Development of an integrative coding framework for evaluating context within implementation science.

BACKGROUND: This research aims to explore an identified gap in implementation science methodology, that is, how to assess context in implementation research. Context is among the strongest influences on implementation success but is a construct that is poorly understood and reported within the literature. Consequently, there is little guidance on how to research context. This study addresses this issue by developing a method to account for the active role of context during implementation research. Through use of a case study, this paper demonstrates the value of using our context coding framework. METHODS: The developed context coding framework was guided by the sub-elements of the Consolidated Framework for Implementation Research (CFIR). Employing a constructivist approach, this framework builds on the CFIR and enables a deeper exploration of context at multiple levels of the health system. The coding framework enables the collation of various data sources such as organisational reports, culture audits, interview, survey, and observational data. It may be continuously updated as new data emerge and can be adapted by researchers as required. A pre-existing rating criterion has been integrated to the context coding framework to highlight the influence and relative strength of each contextual factor prior to and during implementation. RESULTS: It is anticipated that the context coding framework will facilitate a standardised approach to assessing context. This will provide a deeper understanding of how to account for the influence of context, ultimately providing guidance that should increase the likelihood of implementation success. The coding framework enables implementation progress to be monitored, facilitating the identification of contextual changes and variations across settings at different levels of the healthcare system. It is expected this framework will inform the selection of appropriate implementation strategies and enable the monitoring of such strategies regarding their impact on local context. CONCLUSIONS: This research contributes to the extant literature by advancing methodologies for the consideration and assessment of context in implementation research. This context coding framework may be used in any setting to provide insight into the characteristics of particular contexts throughout implementation processes.

Application of the critical incident technique in refining a realist initial programme theory.

BACKGROUND: As realist methodology is still evolving, there is a paucity of guidance on how to conduct theory driven interviews. Realist researchers can therefore struggle to collect interview data that can make a meaningful contribution to refining their initial programme theory. Collecting data to inform realist Inital Programme Theories (IPTs) in healthcare contexts is further compounded due to the healthcare workers' busy work schedules. In this case study of team interventions in acute hospital contexts, we explore the benefits of using the Critical Incident Technique (CIT) in order to build and refine an initial programme theory. We contend that use of the CIT helps to draw on more specific experiences of "Key Informants" and therefore elicits richer and more relevant data for realist enquiry. METHODS: The five steps of the CIT were mapped against realist methods guidance and adapted into an interview framework. Specifications to identify an incident as "critical" were agreed. Probes were embedded in the interview framework to confirm, refine and/or refute previous theories. Seventeen participants were interviewed and recordings were transcribed and imported for analysis into NVivo software. Using RAMESES guidelines, Context-Mechanism-Outcomes configurations were extrapolated from a total of 31 incidents. RESULTS: We found that the CIT facilitated construction of an interview format that allowed participants to reflect on specific experiences of interest. We demonstrate how the CIT strengthened initial programme theory development as it facilitated the reporting of the specifics of team interventions and the contexts and mechanisms characteristic of those experiences. As new data emerged, it was possible to evolve previous theories synthesised from the literature as well as to explore new theories. CONCLUSIONS: Utilising a CIT framework paid dividends in terms of the relevance and usefulness of the data for refining the initial programme theory. Adapting the CIT questioning technique helped to focus the participants on the specifics relating to an incident allowing the interviewers to concentrate on probes to explore theories during the interview process. The CIT interview format therefore achieved its purpose and can be adapted for use within realist methodology.

Defining and assessing context in healthcare implementation studies: a systematic review.

BACKGROUND: The implementation of evidence-based healthcare interventions is challenging, with a 17-year gap identified between the generation of evidence and its implementation in routine practice. Although contextual factors such as culture and leadership are strong influences for successful implementation, context remains poorly understood, with a lack of consensus regarding how it should be defined and captured within research. This study addresses this issue by providing insight into how context is defined and assessed within healthcare implementation science literature and develops a definition to enable effective measurement of context. METHODS: Medline, PsychInfo, CINAHL and EMBASE were searched. Articles were included if studies were empirical and evaluated context during the implementation of a healthcare initiative. These English language articles were published in the previous 10 years and included a definition and assessment of context. Results were synthesised using a narrative approach. RESULTS: Three thousand and twenty-one search records were obtained of which 64 met the eligibility criteria and were included in the review. Studies used a variety of definitions in terms of the level of detail and explanation provided. Some listed contextual factors (n = 19) while others documented sub-elements of a framework that included context (n = 19). The remaining studies provide a rich definition of general context (n = 11) or aspects of context (n = 15). The Alberta Context Tool was the most frequently used quantitative measure (n = 4), while qualitative papers used a range of frameworks to evaluate context. Mixed methods studies used diverse approaches; some used frameworks to inform the methods chosen while others used quantitative measures to inform qualitative data collection. Most studies (n = 50) applied the chosen measure to all aspects of study design with a majority analysing context at an individual level (n = 29). CONCLUSIONS: This review highlighted inconsistencies in defining and measuring context which emphasised the need to develop an operational definition. By providing this consensus, improvements in implementation processes may result, as a common understanding will help researchers to appropriately account for context in research.

Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare - systematic review.

INTRODUCTION: Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents' decision making when seeking unscheduled healthcare for their children. The systematic review question was "What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?" METHOD: Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data. RESULTS: Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent's perception that the child's condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP. CONCLUSION: Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.

Team interventions in acute hospital contexts: a systematic search of the literature using realist synthesis.

BACKGROUND: Research on team effectiveness in healthcare has focussed on whether effective teams yield positive outcomes for patients and on the effectiveness of team interventions to improve performance. Limited understanding exists of what works for whom within an effective team, or how and why the context in which the team operates enables team members both as individuals and as a collective to enact behaviours that promote positive outcomes. METHODS: This realist synthesis of the literature explores the relationship between team interventions, underlying teamwork mechanisms generated by those interventions, and the resultant impact on patient outcomes in an acute hospital context. A systematic search of five healthcare and healthcare management academic databases: PubMed, PsychINFO, CINAHL, ABInform, Emerald Management and three grey literature databases: ERIC, OpenDOAR and Open Grey was undertaken. Five experts in the field were also contacted to source relevant literature. Using PRISMA guidelines, relevant studies published between January 2006 and January 2017 were systematically searched by a team of three people. Drawing on realist methodology, data were synthesised using context, mechanism and outcome configurations as the unit of analysis to identify enablers and barriers to effective team interventions. RESULTS: Out of 3347 papers retrieved, 18 were included in the final synthesis. From these, five contextual enablers were identified: an inter-disciplinary focus and flattened hierarchy; effective communication; leadership support and alignment of team goals with organisational goals; credibility of intervention; and appropriate team composition with physician involvement. Ten recurring mechanisms were identified, the most frequently occurring of which was shared responsibility. CONCLUSIONS: The advantage of using realist synthesis to extrapolate data from the literature is that it considers the context and mechanisms that will impact effectiveness of healthcare team interventions. This methodological approach provides a different perspective to other types of syntheses and offers insight as to why certain contextual elements may yield more success than others. Findings therefore tend to have more practical implications. Specificity of detail in terms of how external drivers impact on healthcare team interventions was limited in the articles extracted for analysis. This broader perspective is therefore an important consideration for future research.

Evaluation of a formative peer assessment in research methods teaching using an online platform: A mixed methods pre-post study.

BACKGROUND: In higher education settings, there are increasing calls to shift away from traditional summative assessment practices, such end of term written tests, to explore methods of assessing learning in alternative ways. Peer assessment has been advocated as a means of formative assessment to enhance student engagement, empowering students to take responsibility for their own learning. While there is accumulating evidence for the value of peer assessment in higher education, one cannot assume peer feedback will translate appropriately to all settings and educational contexts. OBJECTIVES: This study evaluated the implementation of formative online peer assessment in a nursing and midwifery research methods module. We explored students' expectations, experiences, and ultimately the acceptability of this approach. DESIGN: A quantitative descriptive study. SETTING: Ireland. METHODS: An online survey to collate expectations and experiences of engagement in peer assessment. Scales were drawn from previous research and non-parametric tests explored changes in perceptions over time. Qualitative content analysis explored patterns evident in open-text responses. RESULTS: The response rate was 28% (n = 74) at baseline and 31% at follow-up (n = 81). Peer assessment was a new experience for 95% of respondents. Students initially expressed apprehension, perceiving the task as daunting, and doubting their ability to provide feedback to peers. However, through providing instruction and tools to support students in the activity, high levels of satisfaction with the process and the experience were reported. Significant differences in perceptions of peer assessment were evident over time, including an enhanced belief that respondents had the requisite skills to appraise the work of their peers. CONCLUSIONS: In sum, nursing and midwifery students agreed that peer assessment was a valuable learning experience as part of research methods training and critical skills development.

The impact of COVID-19 on health systems, mental health and the potential for nursing.

This paper offers a perspective on nursing and lived experience responses to the COVID-19 pandemic. It charts health systems and mental health impacts with a particular focus on children and adolescents, older people and people availing of mental health services. Issues of moral distress and the nursing reaction are considered alongside psychological and social concerns which continue to rapidly evolve. The perspective of a person attending adult community mental health services and the experience of engaging with a mental health service remotely is provided. Matters of note for acute inpatient mental health nursing are highlighted and informed by the lived experience of a mental health nurse. The need for integrated health systems responses across nursing disciplines and the wider interdisciplinary team is elucidated.