Using Nonparticipant Observation as a Method to Understand Implementation Context in Evidence-Based Practice.

BACKGROUND: The uptake of evidence-based knowledge in practice is influenced by context. Observations are suggested as a valuable but under-used approach in implementation research for gaining a holistic understanding of contexts. AIM: The aim of this paper is to demonstrate how data from observations can provide insights about context and evidence use in implementation research. METHODS: Data were collected over 24 months in a randomised trial with an embedded realist evaluation in 24 nursing homes across four European countries; notes from 183 observations (representing 335 hours) were triangulated with interview transcripts and context survey data (from 357 staff interviews and 725 questionnaire responses, respectively). RESULTS: Although there were similarities in several elements of context within survey, interview and observation data, the observations provided additional features of the implementation context. In particular, observations demonstrated if and how the resources (staffing and supplies) and leadership (formal and informal, teamwork, and professional autonomy) affected knowledge use and implementation. Further, the observations illuminated the influence of standards and the physical nursing environment on evidence-based practice, and the dynamic interaction between different aspects of context. LINKING EVIDENCE TO ACTION: Although qualitative observations are resource-intensive, they add value when used with other data collection methods, further enlightening the understanding of the implementation context and how evidence use and sharing are influenced by context elements. Observations can enhance an understanding of the context, evidence use and knowledge-sharing triad in implementation research.

'I have the world's best job' - staff experience of the advantages of caring for older people.

RATIONALE: Besides a growing demand for safe high-quality care for older people, long-term care (LTC) often struggles to recruit appropriately qualified nursing staff. Understanding what LTC staff value in their work may contribute to a more comprehensive understanding of what can attract staff and support person-centred care. AIM: To explore staff experience of the advantages of working in LTC settings for older people. METHODS: Narrative descriptions of 85 LTC staff in Ireland, the Netherlands and Sweden on what they value in their work were analysed with qualitative content analysis. ETHICS: Ethical approval was obtained according to the requirements of each country, and participants provided informed consent prior to the individual interviews. FINDINGS: Working in LTC signifies bonding with the older people residing there, their next of kin and the team members. It means autonomy in one's daily tasks amalgamated with being a part of an affirmative team. Participants reported a sense of accomplishment and fulfilment; caring meant consideration and recognition of the older people and the relationships formed, which provided for professional and personal growth. The sharing of compassion between staff and residents indicated reciprocity of the relationship with residents. STUDY LIMITATIONS: The findings may be transferable to LTC in general although they address only the positive aspects of caring for older people and only the experiences of those staff who had consented to take part in the study. CONCLUSIONS: The findings add to what underpins the quality of care in nursing homes: compassion in the nurse-resident relationship and person-centred care in LTC. They indicate reciprocity in the relations formed that may contribute to the empowerment of older people, but further studies are needed to explore this in more detail.

A Bridge Over Turbulent Waters: Illustrating the Interaction Between Managerial Leaders and Facilitators When Implementing Research Evidence.

BACKGROUND: Emerging evidence focuses on the importance of the role of leadership in successfully transferring research evidence into practice. However, little is known about the interaction between managerial leaders and clinical leaders acting as facilitators (internal facilitators [IFs]) in this implementation process. AIMS: To describe the interaction between managerial leaders and IFs and how this enabled or hindered the facilitation process of implementing urinary incontinence guideline recommendations in a local context in settings that provide long-term care to older people. METHODS: Semistructured interviews with 105 managers and 22 IFs, collected for a realist process evaluation across four European countries informed this study. An interpretive data analysis unpacks interactions between managerial leaders and IFs. RESULTS: This study identified three themes that were important in the interactions between managerial leaders and IFs that could hinder or support the implementation process: "realising commitment"; "negotiating conditions"; and "encouragement to keep momentum going." The findings revealed that the continuous reciprocal relationships between IFs and managerial leaders influenced the progress of implementation, and could slow the process down or disrupt it. A metaphor of crossing a turbulent river by the "building of a bridge" emerged as one way of understanding the findings. LINKING EVIDENCE TO ACTION: Our findings illuminate a neglected area, the effects of relationships between key staff on implementing evidence into practice. Relational aspects of managerial and clinical leadership roles need greater consideration when planning guideline implementation and practice change. In order to support implementation, staff assigned as IFs as well as stakeholders like managers at all levels of an organisation should be engaged in realising commitment, negotiating conditions, and keeping momentum going. Thus, communication is crucial between all involved.

A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar.

BACKGROUND: Facilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice. METHODS: This realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time points using multiple qualitative methods: observation (372 h), interviews with staff (n = 357), residents (n = 152), next of kin (n = 109) and other stakeholders (n = 128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing. RESULTS: The content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators' (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes. CONCLUSION: The scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist-informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally, a realist-informed process evaluation framework is outlined, which could inform future research of this nature. TRIAL REGISTRATION: Current controlled trials ISRCTN11598502 .

Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework.

BACKGROUND: Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice. METHODS: A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention. Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering. RESULTS: Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time. CONCLUSIONS: This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11598502 . Date 4/2/10. The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223646.