response program for health system decision-makers. 28Although the literature shows no use of deliberative methods in policy formulation specifically in the nursing field, it is believed that nurses have a growing role in policy making, and the deliberative dialogue may be an innovative strategy to develop, implement, and evaluate nursing policies.
More recently, deliberative dialogue has been used to initiate and implement practice changes.It engages participants in conversations focusing on solutions rather than issues in order to develop collective actions to ensure ownership and facilitate change in practice or in the way services are delivered.The method was used to engage a broad group of stakeholders in developing actions and setting priorities to optimize nursing roles in primary care settings. 24It was also used in the integration of nurse practitioners in primary healthcare practice in British Columbia, Canada. 29Such dialogue approaches resulted in the development of robust recommendations for action, and hold promise for engaging stakeholders in creating change in nursing practice and other settings in healthcare systems.Future work should be done to evaluate the impact of the set of recommendations that arose from the meeting in decision-making and real change in nursing practice.
In addition to the literature showing the use of deliberative dialogue for promoting macro-level nursing practice change, it is believed that it can also substantially contribute to solve routine and micro level nursing problems in care settings.Nursing coordination can use the method to inform decisionmaking in clinical settings, such as implementing a new program, developing care protocols, or solving conflicts within the health team.It may also help the team to set priorities for themes for permanent education.The process of collective problem solving can facilitate in having nurses become more criticalreflexive as well as utilizing more evidence-based practices and more nurse-led innovation in clinical settings that result in better health outcomes.
With regard to research, deliberative dialogue can be used as a tool for data collection and synthe-sis in investigation. 9Considering this method as a means to bridge research with action, researchers argue that it can be an alternative to traditional surveys, interviews, and focus groups for generating data when the objective of the research is focused on influencing practice or policy. 9,16Researchers using deliberative dialogue generate collective data, because participants together create new understanding through the combination of synthesized evidence and their own tacit knowledge. 9 a qualitative study to improve the integration of nurse practitioners in primary healthcare settings, 29 deliberative dialogue was used as an approach to data collection.Data were collected and then synthesized and reported back to participants during the deliberative session for further reflection and discussion.A report of discussions and decisions from the session was also circulated to participants, with the opportunity to provide feedback on the accuracy of the discussion as well as additional thoughts on the results of the research.This process illustrates the iterative nature of data collection and the synthesis of deliberative dialogue as an approach for qualitative research. 9other significant contribution of the deliberation process during a nursing investigation is its use as an integrated knowledge translation strategy, 6 which includes stakeholders in the research process, involving them in collaborative problem-solving and decision-making.It may also be used as an end-of-grant knowledge translation strategy 6 at the end of the study to disseminate research results and transform practice.According to some authors, nursing scientific production is completed in academia and little is consumed by policy-makers, providers, and patients. 1,30The use of deliberative dialogue as a knowledge translation method may provide an approximation between research and practice, serving as an opportunity for researchers to return study results to healthcare services, healthcare systems, and the community.
Finally, deliberative dialogue can also contribute to nursing education, as it can involve students and professors in discussing public issues and possible evidence-based interventions.Courses could include deliberation in classrooms as an alternative to forums and seminars, especially when the target theme is controversial and requires multiple views for a comprehensive understanding.In addition, deliberative dialogue may be an interesting method to engage professors, students, deans, and graduated nurses in discussion when making curriculum or syllabus changes.Despite its being a unique experience for nursing education, there is no report in the literature of the use of a deliberative approach in nursing teaching and learning.

CONCLUSION
Deliberative processes are a recent phenomenon in the health sector, where some responsibility is given to individuals, communities, politicians, and institutions to take up scientific knowledge into reasoned changes.Reflections on deliberative dialogue enable researchers, managers, policy-makers, and providers to identify an alternative strategy to facilitate evidence use into practice and policy.This study has shown theoretical aspects and methodological conceptions that can guide nurses in using deliberative dialogue to collectively solve problems and transform practice.
The key characteristics of the method include careful selection of participants to ensure that multiple perspectives are represented; that a background reading document with evidence synthesis is completed; and that there are appropriate venues and facilities for the meeting(s), skilled and neutral facilitation, use of innovative approaches for group activities, and data analysis with integrated methods.Conducting a deliberative dialogue is a complicated process and requires significant planning and work before, during, and after the meeting session.Some difficulties in developing and implementing a deliberative dialogue can arise during the process.An important challenge is to have the right stakeholders in the meeting.If a stakeholder group (e.g., patients) is missing, there will be a limitation of voices and data.The careful use of stakeholder analyses and mapping methods during the planning stage is a way to overcome this difficulty.Another way is to ask participants in the first meeting if there is any group missing and, if so, to include them in the next meeting.Another difficulty is that sometimes during the session the activities do not generate the dialogue as anticipated.Then, being flexible and making changes are required throughout the deliberative session.
Deliberative principles have been used more for policy decision-making, with little use in nursing care.However, their use may be a unique experience for the nursing field, contributing to data collection for qualitative research, engaging stakeholders to change practice and policy, and as a knowledge translation strategy.It is a new approach that can facilitate more critical-reflexive nurses, evidencebased practices, and nurse-led innovation in clinical settings.The process of collective problem-solving can assist in implementing purposeful changes and achieving better health outcomes.
This study provides an innovative perspective for research in nursing and health by exploring a new way to build scientific knowledge.Further investigation regarding the use of deliberative dialogue for nursing practice, education, policy, and research is needed.

Figure 1 -
Figure 1 -Illustration of key steps for planning and implementing a deliberative dialogue session.Porto Alegre, RS, Brazil.2016